How to use the guide Column listing

all interventions
Column where all the necessary actions to be done during the given
intervention are explained, developed, annotated, and illustrated

This clinical practice guide is ADDITIONAL NEONATAL CARE’S

Chapter title
MAINTENANCE
ENVIRONMENT CHECKLIST
organized chronologically. CARE
ADDITIONAL
CARE
NEONATAL CARE’S
ENVIRONMENT
MAINTENANCE
CHECKLIST
It guides health workers INTERVENTION ACTION
B.INTERVENTION
CARE FOR A SMALL BABY (OR TWIN) (continued)
through the standard Section TIME BAND:
B. CARE FOR
Skin-to-skin Upon (in arrival
A SMALL
care
ACTION
ofStart
BABY (OR thekangaroo
TWIN)woman in thecare
(continued)
mother facility
(KMC) when:
precautions for essential kangaroo position)
Skin-to-skin care (in
» the baby is able to breathe on its own (no apnoeic episodes); and
 Start kangaroo mother care (KMC) when:
» the baby is free of life-threatening conditions.
newborn care practices, Sub-section
kangaroo position) » the baby is able to breathe on its own (no apnoeic episodes); and
» the
 The baby is free
management ofof life-threateningconditions
life-threatening conditions.
takes first priority over KMC, although skin-
beginning at the intrapartum Time band
to-skin contact is still beneficial until KMC is possible.
 The management of life-threatening conditions takes first priority over KMC, although skin-
to-skin
NOTES * The ability contact is still
to coordinate benefi
sucking cialswallowing
and until KMC is possible.
is NOT an essential requirement for KMC. Other methods of
`` viii period with the process of  62 feeding, e.g. feeding by naso- or oro-gastric tube or later by cup, can be used until the baby can breastfeed.
NOTES * *KMC
The can
ability to coordinate
begin after birth,sucking and assessment
after initial swallowing andis NOT an essential
where requirement
needed basic for KMC.
resuscitation, Other methods
provided the baby of
preparing the delivery area, Intervention  62 feeding,
and mothere.g.
arefeeding
stable.by naso- or oro-gastric tube or later by cup, can be used until the baby can breastfeed.
* *LBW
KMCbabies
can begin after<birth,
weighing 2000after initial
g who areassessment and where
clinically stable shouldneeded basic KMC
be provided resuscitation, provided
immediately. the baby
Experience
and emphasizing care practices and mother
shows are stable.
that babies weighing ≥ 1800 g can usually start KMC at birth.
* LBW babies weighing < 2000 g who are clinically stable should be provided KMC immediately. Experience
in the first hours and days shows that babies weighing ≥ 1800 g can usually start KMC at birth.
IF KMC is not possible, wrap the baby in a clean, dry, warm cloth and place in a crib. Cover with

of a newborn’s life. Specific action IFa KMC

blanket. Usepossible,
is not a radiant warmer
wrap if theinroom
the baby is not
a clean, dry,warm
warmorcloth
the baby is small.
and place in a crib. Cover with
a blanket.
 Explain KMCUse a radiant
to the warmer
mother, if the room is not warm or the baby is small.
including:
Specific context continuous
» Explain KMCskin-to-skin contact;
to the mother, including: » caring for her baby;
Notes, if needed » »positioning
continuousher baby;
skin-to-skin contact; » » continuing
caring for her
her daily
baby;activities; and
Each section has a colour tab » »attaching her baby for
positioning her baby;
» »expressing
breastfeeding; » » preparing a ”support
continuing binder”. and
her daily activities;
attaching her
her milk;
baby for breastfeeding; » preparing a ”support binder”.
for easy reference. » expressing her milk;

Accent put on When the list of recommendations is too long, it appears in 2 columns,
specific situations to be read from left to right, and then from page to page

1. Preparing for a birth

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1. Preparing for a birth

intervention action
TIME BAND: Upon arrival of the woman in the facility

`` Introduce yourself to the woman.

`` Obtain the pregnancy history and birth plan.
`` 4 `` Identify the companion(s) of choice.
`` Perform proper handwashing (see pages 75–77).
`` Examine the woman. Check for pallor, and take:
»» blood pressure (BP),
»» heart rate (HR) or pulse rate (PR),
»» respiratory rate (RR),
»» temperature.
`` Assess fetal heart rate.
`` Assess the progress and stage of labour.

TIME BAND: Upon confirmation THAT laboUr has begun

`` Check results of woman’s laboratory tests including haemoglobin, syphilis – rapid plasma
reagin (RPR) or Venereal Disease Research Laboratory (VDRL) – and HIV tests.

Fill out WHO partograph, which includes:

»» hours in active labour, »» urine voided,
»» hours since ruptured membranes, »» temperature,
»» rapid assessment, »» heart rate or pulse rate,
»» vaginal bleeding, »» blood pressure, `` 5
»» amniotic fluid, »» cervical dilatation, and
»» uterine contractions, »» any problems.
»» fetal heart rate,

If diastolic blood pressure is ≥ 90 mm Hg,

confirm with a second reading and check urine for protein.
If diastolic blood pressure is ≥ 90 mm Hg on two readings AND ≥ 2+ proteinuria,
STABILIZE the woman.

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intervention action
`` THAT laboUr has begun (continued)
TIME BAND: Upon confirmatIon
If labour has lasted for > 24 hours or the cervical dilatation is at the WHO partograph action line:
STABILIZE and do vacuum/forceps extraction.
NOTE Do not give (tocolytic) medications to stop labour if:
* gestation is more than 36 weeks;
* there is chorioamnionitis, pre-eclampsia or active bleeding;
* the mother has heart disease; or
* the fetal heart rate is not heard or the fetus is known to have a potentially lethal major malformation,
`` 8 for example, anencephaly.

TIME BAND: During laboUr

`` Encourage birth companion(s) to be present.

`` Encourage the woman to:
»» move around if she wants and assume a position she is comfortable in;
»» take in light snacks and oral fluids; and
»» empty her bladder.
`` Every
»» 30 minutes: plot heart or pulse rate, contractions and fetal heart rate;
»» 2 hours: plot temperature; and
»» 4 hours: plot blood pressure and cervical dilatation.

TIME BAND: Preparing for the birth

`` Ensure privacy.
`` Ensure that the delivery area is between 25–28 °C using a non-mercury room thermometer.
`` Test whether the delivery area is draft-free by hanging a piece of tissue paper.
`` Eliminate draft if present, e.g. turn off fans and/or air-conditioning units.
`` Introduce yourself to the mother and her companion of choice or support person.
`` Review with the mother what care to expect for herself and her baby in the immediate `` 9
postpartum period.
`` Wash hands with clean water and soap (see pages 75–77).
`` Place a dry cloth on her abdomen or within easy reach.
`` Prepare the following:
»» clean linen or towel(s), »» 10 IU ampoule of oxytocin,
»» bonnet, »» basin with 0.5% chlorine solution for
»» syringe, decontamination (see page 78).
`` Open the delivery kit containing sterile umbilical clamp or tie, instrument clamp, and scissors.
Do not touch the sterile items.

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intervention action
TIME BAND: Preparing for the birth (continued)

`` Prepare newborn resuscitation area by:

»» clearing a flat, firm surface; and
»» checking that resuscitation equipment including bag, masks and a suction device
(preferably single-use) are within reach, clean and functional.

TIME BAND: Prior to delivery at perineal bulging, with presenting part visible (2nd stage of laboUr, perineal phase)
`` 10
Prepare for the delivery `` Perform proper handwashing (see pages 75–77).
NOTE – If lone birth attendant, `` Put on sterile gloves.
put on two sets of sterile gloves;
if a team, the gloves of the `` Allow the mother to push as she wishes with contractions.
health worker who will handle `` Do not perform routine episiotomy.
the cord should be sterile.
`` Episiotomy should be considered only in the case of:
»» complicated vaginal delivery (breech, shoulder dystocia, vacuum or forceps extraction);
»» scarring of the female genitalia or poorly healed third- or fourth-degree tears; or
»» fetal distress.
`` Provide good perineal support with controlled delivery of the head.

2. Immediate newborn care: the first 90 minutes

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 newborn care
0 – 90 min

Algorithm 2: Essential newborn care

birth * Call out time of birth and sex of the baby
* Deliver the baby onto the dry cloth draped over the mother’s abdomen or arms
* Start drying baby within 5 seconds after birth:
–– wipe eyes, face, head, trunk, back, arms and legs thoroughly
–– check breathing while drying
* Remove wet cloth to start skin-to-skin contact
* Cover the baby with dry cloth and head with bonnet
* Do not do routine suctioning
`` 12 Newborn resuscitation:
30 seconds Is the baby gasping or not breathing?
YES
–– clamp and cut cord
NO –– start ventilation
then
1 minute * Continue skin-to-skin contact on mother’s abdomen or chest
* Inject oxytocin 10 IU IM after excluding a second baby and informing the mother, then remove soiled
set of gloves, if you are lone birth attendant
* Clamp/cut cord after pulsations stop, no earlier than 1 minute Go to clinical algorithm 3:
* Do not separate the baby from the mother for at least 60 minutes, unless in respiratory distress or with “Resuscitation”
maternal emergency
* Encourage breastfeeding when baby shows feeding cues
* Do eye care (before 1 hour)
* Monitor the baby every 15 minutes
* Postpone bathing until after baby > 24 hours of age

YES Examine the baby and manage

Does the baby have signs of illness?
urgent conditions

NO
90 minuteS
After the baby has detached from breast:
–– examine the baby – weigh the baby and record

Does the baby have:

  – birthweight < 1500 g? YES
Manage urgent conditions
  – a danger sign?
– feeding difficulty?

NO

Provide preventive measures – Inject vitamin K, hepatitis B and BCG vaccines `` 13

YES
Does the baby have other problems? Manage other problems

then
NO

Provide routine postnatal care – Re-examine the baby before discharge

Does the baby have: YES

– a danger sign? Manage urgent conditions
– jaundice?

NO
24 hours Provide counselling and discharge – Do not discharge before 24 hours after birth

Essential care for all

Decision points
Conditions needing urgent care

YES NO then
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2. Immediate newborn care: the first 90 minutes

intervention action

TIME BAND: Within the first 30 seconds

Dry and provide warmth `` Call out time of birth.

`` Immediately dry the baby (starting within the first 5 seconds after birth), as follows:
»» use a clean, dry cloth and dry the baby thoroughly;
`` 14
»» wipe the eyes, face, head, front, back, arms and legs; and
»» do a quick check of baby’s breathing while drying (see page 12).
`` Remove wet cloth and place baby in skin-to-skin contact with the mother.
`` Cover the baby and mother with a clean warm cloth.
`` Cover the baby’s head with a bonnet.
NOTE Do not do routine suctioning. During the first 30 seconds:
–– do not suction unless the mouth/nose is/are blocked; and
–– do not suction meconium unless the baby is not vigorous.

TIME BAND: from 30 seconds TO 3 MINUTES

If after thorough drying and stimulation (as close to 30 seconds as possible), newborn is gasping or is not breathing:
Start of positive pressure `` Call for help.
ventilation
`` Clamp and cut the cord with sterile scissors and with sterile gloves on.
`` Transfer to warm, firm surface.
`` Inform the mother in a kind and gentle tone that the baby has difficulty breathing
and that you will help the baby to breathe.
`` 15
`` Start ventilation (see page 53).
If breathing or crying
Continue skin-to-skin `` If baby is breathing normally or crying, avoid manipulation such as routine suctioning that may
contact cause trauma or introduce infection. Postpone routine procedures such as weighing and
measurements.
`` Continue skin-to-skin contact with the baby prone on the mother’s abdomen or chest.
Turn the baby’s head to one side.
`` Keep the baby’s back covered with a blanket and head with a bonnet.

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intervention action
TIME BAND: from 30 seconds TO 3 MINUTES (continued)

NOTES * Do not separate baby from the mother as long as the baby is well – i.e. does not exhibit severe chest
in-drawing, gasping or apnoea, or severe malformation – and the mother does not need urgent medical
stabilization, e.g. emergency hysterectomy.
* Do not wipe off the vernix, if present.
* Do not bathe the baby during the first 24 hours of life.
* If an identification band is used, place on the baby’s ankle.
* If the baby must be separated from his/her mother, clamp and cut the cord and put the baby on a warm
`` 16 surface in a safe place close to the mother.

Inject oxytocin into the `` Explain to the mother that you will be injecting her with oxytocin to make her uterus contract
mother’s arm or thigh and protect her from excessive bleeding.
`` A trained second health worker, if available, could inject the oxytocin.
`` Put soiled instruments into a decontaminating solution.

Assist with multiple births `` If there is another baby/ies, get help. Deliver the next baby. Manage as in a multifetal
pregnancy.

Do appropriately timed `` Ensure gloves are sterile when touching or handling the cord:
cord clamping and cutting »» if single health worker with double sterile gloves: remove soiled set of gloves prior to touching
or handling the cord;
»» if other health worker: wash hands and use sterile gloves.
`` Clamp and cut the cord after cord pulsations have stopped (between 1–3 minutes), as follows:
»» apply a sterile plastic clamp or tie around the cord at 2 cm from the umbilical base;
»» drain the cord of blood by stripping away from the baby;
»» apply the second clamp at 5 cm from the umbilical base (which is 3 cm from the first clamp);
»» cut close to the first clamp or tie using sterile scissors; and
`` 17
»» apply a second tie if there is oozing blood.
`` Put soiled instruments into a decontaminating solution.

TIME BAND: Within 90 minutes

`` Leave the baby on mother’s chest in skin-to-skin contact, with the head turned to one side
and mother in a semi-upright position, or on her side.
`` Observe the baby. Only when the baby shows feeding cues (e.g. opening of the mouth, tonguing,
licking, rooting), suggest to the mother to encourage/nudge her baby towards the breast.

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intervention action
TIME BAND: Within 90 minutes (continued)

`` Provide breastfeeding support to ensure good positioning and attachment.

When the baby is ready, advise the mother to:
»» make sure the baby’s neck is not flexed or twisted;
»» make sure the baby is facing the breast with the baby’s nose opposite her nipple and chin
touching the breast;
»» hold the baby’s body close to her body;
`` 18 »» support the baby’s whole body, not just the neck and shoulders;
»» wait until her baby’s mouth is opened wide; and
»» move the baby onto her breast, aiming the lower lip well below the nipple.
`` Look for signs of good attachment and suckling, including:
»» mouth wide open;
»» lower lip turned outwards;
»» baby’s chin touching breast; and
»» slow and deep suckling, with some pauses.
NOTE Breastfeeding is a learned behaviour for both baby and mother. Baby will make several attempts to breastfeed
before being successful. Health workers should avoid interfering with this process (e.g. manipulating baby’s head
and/or body).

Diagrams of infant’s mouth Good attachment to the breast

`` 19

Bad attachment to the breast

© WHO

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intervention action
TIME BAND: Within 90 minutes (continued)
If attachment or suckling is not good, try again, and reassess.
`` Do not leave the mother and baby alone. Monitor breathing and warmth.
If the baby has signs of illness or does not show readiness to feed, i.e. feeding cues within
90 minutes, EXAMINE the baby and MANAGE urgent conditions.
If the breast is engorged, express a small amount of breast milk before starting breastfeeding
`` 20 to soften the areola area so that it is easier for the baby to attach.
NOTES * Do not touch the baby 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.
* If the mother is HIV-positive, take measures to prevent mother-to-child transmission. Do counselling and testing.

Do eye care `` Explain to the mother that you will be putting an ointment or drops into her baby’s eyes to
prevent infection. Reassure her that this is a routine procedure.
`` After baby has located the breast, administer erythromycin or tetracycline ointment, or 2.5%
povidone-iodine drops, to both eyes according to national guidelines. Apply from the inner
corner of each eye, outwards.
`` Do not wash away the eye antimicrobial.

Provide additional care `` For a visibly small baby or a baby born > 1 month early:
for a small baby (or twin) »» encourage the mother to keep the baby in skin-to-skin contact;
»» provide extra blankets to keep the baby warm;
»» do not bathe the baby; and
»» ensure hygiene by wiping with a damp cloth, but only after 24 hours.
If the mother cannot keep the baby in skin-to-skin contact because of complications:
»» wrap the baby in a clean, dry, warm cloth;
»» place in a cot;
»» cover with a blanket; and
»» encourage another family member to keep the baby in skin-to-skin contact or use `` 21
a radiant warmer if room is < 28 °C.

`` Prepare a very small baby (< 1500 g or a baby born > 2 months early) for referral.
Keep the baby in skin-to-skin contact or in an incubator while waiting for referral
(see Additional care for a small baby, page 60).

NOTE Low-birth-weight (LBW) babies weighing >1200 g who do not have complications should be maintained
in skin-to-skin contact with the mother or other family member immediately after birth, after drying them
thoroughly to prevent neonatal hypothermia.
See Bibliography. Pocket book of hospital care for children: guidelines for the management of common
childhood illnesses.

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3. Newborn care (from 90 minutes to 6 hours)

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3. Newborn care (from 90 minutes to 6 hours)

intervention action
TIME BAND: From 90 minutes to 6 hours

Examine the baby `` After the baby has detached from the breast:
»» wash hands;
»» thoroughly examine the baby;
`` 24 »» put an identification tag around the ankle; and
»» weigh the baby and record.
`` Explain to the mother that you will be examining her baby and checking for birth injuries
and/or malformations, especially those that need additional care or early referral.
`` Check for breathing difficulties including:
»» grunting,
»» chest in-drawing, or
»» fast or slow respiratory rate.

NOTE Normal breathing rate of a newborn is 30–60 breaths per minute.

`` Check the baby’s

»» temperature – normal axillary temperature is of 36.5–37.5 °C;
»» eyes for redness, swelling or pus draining; or
»» umbilical stump for oozing blood.
`` Check for abdominal distention.
`` Look at the head, trunk and all limbs of the baby.
Check for possible birth injuries, including:
»» bumps on one or both sides of the head;
»» bruises, swelling on the buttocks; `` 25
»» abnormal position of legs (after breech extraction);
»» asymmetrical arm movement; or
»» arm that does not move.
If the above birth injuries are present:
»» explain to parents that these are likely to disappear in a week or two, and do not need
special treatment;
»» gently handle the limb that is not moving; and
»» do not force the legs into a different position.

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intervention action
»» 6dohours
TIME BAND: From 90 minutes to not force the legs into a different position.
(continued)

Examine the baby `` Look for signs of fracture, including:

(continued) »» swelling, or baby crying when part is touched.
If suspected fracture, refer.
`` Look for malformations:
»» club foot (talipes);
`` 26 »» odd/unusual appearance;
»» open tissue on head, abdomen or back;
»» no anal opening; or
»» any other abnormalities.
If any of the above malformations are present, refer, and:
»» cover any open tissue with sterile gauze and keep warm, before referral; and
»» pass a nasogastric tube, if the baby has an abdominal malformation or no anal opening.
Keep it open during transport to minimize risk of abdominal distension or bloating.
`` Look at the baby’s skin for cuts or abrasions.
`` Look into the baby’s mouth for cleft palate or lip.
`` Inform the mother of your examination findings. Reassure her as necessary.

If the baby weighs < 1500 g or looks very small, and:

»» is not feeding well; or
»» has any danger signs;
MANAGE urgent conditions as follows:
»» start resuscitation if necessary (see pages 50–51);
»» re-warm and keep warm during referral for additional care;
»» give first dose of IM ampicillin and gentamicin;
»» stop any bleeding; and
»» give oxygen, if available.
`` Refer for special treatment and/or evaluation if available. `` 27

`` Help the mother to breastfeed. If not successful, teach her alternative feeding methods
(see pages 65–69).

Give vitamin K prophylaxis `` Wash hands (see pages 75–77).

Inject hepatitis B and BCG `` Explain to the mother that you will be injecting:
vaccinations »» vitamin K to prevent bleeding and hepatitis B vaccine to prevent her baby from catching
an infection of the liver that can cause cancer later in life; and BCG vaccine to prevent
serious infections due to tuberculosis.

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intervention action
TIME BAND: From 90 minutes``to 6 hours (continued)
Inject hepatitis B and `` Explain to her that there may be soreness at the injection site or other minor side-effects, but
BCG vaccinations at birth that these are uncommon and that the benefits of getting the injections outweigh the risks.
(continued)
`` Inject a single dose of vitamin K (phytomenadione) 1 mg IM.
`` Inject hepatitis B vaccine IM and BCG intradermally, as per national guidelines.
`` Ensure that there is no excessive bleeding before leaving the baby and mother.
`` Wash hands.
`` 28
`` Record the injections.
If the baby has other problems, MANAGE accordingly.
NOTE Babies requiring surgical procedures, those with birth trauma, preterm, and in utero to maternal medication
known to interfere with vitamin K are at high risk of bleeding and must be given vitamin K 1 mg IM.

Dry cord care `` Wash hands (see pages 75–77).

`` Instruct the mother to:
»» keep cord stump loosely covered »» wash stump with clean water and soap,
with clean clothes; only if it is soiled and dry it thoroughly
»» fold diaper below the stump; with a clean cloth;
»» put nothing on the stump; »» seek care if the umbilicus is red or draining pus;

»» treat local umbilical infection 3 times a day; »» dry the area with a clean cloth;
»» wash hands with clean water and soap; »» wash hands; and
»» gently wash off pus and crusts with boiled
and cooled water, and then soap;

refer urgently to the hospital if pus or redness worsens or does not improve in 2 days.

NOTES * Do not bandage the stump or abdomen.

* Avoid touching the stump unnecessarily.
`` 29
Provide additional care If the baby is delivered:
for a small baby (or twin)
`` 2 months early or weighs < 1500 g, refer to specialized hospital;
`` 1–2 months early or weighs 1500 to less than 2500 g (or is visibly small when scale is not
available), see Additional care for a small baby (see page 60).

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, another family member
(grandmother or father) should be instructed on how to do so.
* Do not bathe the small baby. Keep the baby clean by wiping with a damp cloth, but only after 24 hours.
* Measure the baby’s temperature every 6 hours.

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4. Care prior to discharge (but after the first 90 min)

`` 31

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intervention action
TIME BAND: After 90 minutes``of age, but prior to discharge (continued)

Sleeping `` Let the baby sleep on his/her back or side.

`` Keep the baby away from smoke and from people smoking.
`` In malaria settings, ensure mother and baby are sleeping under an impregnated bed net.

Look for danger signs `` Re-examine the baby before discharge.

`` 34 `` Look for danger signs, including:
»» stopped feeding well;
»» convulsions;
»» fast breathing (breathing rate ≥ 60 per minute);
»» severe chest in-drawing;
»» no spontaneous movement;
»» fever/high body temperature (> 37.5 °C);
»» low body temperature (< 35.5 °C).

If any of the above is present, consider possible serious illness.

`` MANAGE urgent conditions, as follows:
»» start resuscitation if necessary (see pages 52–57);
»» re-warm and keep warm during referral for additional care;
»» give first dose of IM ampicillin and gentamicin;
»» stop any bleeding; and
»» give oxygen, if available.

Look for signs of jaundice `` Look at the skin: is it yellow?

»» Observe in good daylight. `` 35
Jaundice will look more severe if observed in artificial light and may be missed in poor light.
»» Refer urgently if jaundice is present:
– on face of a baby < 24 hours old; or
– on palms and soles of a baby at any age.
»» Encourage breastfeeding.
If feeding difficulty is present, give expressed breast milk by cup.

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intervention action
TIME BAND: After 90 minutes``of age, but prior to discharge (continued)

Look for signs Look at the eyes

of local infection:
– eyes `` Are they swollen and draining pus?
– umbilicus If so, consider gonococcal eye infection:
– skin »» give single dose of appropriate antibiotic for eye infection;
– baby’s mouth »» teach mother to treat the eyes;
`` 36 »» follow up in 2 days. If pus or swelling worsens or does not improve, refer urgently; and
»» assess and treat mother and her partner for possible gonorrhoea.

Look at the umbilicus

© WHO

`` What has been applied to the umbilicus?

»» Advise the mother on proper cord care (see pages 28–29).

`` Is there redness, pus draining or hardness of the skin around the umbilicus?
If the redness extends to < 1 cm beyond the umbilicus, treat as a local infection of
the umbilicus. Teach the mother to treat this local infection with gentian violet. If no
improvement in 2 days, or if worse, refer the baby urgently.
If the redness extends to > 1 cm beyond the umbilicus, there is pus draining or hardness,
treat as a severe infection of the umbilicus. Give the first dose of IM ampicillin and
gentamicin. Refer the baby urgently.
If the umbilicus is draining pus, consider possible serious illness. Give the first dose of IM
ampicillin and gentamicin. Refer the baby urgently. `` 37

Look at the skin, especially around the neck, armpits, inguinal area.
`` Are there pustules?
If > 10 pustules or bullae, consider possible serious infection. Refer for evaluation.
If < 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.
`` Is there fluctuant swelling?
»» Consider abscess or cellulitis, and refer for evaluation.

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5. Care from discharge to 6 weeks

`` 41

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5. Care from discharge to 6 weeks

intervention action
TIME BAND: From discharge`to
` 6 weeks

Support unrestricted, `` All babies, whether term or preterm, whether LBW or not, whether in high-, middle- or low-
on demand, exclusive resource settings should be exclusively breastfed from birth until 6 months of life.
breastfeeding (day and
night) `` Counsel all mothers and provide support for exclusive breastfeeding at each postnatal contact.
`` 42
Provide intensive support for exclusive breastfeeding for mothers who deliver by caesarean
section or prematurely.
`` 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 pacifiers.
Ask about stooling and wet diapers.
`` Praise any mother who is breastfeeding and encourage her to continue exclusive breastfeeding.
`` Explain that exclusive breastfeeding is the only food that protects her baby against serious illness.
Define that exclusive breastfeeding means no other food or water except for breast milk.
`` Reassure the mother that she has enough breast milk for her baby’s needs.

`` Advise the mother to:

»» keep the baby in the room with her, on her bed or within easy reach; and
»» exclusively breastfeed on demand, day and night (> 8 times in 24 hours, except in the first
day of life when the baby sleeps a lot).
`` Observe a breastfeed, if possible. Ensure mother knows about good position and good
attachment.
`` Ask the mother to alert you if she has breastfeeding difficulty, pain or fever.
`` Observe, treat and advise if nipple(s) is/are sore or fissured, and the baby is not well attached.
In addition to the above: `` 43
»» reassess after two feeds (within the same day);
»» advise the mother to smear breast milk over the sore nipple(s) after a breastfeed;
»» check the baby’s mouth for thrush and treat baby and mother; and
»» 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;
`` but shiny and the milk is not dripping, mother’s temperature is < 38 °C and the baby is not
well attached, treat and advise for engorgement.

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TIME BAND: From discharge to 6 weeks (continued)

Support unrestricted, »» In addition to the above:

on demand, exclusive – breastfeed more frequently;
breastfeeding, day and – reassess after two feeds (within the same day); and
night (continued) – if not better, teach and help the mother to express enough breast milk to relieve the discomfort.
`` But, if painful, there is patchy redness and mother’s temperature is > 38 °C, treat and advise
for mastitis. In addition to the above:
`` 44
»» give cloxacillin 500 mg every 6 hours for 10 days;
»» give paracetamol, if severe pain;
»» reassess in 2 days; and
»» refer to a hospital, if no improvement or worse.
NOTES * Do not give sugar water, formula or other liquids.
* Do not give bottles or pacifiers.

Ensure warmth for `` Delay bathing until after 24 hours. If this is not possible due to cultural reasons, delay for
the baby at least 6 hours.
`` Explain to the mother that babies need an additional 1–2 layers of clothing for ambient
temperature compared to older children or adults. Bonnets or caps are recommended.

`` Keep the room or part of the room warm, especially in a cold climate.
`` Do not separate the mother and baby. Keep them together in a room, both night and day.
Instruct the mother to:
»» dress or wrap the baby up during the day; and
»» let the baby sleep with her or within easy reach, to facilitate breastfeeding at night.
NOTES * Do not put the baby on any cold or wet surface.
* Do not swaddle/wrap the baby too tightly.
* Do not leave the baby in direct sunlight.
* Ensure additional warmth for the small baby.
`` 45
`` Look for danger signs and refer for further evaluation if the baby has any of the following:
»» stopped feeding well;
»» convulsions;
»» fast breathing (breathing rate ≥ 60 per minute);
»» severe chest in-drawing;
»» no spontaneous movement;
»» fever/high body temperature (> 37.5 °C);
»» low body temperature (< 35.5 °C);
»» any jaundice in first 24 hours of life; or
»» yellow palms and soles at any age.

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` 6 weeks (continued)
TIME BAND: From discharge`to

Ensure warmth for `` REFER the baby urgently to hospital. After emergency treatment:
the baby (continued) »» 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; and
»» inform the referral centre by radio or telephone, if possible.
`` 46 `` Assess all postpartum mothers regularly for:
»» vaginal bleeding, »» temperature,
»» uterine contraction, »» heart (pulse) rate, and
»» fundal height, »» anaemia.
`` At each subsequent postnatal contact, ask about the mother’s general well-being and
symptoms suggestive of complications including:
»» excessive bleeding, »» breathing difficulties,
»» headache, »» foul-smelling discharge,
»» fits, »» painful urination, and
»» fever, »» severe abdominal or perineal pain.
»» feeling very weak,

If the mother has any of these symptoms, refer her to a health facility.
`` Advise all mothers about recovery after giving birth and reporting any health concerns.
`` Ask if breast or nipples are swollen, red or tender. Manage breastfeeding problems if possible.
If not, refer to a health facility for care.
`` At each postnatal visit, counsel on:
»» breastfeeding;
»» hygiene, especially handwashing;
»» use of antibiotics for third- and fourth-degree perineal tears;
»» birth spacing; `` 47
»» nutrition;
»» safe sex, including use of condoms;
»» early walking, gentle exercise and rest; and
»» iron supplementation.

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6. Additional care

`` 49

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Algorithm 3: Newborn resuscitation

birth
Immediate newborn care
* Immediate and thorough drying with quick check of breathing
* Skin-to-skin contact covered with blanket and bonnet

RESUSCITATION
* Call for help and explain gently to mother
YES * Clamp/cut the cord using sterile scissors and gloves
30 seconds Is baby gasping or not breathing? * Transfer the baby to the newborn resuscitation area
`` 50
* Position head/neck
* Only suction if the mouth/nose are blocked or prior to bag/mask
ventilation of a non-vigorous meconium stained baby
NO
1 minute * Start bag/mask ventilation with air
Maintain skin-to-skin contact with mother then At any time if baby starts
and monitor baby and the mother breathing or crying and
has no severe chest in
drawing, stop ventilation
and observe to ensure
Go to clinical algorithm 2: that the baby continues to
“Essential newborn care” breath well

then
Check breathing and heart rate every
1 or 2 minutes of effective ventilation

Periodic intervals Are any of the following present:

NO NO – heart rate < 100? YES
POST-RESUSCITATION CARE Is heart rate < 60?
– gasping or not breathing?
* Stop ventilation – severe chest in-drawing?

* Return baby to mother’s chest

* Do routine care
(see “Immediate newborn care”)
NO YES
* Record the event
* Monitor baby for breathing * Take ventilation corrective steps and * Take ventilation corrective steps
difficulties, signs of asphyxia continue ventilation and continue ventilation
* Monitor mother for bleeding, * Ensure proper seal and effective chest `` 51
breathing and blood pressure
* Where feasible, consider:
rise for effective ventilation
problems
– supplemental oxygen
then – chest compressions
then – other ventilatory support
– medications referral/transport

* Stop bag/mask ventilation

After effective ventilation, * Explain gently to the mother that
are any of the following present: the baby is dead
YES
– no heart rate after 10 minutes? * If the baby still has a heart rate,
– no breathing and heart rate < 60 provide comfort care
after 20 minutes? * Provide psychosocial support
NO * Record the event

Essential care for all

Decision points
Conditions needing urgent care
Advanced resuscitation

YES NO then
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intervention action
A. Newborn resuscitation
If baby is gasping or not breathing after thorough drying and stimulation (for as close as possible to 30 seconds):
`` Call for help and explain gently to the mother that her baby needs help to breathe.
`` Clamp and cut the cord immediately to allow effective ventilation to be performed.
`` Transfer the baby to the resuscitation area (a dry, clean and warm surface).
`` Keep the baby wrapped or under a heat source, if available.
`` 52 `` Consider immediate referral at any point, where feasible.

Open airway `` Position the head so it is slightly extended.

Clear the airway only
if it is blocked `` Only if the mouth/nose are blocked, introduce the suction/tube:
»» first, into the baby’s 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 seconds; and
»» do tracheal suctioning, where feasible.
NOTE DO NOT do routine suctioning of the mouth and nose of babies with:
–– clear amniotic fluid if they are breathing on their own;
–– clear amniotic fluid prior to positive pressure ventilation if mouth and nose are free of secretions;
–– meconium staining if they have started breathing on their own, meaning that they are vigorous.

Ventilate, if still `` Start bag/mask ventilation within one minute after birth:
not breathing »» for babies < 32 weeks, it is preferable to start with 30% oxygen, where feasible.
`` Place mask to cover chin, mouth and nose to achieve a seal.
NOTE DO not cover the eyes.
`` Squeeze bag attached to the mask with two fingers or whole hand, according to bag size,
2–3 times. Observe rise of chest.
If chest is not rising:
»» first, reposition the baby’s head. `` 53
If 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 baby starts crying or breathing.

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A. Newborn resuscitation (continued)
Neonatal self-inflating
resuscitation bag with
round mask

`` 54
Fitting mask over face RIGHT WRONG WRONG WRONG

right size and right mask held too low mask too small mask too large © WHO
position of the mask

Ventilating a neonate Lift the chin with the third

with bag and mask finger of the hand holding
the mask.
Do not hyperextend the neck.

© WHO
`` 55
Inadequate seal If you hear air escaping from
the mask, form a better seal.
The most common leak is
between the nose and the
cheeks.

© WHO

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A. Newborn resuscitation (continued)
Ventilate, if still not `` Check breathing; and check heart rate every 1–2 minutes of ventilation.
breathing (continued) »» Assess chest rise.
»» Assess heart rate:
– if heart rate is < 100 per minute, take ventilation corrective steps (see below); or
– if heart rate is < 60 per minute, where feasible give supplemental oxygen, chest
compressions, other ventilatory support and medications.

`` 56 If baby fails to improve, follow ventilation corrective steps (see below).

Ventilation corrective steps
1. Check position of head
2. Check for adequate mask seal
3. Check for blocked airway
4. Check resuscitator bag

`` At any time, if the baby starts breathing or crying and has no chest in-drawing, stop
ventilating. Observe to ensure that the baby continues to breathe well. Then:
»» return the baby to the mother’s chest on skin-to-skin contact;
»» exclude a second baby, give oxytocin (if not already given);
»» wash hands, re-glove and trim the cord, as needed.

If the baby is gasping or not breathing, or has severe chest in-drawing:

»» continue bag/mask ventilation;
»» continue assessing at regular intervals while transporting; and
»» where feasible, consider supplemental oxygen, chest compressions, other ventilatory
support and medications.
If after 10 minutes of effective ventilation, the heart rate remains zero:
»» STOP bag/mask ventilation;
»» explain to the mother in a kind and gentle tone that the baby is dead;
»» give supportive care; and
»» record the event. `` 57
If after 20 minutes of effective ventilation, the baby does not start to breathe or gasp
and heart rate is < 60 per minute:
»» STOP bag/mask ventilation;
»» explain to the mother in a kind and gentle tone that despite all attempts you were unable
to help her baby to breathe;
»» provide comfort care, including warmth and psychosocial support; and
»» record the event.

NOTES * While ventilating, refer and explain to the mother what is happening, what you are doing, and why.
* Ventilate, if needed, during transport.
* Record the event on the referral form and labour record.

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Algorithm 4: Optimal feeding of the clinically stable

baby weighing < 2500 g
Maintain the baby in skin-to-skin contact after birth with head and back covered

Does the baby weigh < 1500 g?

NO YES
`` 58
* Maintain skin-to-skin contact in kangaroo care position * Start enteral feeds with colostrum at 10 ml/kg/day plus IV fluids to
* Watch for feeding cues and encourage mother to nudge meet the daily fluid requirement
her baby to the breast * Feed via oro- or naso-gastric bolus feeds, then cup or spoon feeding
* Encourage the mother to breastfeed every 2 or 3 hours * Increase by up to 30 ml/kg per day with careful monitoring for
* Assess breastfeeding daily: positioning attachment, feeding intolerance
suckling, duration and frequency of feeds, and baby * Consider kangaroo mother care once no danger signs noted in
satisfaction with the feed mother and baby
* At 6–8 weeks, start iron supplementation * Weigh daily
* Once full feeds tolerated, start vitamin D, calcium, phosphorus
supplements
* At 2 weeks age start iron supplements

Is mother having difficulty

with breastfeeding supply?
NO YES

NO * Give donor human milk

* Continue or resume direct exclusive
* Provide intensive breastfeeding support
breastfeeeding
* Continue kangaroo mother care

Is baby failing to gain weight?

`` 59

YES

REFER

NOTE – Breast-milk substitutes should only be resorted to after all efforts have been exerted to provide mother’s own milk or donor human milk.
Breast-milk substitutes increase the risk for necrotizing enterocolitis, pneumonia, diarrhea, meningitis and death.

Essential care for all

Decision points
Conditions needing urgent care

YES NO then
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intervention action
B. Care for a small baby (or twin)

If baby is preterm, 1–2 months early or weighs 1500–2500 g (or is visibly small when scale is not available)
Warmth `` Ensure additional warmth for a small baby by:
»» maintaining the room at 25–28 °C, and draft-free;
»» teaching the mother how to keep the small baby warm in skin-to-skin contact via
kangaroo mother care (KMC) (see pages 62–64); and
»» providing extra blankets for the mother and baby plus bonnet, mittens and socks for the baby.
`` 60
NOTE Do not bathe a small baby. Keep the baby clean by wiping with a damp cloth, but only after 24 hours.

Feeding support `` LBW babies, including those with very low-birth-weight (VLBW), should be fed with the
mother’s own milk.
NOTE – Refer to the Pocket book `` Start VLBW babies on expressed breast milk at 10 ml/kg per day via enteral feeds (either cup
for hospital care for children or spoon feeding) or naso- or oro-gastric tube feeds (bolus feeding) starting from the first
(see Bibliography). hours of life, with the remaining fluid requirement met by intravenous fluids:
»» increase feed volumes by up to 30 ml/kg per day with careful monitoring for feeding intolerance;
»» if mother’s own milk supply is not increasing fast enough for the above, give donor human
milk to the baby and provide intensive support to increase mother’s milk supply.

`` VLBW babies being fed breast milk should be given the following supplements:
»» vitamin D (400–1000 IU per day) until 6 months of age;
»» daily calcium (120–140 mg/kg per day) and phosphorus (60–90 mg/kg per day)
during the first months of life; and
»» iron (2–4 mg/kg per day) starting at 2 weeks until 6 months of age.
NOTE – Refer to the Guidelines * The following supplements are NOT recommended at the current time:
on optimal feeding of low- –– Bovine milk-based human milk fortifier. VLBW babies who fail to gain weight despite adequate breast-
birth-weight infants in low- milk feeding should be given human milk-based fortifiers.
and middle-income countries. –– Daily oral vitamin A supplementation for LBW babies who are fed mother’s own milk or donor human milk.
–– Routine zinc supplementation for LBW babies who are fed mother’s own milk or donor human milk. `` 61
`` Give special support for breastfeeding by:
»» encouraging the mother to breastfeed every 2–3 hours; and
»» assessing breastfeeding daily, including positioning, attachment, suckling, duration and
frequency of feeds, and baby satisfaction with the feed.
`` Weigh the baby daily, and record.
`` When mother and baby are separated, or if the baby is not suckling effectively, use
alternative feeding methods (cup or spoon), and feed these LBW babies based on baby’s
hunger cues, but at no longer than 3-hour intervals.
Refer to Dealing with feeding problems (see pages 65–69).

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B. Care for a small baby (or twin) (continued)

Skin-to-skin care `` Start kangaroo mother care (KMC) when:

(in kangaroo position) »» the baby is able to breathe on its own (no apnoeic episodes); and
»» the baby is free of life-threatening conditions.
`` The management of life-threatening conditions takes first priority over KMC, although
skin-to-skin contact is still beneficial until KMC is possible.
NOTES * The ability to coordinate sucking and swallowing is NOT an essential requirement for KMC. Other methods of
`` 62 feeding, e.g. feeding by naso- or oro-gastric tube or later by cup, can be used until the baby can breastfeed.
* KMC can begin after birth, after initial assessment and where needed basic resuscitation, provided the baby
and mother are stable.
* LBW babies weighing < 2000 g who are clinically stable should be provided KMC immediately. Experience
shows that babies weighing ≥ 1800 g can usually start KMC at birth.

If KMC is not possible, wrap the baby in a clean, dry, warm cloth and place in a crib. Cover with
a blanket. Use a radiant warmer if the room is not warm or the baby is small.
`` Explain KMC to the mother, including:
»» continuous skin-to-skin contact; »» caring for her baby;
»» positioning her baby; »» continuing her daily activities; and
»» attaching her baby for breastfeeding; »» preparing a ”support binder”.
»» expressing her milk;

`` Position the baby for KMC, as follows:

»» place the baby in upright position between the mother’s breasts, chest-to-chest;
»» position the baby’s hips in a ”frog-leg” position with the arms also flexed;
»» the baby’s abdomen should be somewhere at the level of the mother’s stomach, but
should not be constricted. The mother’s breathing helps stimulate the baby to breathe;
»» secure the baby in this position with the support binder;
»» turn the baby’s head to one side, slightly extended to keep the airway open and allow eye
contact with the mother; and
»» tie the cloth binder firmly with the top of the binder just beneath the baby’s ear.
`` 63

© WHO

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B. Care for a small baby (or twin) (continued)
NOTES * KMC should last for as long as possible each day. If the mother needs to interrupt KMC for a short period,
the father or immediate family member should take over.
* Once the baby is positioned correctly, during the daytime the mother can carry out her usual activities and
movements. She should wash her hands frequently, feed her baby regularly (every 2–3 hours throughout the
day and night), and avoid loud noises and exposure to tobacco smoke.
* When the mother needs to rest or sleep, a reclined or semi-sitting position is best. Use pillows or cushions to
prop the mother up.
* If the surrounding temperature is 22–24 °C, then the baby should be naked inside the “pouch” except for a
`` 64 diaper, warm hat and socks.
* If the temperature is below 22 °C, in addition to the above, put a sleeveless cotton shirt on the baby. Keep
the shirt open at the front to allow the baby’s face, chest, abdomen and arms and legs to remain in skin-to-
skin contact with the mother’s chest. Advise the mother to then cover herself and her baby with her usual
clothes.
* KMC can be used for babies until they are about 2500 g or 40 weeks post-conceptual age, meaning the date
that they were expected to have been born, or until the mother so desires.

Discharge planning `` Plan to discharge when:

»» baby is breastfeeding well and gaining at least 15 grams per kg body weight per day;
»» baby’s body temperature is between 36.5–37.5 °C for 3 consecutive days; and
»» mother is able and confident in caring for her baby.

C. Dealing with feeding problems

`` When the mother and baby are separated, or if the baby is not suckling effectively:
use alternative feeding methods.
`` Teach the mother hand expression of milk.
`` Do not do it for her. Teach her to:
»» wash her hands thoroughly;
»» sit or stand comfortably and hold a clean container below her breasts;
»» press slightly inward towards the breast between her finger and thumb;
»» express one side until milk flow slows, then express the other side; and `` 65
»» continue alternating sides for at least 20–30 minutes.
If milk does not flow well:
»» apply warm compress; and
»» have someone massage her back and neck before expressing.

Feed the baby with the mother’s own milk whenever possible by one of three methods, as follows:
1. expressing milk directly »» Hold the baby in skin-to-skin contact, the mouth close to the nipple.
into the baby’s mouth »» Express the breast until some drops of breast milk appear on the nipple.
»» Wait until the baby is alert and opens mouth and eyes, or stimulate the baby lightly
to awaken her/him.

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C. Dealing with feeding problems (continued)

»» Let the baby smell and lick the nipple.

»» Let some breast milk fall into the baby’s mouth.
»» Wait until the baby swallows before expressing more drops of breast milk.
»» When the baby has had enough, she/he will close her/his mouth and take no more breast milk.
»» Repeat this process every 1–2 hours if the baby is very small (> 2 months early or <1500 g),
or every 2–3 hours if the baby is not very small.
»» Be flexible at each feed, but make sure the intake is adequate by checking daily weight.
`` 66

2. expressing milk by hand »» Place finger and »» Press behind

thumb on each the nipple and
side of the areola areola between
and press inwards your finger and
towards the chest thumb.
wall.

© WHO

3. cup feeding, if indicated »» Do not feed the baby yourself.

»» Teach the mother to feed the baby with a cup.
»» Measure the quantity of milk in the cup.
»» Hold the baby sitting semi-upright on her lap.
»» Hold the cup of milk to the baby’s lips.
»» Rest cup lightly on lower lip.
»» Touch the edge of cup to outer part of upper lip.
»» Tip cup so that milk just reaches the baby’s lips.
»» Do not pour the milk into baby’s mouth.
»» Baby becomes alert, opens mouth and eyes and starts to feed. `` 67
»» Baby will suck the milk, spilling some.
»» Small babies will start to take milk into their mouth using the tongue;
»» Baby swallows milk.
»» Baby is finished feeding when mouth closes or when not interested in taking more.
»» If baby does not take the calculated amount:
© WHO – feed more often; and
– teach the mother to measure the baby’s intake over 24 hours, not just at each feed.
»» Baby is cup-feeding well if required amount of milk is swallowed, spilling little, and weight
gain is maintained.

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C. Dealing with feeding problems (continued)

If the mother does not express enough milk in the first few days or if the mother cannot breastfeed
at all, use one of the following feeding options:
»» donor heat-treated human milk;
»» donated raw milk (in circumstances where benefit of providing raw donor milk outweighs
small risk of HIV transmission); or
»» artificial formula (as a last resort).
`` 68 `` LBW babies, including those with VLBW, who cannot be fed mother’s own milk:
»» should be fed donor human milk (where safe and affordable milk-banking facilities are
available or can be set up).
`` Artificial formula should only be resorted to after all efforts have been exerted to provide
mother’s own milk or human milk from donors. The use of powdered milk substitutes
increases the risk for necrotizing enterocolitis, pneumonia, diarrhoea, meningitis and death.
`` LBW babies, including those with VLBW, who cannot be fed mother’s milk should be fed
standard infant formula. If VLBW babies on standard formula fail to gain weight despite
adequate feeding, they should be given preterm infant formula.

`` When these methods are used:

»» determine appropriate amount for daily feeds by age;
»» assess the total daily amount of breast milk given; and
»» plan to keep a small baby longer before discharging.
`` Refer for breastfeeding counselling and further investigation if:
»» feeding difficulty persists for 3 days; or
»» there is weight loss of > 10% of birth weight.
`` Assess and plan to discharge when:
»» baby is breastfeeding well and gaining weight adequately for 3 consecutive days; `` 69
»» baby’s body temperature is between 36.5–37.5 °C for 3 consecutive days; and
»» mother is able and confident in caring for her baby.

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7. Setting up the environment for good neonatal care

`` 71

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7. Setting up the environment for good neonatal care

intervention action
A. preparing for shifts

Prepare workplace `` The incoming and outgoing teams together should perform the following actions:
for deliveries »» complete the equipment and supplies maintenance checklist to ensure all equipment
is disinfected and functioning, and that supplies and drugs are maintained in the right
quantity (see Equipment and supplies maintenance checklist on pages 84–88);
`` 72 »» establish staffing lists and schedules;
»» maintain and appropriately file all clinical records, certificates, referrals and all other
documentation; and
»» ensure that there are no violations of the International Code of Marketing of Breast-milk
Substitutes or national codes and other legislation pertaining to infant feeding.
B. after every delivery

Restock delivery area `` Replace and process used delivery instruments (see page 86).
`` Replace used linen.
`` Update essential information in the logbook. Document findings, treatments, referrals,
and follow-up plans on clinical and home-based records.

C. standard precautions
General standard `` Consider every person potentially infectious (even the baby and medical staff).
precautions and cleanliness Practice the routine procedures that protect both health workers and patients from
contact with infectious materials.

»» Wash hands before and after caring for a woman or baby, before any treatment procedure
including injection sessions or cord cutting (see pages 75–77), and after handling waste or
potentially contaminated materials.
»» Wear fresh sterile gloves when performing delivery, cord cutting or blood drawing.
`` 73
»» Wear non-sterile, well-fitting latex or latex-free gloves when coming into contact with
blood or blood products.
»» Wear sterile gloves when handling and cleaning instruments, handling contaminated
waste, cleaning blood and body fluid spills.
»» During deliveries: wear gloves, cover any cuts, abrasions or broken skin with a waterproof
bandage, wear a long apron made from plastic or other fluid-resistant material and shoes,
and protect your eyes from splashes and blood.
»» Gloves DO NOT provide protection against needle-stick or other puncture wounds caused
by sharp objects. Needles, scalpels and other sharps should be handled with extreme caution.

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intervention action
C. standard precautions (continued)

General standard `` When undertaking injections, gloves are not needed:

precautions and cleanliness – for routine intradermal, subcutaneous and intramuscular injections;
(continued) – if the health worker’s skin is intact; and
– if the patient’s skin is intact.
»» Safely dispose sharps in a puncture-resistant container kept near the bed.
»» Never reuse, recap or break needles after use.
`` 74
»» Discard a multidose vial as per WHO or manufacturer’s recommendation.
»» Dispose of bloody or contaminated items in leak-proof containers.
»» Pour liquid waste down a drain or flushable toilet.
»» Collect and keep clothing or sheets stained with blood or body fluids separate from other
laundry.
»» Make sure that instruments that penetrate the skin are adequately sterilized and that
single-use instruments are disposed of after one use.
»» Thoroughly clean or disinfect any equipment which comes into contact with intact skin.
»» Use bleach for cleaning bowls, buckets, bloody or body fluid spills.

Hand hygiene `` Handwashing

»» Remove all hand jewelry and/or watches.
»» Wet hands with running water or alcohol handrub/hand sanitizer. When clean running
water is not available, use either basin/bucket of water and pitcher/dipper (ask another
person to pour the clean water for handwashing).
»» Apply plain or antimicrobial soap or alcohol handrub/hand sanitizer to hands;
»» Rub all surfaces using five strokes each, as follows:
– rub hands palm to palm;
– rub right palm over left dorsum with interlaced fingers and vice versa;
`` 75
– rub palm to palm with fingers interlaced;
– rub back of fingers to opposing palms with fingers interlocked;
– rub left thumb clasped in right palm rotationally and vice versa; and
– rub rotational, backwards and forwards with clasped fingers of right hand in left palm
and vice versa.
If using running or poured water.
– rinse with a stream of water;
NOTE on cell phones – dry hands thoroughly with a single-use towel;
They can be heavily contaminated – turn off the faucet using the towel.
with disease-causing microbes »» With soap, perform the whole procedure over 40–60 seconds (see pages 76–77),
and should not be used during
patient care.
or steps 0 to 7 over 20–30 seconds if using alcohol handrub/hand sanitizer.

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Hand hygiene technique with soap

Duration of the entire procedure: 40–60 seconds

`` 76
`` Wet hands with water `` Apply enough soap to cover all `` Rub hands palm to palm
hand surfaces

`` Right palm over left dorsum with `` Palm to palm with fingers interlaced `` Backs of fingers to opposing palms
interlaced fingers and vice versa with fingers interlocked

`` Rotational rubbing of left thumb `` Rotational rubbing, backwards `` Rinse hands with water
clasped in right palm and vice versa and forwards with clasped
fingers of right hand in left palm
and vice versa
`` 77

`` Dry hands thoroughly with a single `` Use towel to turn off faucet `` Your hands are now safe
use towel

© WHO

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intervention action
C. standard precautions (continued)
Processing instruments Step 1. Decontamination
and other items »» Put items in a plastic container of 0.5% chlorine solution immediately after use.
»» Cover items completely with chlorine solution and soak for 10 minutes.
»» Remove items from chlorine solution (with utility gloves on).
»» Rinse items with water. Set aside until you are ready to clean them.
`` 78 »» Change chlorine solution:
– at the beginning of each day; or
– whenever the solution is very contaminated or cloudy.

Using liquid household bleach

You can use any household bleach to make a 0.5% chlorine solution by using the following formula:
[% chlorine in the liquid bleach divided by 0.5%] minus [1] = parts of water for each part bleach

`` Example: to make a 0.5% chlorine solution from a 5% chlorine concentrate, calculate as

follows: [5% divided by 0.5%] minus [1] = [10] minus [1] =  9
Mix 1 part liquid bleach with 9 parts water to get a 0.5% chlorine solution.

Processing instruments `` Step 2. Cleaning

and other items »» Wear utility gloves, a mask, and protective eyewear when cleaning.
(continued)
»» Use a soft brush or old toothbrush, soap, and water to scrub items.
»» Rinse all items well with clean water to remove all soap.
NOTE Use household cleaning soap (bar or liquid), rather than bath soap. If you use bar soap, keep it in a dish
with holes for drainage.

`` Step 3. High-level disinfection (HLD) by boiling

`` 79
»» Put all instruments and other items into a pot, open up scissors and other instruments
with joints. Place forceps or pickups on top of all other items.
»» Cover all items completely with water. When water comes to a boil, cover pot and boil
for 20 MINUTES.
»» Remove items from pot with HLD forceps or pickups and put in a HLD container.
»» Air-dry boiled items before use or storage. Do not leave boiled items sitting in water that
has stopped boiling.
NOTE HLD kills all germs except some endospores (difficult-to-kill bacteria, such as tetanus or gas gangrene).
If sterilization is not available, HLD (by boiling or steaming) is the only other acceptable choice.

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intervention action
C. standard precautions (continued)

Processing instruments `` Step 4. HLD by steaming

and other items »» Put water into the bottom of a steamer pot.
(continued)
»» Put all items onto a steamer tray. Open up scissors and other instruments with joints.
Place forceps or pickups on top of all other equipment in the pot.
»» Bring the water to a boil, then when the water starts to boil, cover the pot and boil for
20 MINUTES.
`` 80 »» Remove items from the pot with HLD forceps or pickups and put in a HLD container.
»» Air-dry items, then use or store items in a covered, HLD container.
NOTE Steaming causes less damage to gloves and other plastic or rubber items, uses less water and fuel, and does
not cause build-up of lime salts on metal items.

`` Step 5. Sterilization by steaming (autoclave)

»» Dry all cleaned items to be sterilized. Open all jointed instruments, e.g. scissors, so steam
can reach all surfaces of item.
»» If wrapping items for autoclaving, use two layers of paper, newsprint, or cotton.

Processing instruments »» Leave space between items so that steam can move about freely. Follow manufacturer’s
and other items instructions whenever possible. In general, sterilize at 121 °C (250 °F) and 106 kPa (15 lb/in2)
(continued) pressure. Do not begin timing until autoclave reaches required temperature and pressure:
wrapped items take 30 minutes; unwrapped items 20 minutes.
»» At end of cycle: if autoclave is automatic, heat will shut off and pressure will begin to fall.
If autoclave is not automatic, turn off heat or remove autoclave from heat source.
»» Wait until pressure gauge reaches “zero.” Open autoclave lid/door so that remaining
steam escapes.
»» Leave instrument packs or items in autoclave until completely dry. Damp packs draw
microorganisms from the environment and should be considered contaminated. `` 81
»» Remove items from autoclave when dry.
»» Use or store autoclaved equipment immediately.
NOTE Sterilization kills all germs, including endospores. Any item that will come into contact with the bloodstream or
tissues under the skin should be sterilized using steam (autoclaving) or dry heat. Steam sterilization uses moist
heat under pressure, so both water and heat are needed. The autoclave machine must have a pressure gauge.

`` Step 6. Store or use

After processing, HLD or sterilized items should be used immediately or stored properly to prevent
contamination. Proper storage is as important as decontamination, cleaning, sterilization, or HLD.

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8. Equipment and supplies maintenance checklist

`` 83

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8. Equipment and supplies maintenance checklist

area of concern action

Warm and clean room `` Light source

`` Heat source
`` Room thermometer
`` Clean bed linen
`` 84 `` Curtains if more than one bed, or impregnated bed net in malaria areas
`` Work surface for resuscitation of newborn near delivery beds
`` Clean surface (for alternative delivery position)
`` Detergent for cleaning walls, windows, floors (if no body fluids present)

Handwashing `` Clean water supply

`` Bar soap in small pieces
`` Nail brush or stick
`` Clean towels
`` Alcohol handrub

Waste `` Container for sharps disposal

`` Receptacle for soiled linens
`` Bucket for soiled pads and swabs
`` Bowl and plastic bag for placenta

Sterilization `` Instrument sterilizer

`` Jar for forceps

Supplies `` Gloves:
»» utility or heavy-duty, sterile or highly disinfected `` 85
»» long sterile, for removal of placenta
»» single-use, for examination
»» surgical, sterile for procedures
`` Long plastic apron
`` Urinary catheter
`` Disposable syringes with needles
`` IV tubing
`` Suture material for tear or episiotomy repair
`` Antiseptic solution (iodophors or chlorhexidine)
`` 70% isopropyl alcohol

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Supplies (continued) `` Swabs
`` Bleach (chlorine-based compound)

Miscellaneous `` Oxygen source

`` Wall clock
`` Flashlight with extra batteries
`` Log book

`` 86 Equipment for the mother `` 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 `` Sponge forceps
`` Needle holder `` Vaginal speculum
`` Artery forceps and clamp `` Clean (plastic) sheet to place under mother
`` Dissecting forceps `` Sanitary pads

Drugs
`` Oxytocin `` Isoniazid
`` Oxygen `` Rapid plasma reagin testing kit
`` Methylergonovine maleate `` HIV testing
`` Magnesium sulfate `` Haemoglobin testing kit
`` Calcium gluconate `` Contraceptives
`` Dexamethasone or betamethasone `` Nevirapine (adult, infant)
`` Diazepam `` Zidovudine (AZT) (adult, infant)
`` Hydralazine `` Lamivudine (3TC) `` 87
`` Ampicillin
Forms and records
`` Gentamicin
`` Birth certificates
`` Metronidazole
`` Health insurance forms
`` Benzathine penicillin
`` Death certificates
`` Lignocaine
`` Referral forms
`` Epinephrine
`` Ringer’s lactate For “comprehensive emergency obstetric
`` Dextrose 10% and newborn care”, the above, plus:
`` Normal saline `` Equipment for caesarean section
`` Sterile water for injection `` Blood supply and needs for blood transfusion

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Equipment for the newborn `` Fetal stethoscope `` Suction tube with mucus trap
`` Clean towels for drying and covering `` Feeding tubes (Fr 5 and 8)
the baby `` Cord ties (sterile) or clamps and forceps
`` Neonatal self-inflating bag and masks `` Blankets
(sizes 1 for term and 0 for preterm) `` Bonnets, mittens and socks

Drugs and vaccines Supplies

`` 88 `` Eye antimicrobial (erythromycin or tetracycline `` 1 cc syringes
ointment or 2.5% povidone-iodine) `` 3 cc syringes
`` Vitamin K (phytomenadione) `` Digital thermometers
`` BCG vaccine `` Baby-weighing scale
`` Hepatitis B vaccine `` Feeding cups
`` Ampicillin `` Support binders for KMC
`` Gentamicin `` Newborn screen filter cards (per national
`` Penicillin G guidelines)
`` Plain Ringer’s lactate or normal saline `` Lancets
`` Dextrose 10%
`` Sterile water for injection

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 9. Index
Airway 52 Betamethasone 87 Breastfeeding problems 43–44,47
Algorithms Birth 12 engorgement 43
1. Preparing for birth 2 defects 26 fever or pain 43
2. Essential newborn care 12 injuries 24–25 mastitis 44
3. Resuscitation 50 preparations 4 sored or fissured nipples 43
4. Optimal feeding of clinically stable baby 58 swollen nipples 47
Bleeding 46
Antibiotics 27,44 See also Complications Breastfeeding support 18
use in preterm labour 6 infant’s mouth 19
Blood pressure 4–6 suckling 20
`` 90 Amniotic fluid 5,52 Breast Breast milk collection 66
Ampicillin 25,35,37 engorged 20,43
Breathing 52,57
Antiretroviral therapy (ART) 7 Breastfeed 27,38–39,44,61–62,68 chest in-drawing 16,24,34,38,45,56–57
See also HIV test Breastfeeding  18–19,32,35,39,42–47, normal rate 24
Autoclave 80 61–62,64,69
Breech 10,25
See also Processing instruments alternative methods 65–69
attachment 18–19,43 Caesarean section 7,42
Bag/mask ventilation 53–54
indication to stop 57 colostrum 20 Care
procedures 53–55 feeding cues 17,20 additional 21,29,60
See also Resuscitation HIV-positive mother 7,20 cord 28–29
on demand 32,43–44 Essential newborn (Algorithm) 12
Bathing 33,44 positioning 8–19 eye 20
BCG vaccination 27–28 Breastfeeding exclusive 32,42–44 kangaroo mother 62–64
skin-to-skin 62

See also Cord care Danger signs 34,45 Engorgement

See also Neonatal care after discharge 34 See Breastfeeding problem
See also Perineal care convulsions 34 Epinephrine 87
Cervical dilatation 5,8 fast breathing 34
fever/high body temperature 34 Episiotomy 10
Cleft palate 26 low body temperature 34 contra indications 10
See also Malformation no spontaneous movement 34 Equipment and supplies checklist 84–88
Cloxacillin 44 severe chest in drawing 34 Eyes 36
Club foot 26 stopped feeding well 34,38,45 Eye care 20
See also Malformation Decontamination 16,78,81 Expressing milk by hand
Colostrum 46 See also Delivery area See Breast milk collection
See Breastfeeding Delivery area 9 `` 91
Family planning 39
Companion of choice 4,8–9 draft free 9
Feeding 17,58,61
preparations 9–10,72
Complications 46 licking 17
room temperature 9
Contractions  7 opening of the mouth 17
Delivery instruments 86 rooting 17
constant pain  7
continuous 7 Delivery kit 9 tonguing 17
Convulsion Discharge 32–38,64 Feeding problems 65–69
See Danger signs counselling 32,42 Fetal heart rate (FHR) 4
planning 62
Cord Forms and records 87
re-examine the baby 34–36
clamping and cutting  17 Forceps 8,79,80,85–86
room 32–33
Cord care 28–29 time 32–33 See also Equipment and supplies
contra indications 28–29 Disposal of sharps 74 Fracture 26
Cup feeding 67 Drugs 87 See also Birth injuries
See also Feeding and Breastfeeding
Dystocia 10