IAP Neonatology Chapter

OFFICE BEARERS 2013-14

Chairperson: Dr Ranjan Kumar Pejaver

Hon. Secretary: Dr Rhishikesh Thakre, Treasurer: Dr Sanjay Wazir

Joint Secretary: Dr Naveen Bajaj, Imm Past Chairperson: Dr Anjali Kulkarni

Executive Members

East Zone: Dr Arjit Mohapatra, Dr Reeta Bora, West Zone: Dr Umesh Vaidya, Dr Nandkishore S
Kabra, North Zone: Dr Ashish Jain, Dr Jaikrishan Mittal, Central Zone: Dr Srinivas Murki, Dr
Deepak Agrawal, South Zone: Dr Naveen Jain, Dr Arun Desai

Indian Academy of Pediatrics

Office Bearers 2014

President: Dr Vijay Yewale

President Elect, 2014: Dr SS Kamath, Vice President: Dr Neeli Ramchander

Imm. Past President: Dr CP Bansal, Secretary General: Dr Pravin J. Mehta

Treasurer: Dr Bakul J.Parekh, Editor in Chief, IP: Dr Dheeraj Shah,

Editor in Chief, IJPP: Dr P Ramchandran, Joint Secretary: Dr AS Vasudev

 Manual of Newborn Nursing
From the desk of Executive Editors

Dr Ranjan Kumar Pejaver Dr Rhishikesh Thakre

FRCP,FRCPCH(UK),FIAP,FNNF DM (Neo), MD, DNB, DCH, FCPS

Nurses are the first point of contact for the parents, patient ie the newborn and the
treating clinician. Working hard with humbleness, they continue to function as a valued member
of comprehensive team of health care providers.

There is a felt need to provide a rapid reference guide, with clear , concise, practical, up
to date and evidence based information about care of the newborn in simple and easy to
understand language with focus on essential newborn nursing skills. An attempt is made here to
meet this requirement through this Manual. Divided into theme based sections, several topics of
practical relevance are being covered under the headings – Fundamentals of Newborn Care,
Essential nursing skills, Nursing Care of the newborn, Assisting Procedures, Nursing Checklist
and Common Neonatal Disorders.

A thorough knowledge of normal newborn characteristics enables the competent nurse to

quickly identify deviations from norm and/ or potential complications. We are confident that this
Manual will be a step in this direction.

With contributions from several national medical experts in Neonatology & Nursing staff
members ,we hope this Manual will bridge the gap between knowledge and practice in the art
and science of newborn nursing.

Our heart felt appreciation and thanks to the managing editors and the contributors ,
whose hard work has made this Manual a reality.
 Manual of Newborn Nursing
From the desk of Managing Editors

Dr Ashish Jain Dr Naveen Bajaj Dr Nandkishor Kabra

MD, DNB (Ped), DM (Neo) MD, DM (Neo) MD, DM (Neo), MSc

It gives us immense pleasure to present this "Manual of Newborn Nursing” as a

simplified book for the benefit of nursing staff working in neonatal intensive care units across
India.

Nursing staff form the backbone of neonatal care throughout the world. Of all the
caregivers in the NICU, nurses usually spend the most time at a baby's bedside caring for the
baby and the family. In India the neonatal mortality rate continues to remain unacceptably high.
If we wish to improve this dismal statistics, we need look after our newborn babies well. We
need to train our nurses for care of the newborn better than before. This manual attempts to
empower nurses with knowledge to care for the sick newborn. This manual has covered all
aspects of essential neonatal nursing such as: fundamentals of newborn care, essential nursing
skills, nursing care of newborn, nursing protocols and checklists, assisting procedures and
common newborn disorders.

We wish to express our heartfelt thanks to Dr Ranjan Kumar Pejavar, Chairperson and Dr
Rhishikesh Thakre, Secretary of IAP Neonatology Chapter for their whole hearted support. We
will also like to thank our entire editorial team which has worked hard to finish the assignment in
timely fashion.

We are extremely grateful to all the respected authors and reviewers who have taken time
out of busy schedule and contributed to this manual. This would not have been possible without
their help.

Finally, we sincerely hope that the nursing staff look after the sick newborn babies
will immensely benefit by reading this manual.

………………………
 MANUAL OF NEWBORN NURSING
CONTENTS

SECTION 1:
Fundamentals of Newborn Care

No TOPIC AUTHORS
1 Classification of Newborn Viraj Sathenahalli
Ashish Jain
2 Basics of newborn resuscitation Poonam Joshi
3 Developmental peculiarities of newborn Neeraj Gupta
4 Identification of Sick newborn & Danger Signs Rajiv Sharan
5 Essentials of breast feeding Surender Singh Bisht
6 Thermoregulation Simin Irani
7 Fluids, Dextrose & Electrolytes Sreeram S
8 Basics of respiratory distress & oxygen therapy Sanjay Wazir
9 Basics of shock Lt Col (Dr) V V Tewari
10 Newborn Transport
11 Newborn Examinatiion KP Sanghavi
SECTION 2:
Essential Nursing Skills

1 Handwashing Anjali Kulkarni,

Rahul Bhamkar
2 Baby Hygiene, bath, skin care, cleaning & bed keeping Manisha Bhandankar
3 Assessing body temperature S. Indu Nair
4 Assessing heart rate Sumitha Nayak
5 Assessing respiration Maneesha P.H.
6 Assessing blood pressure Rajesh Kumar
7 Using a weighing scale LS Deshmukh
8 Anthropometry & Growth monitoring
9 Administering nasogastric, orogastric tubes & tube feeding Rajiv Sharan
10 Monitoring Intravenous site infusion line Rajesh Kumar
11 Changing intravenous dressing (Peripheral/Central) Pradeep Sharma
12 Calculating and Regulating Intravenous Flow Rate
13 Urine collection and measurement VC Manoj
14 Hemoglucostix testing Vinay Joshi
15 Suctioning K. Sankaranarayanan
16 Catheterisation Preetha Joshi
17 Medication Administration: PO, IV, IM, SC, ID,PR, Eye,Gastric LS Deshmukh
18 Parental Counselling Ranjan Kumar Pejaver
19 NICU Housekeeping Ms Sashikala ,
Srinivas Murki
20 Expressing breast milk Sailesh Gupta
21 Kangaroo Care Ruchi Nanavati
22 Identification of pain Somashekhar Nimbalkar
23 Using pulse oximeter Jayashree Mondkar
24 Administering oxygen SR Daga
25 Bag & mask resuscitation Rhishikesh Thakre
26 Ward Round Etiquettes Hebsiba LD, Ankita Raj
27 Metabolic screening Rajath Pejaver
28 Conveying Death Rhishikesh Thakre
29 Consent Ashish Jain
SECTION 3:
Nursing Care of Newborn

1 Care in the Delivery Room Ashwani Sood

2 Care in the postnatal ward Ashwani Sood
3 Care of the baby under radiant warmer Rimple Sharma
4 Monitoring sick newborn Ms Rekha Samant,
Ruchi Nanavati
5 Feeding the LBW baby Ms Shraddha Palekar
6 Care of baby with hypoglycemia/seizures Arjit Mohapatra
7 Care of the baby under phototherapy Rimple Sharma
8 Care of the baby on CPAP/NIPPV Naveen Bajaj
9 Care of baby on ventilator Ashish Jain
10 Care of baby with sudden deterioration Suman Rao, Ms. Vimala Peter
11 Developmentally supportive care Suman Rao, Sunita Namdev
12 Physiotherapy Sandeep Kadam
13 Pain management Tushar Parikh, Nida Siddique
14 TPN preparation & administration Tushar Parikh
15 Care of surgical newborn Sandeep Kadam

SECTION 4:
Nursing Protocols/Checklist

1 Admission procedure Leslie Lewis

2 Basic documentation & Hand over
3 Organisation of discharge from NICU Reeta Bora, Shamim Akhtar
4 Care of NICU Equipment Pradeep Suryawanshi
5 Disinfection & Sterilization Deepak Chawla
6 Blood Transufsion Neeraj Gupta
SECTION 5:
 Assisting Procedures

1 Peripheral venous cannulation and care Naveen Bajaj

2 Arterial puncture and sampling Swarup Kumar Dash
3 Capillary heal sampling Bonny Jasani
4 Endotracheal tube fixation & care Hemant Parakh
5 Surfactant administration Srinivas Murki, Tejo Pratap Oleti
6 Blood Culture Raktima Chakrabarti
7 Chest tube insertion Ashish Mehta
8 Peripherlly inserted central line Jyothi Prabhakar, Naveen Jain
9 Lumbar puncture Sanjay Aher
10 Umbilical cathetrisation Sachin Shah, Amita Kaul
11 Exchange transfusion Asim Mallick
12 Partial exchange Piyush Jain
13 ROP Examination Nandkishor S Kabra
14 Nebulisation Jaikrishan Mittal, Sunil Gothwal
SECTION 6:
Common Newborn Disorders
1 Respiratory Distress Syndrome (RDS)
2 Patent ductus areteriosus (PDA) Naveen Bajaj, Bhawandeep Garg
3 Intra ventricular hemorrhage (JVH) Sachin Shah, Amita Kaul
4 Necrotizing enterocolitis (NEC) Vinay Joshi
5 Perinatal Aspyhyxia Preetha Joshi
6 Sepsis Somashekhar Nimbalkar
7 Jaundice Nandkishor S Kabra
8 Hypoglcyemia Leslie Lewis
9 Seizures K. Sankaranarayanan
10 Polycythemia Sanjay Aher
11 Inborn error of metabolism (IEM) Naveen Jain, Femitha P

12 Pulmonary hypertension of newborn (PPHN) Pradeep Suryawanshi

13 Congenital heart diseae (CHD) Arjit Mohapatra, Vidya Patwari
14 Surgical anomalies Kumar Ankur
15 Bronchopulmonary dysplasia(BPD) Jaikrishan Mittal, Sunil Gothwal
16 Transient tachypnea of newborn (TTNB) VC Manoj
17 Meconium aspiration syndrome (MAS) Rajesh Kumar
18 Intrauterine growth retardation (IUGR) Rohit Arora
19 Apnea Sanjay Wazir
20 Congenital heart failure (CHF) Rohit Arora
21 Retinopathy of prematurity (ROP) Snehal Thakre
22 Large for gestational age (LGA) Dinesh Chirla
23 Multiple gestation Anu Thukral
 SECTION 7:
Miscellaneous Topics
1 High Risk Follow Up Archana Kadam
2 Medical Ethics Nandkishor S Kabra
3 Basics of Evidence Based Medicine Deepak Chawla
APPENDIX
Metric conversion
- Weight/temperature
- Volume
- Weight
Symbols & Abbreivation
Common medication formula
Apgar Score
Glucose infusion Scale
 CONTRIBUTING AUTHORS

Dr Ashish Jain Poonam Joshi Dr Neeraj Gupta

MD, DNB (Ped), DM (Neo) Lecturer in Nursing, DM (Neo), MD
Asst Prof ; Pediatrics College of Nursing, AIIMS, Assistant Professor
Maulana Azad Medical Ansari Nagar, New Delhi. Department of Pediatrics
College, New Delhi. pjoshi495@gmail.com All India Institute of Medical
drashishjain2000@yahoo.co.in Sciences (AIIMS), Jodhpur.
neerajpgi@yahoo.co.in
Dr Rajiv Sharan Dr Surender Singh Bisht Prof (Dr) Simin Irani
DNB, MNAMS B-83, sector 36, Noida, Retd. Prof, Dept of
Consultant in Paediatrics Dist Gautam Buddha Nagar,UP Neonatology, KEM Hospital,
Tata Motors Hospital drbisht02@gmail.com KJ Somaiya Medical College &
Jamshedpur Hospital, Mumbai
drrajeev_sharan@yahoo.com
Dr Sreeram S Dr Sanjay Wazir Lt Col (Dr) V V Tewari
DM (Neo), MD DM (Neo), MD Classified Specialist
Consultant, NeoBBC hospital, Neonatal Division (Pediatrics & Neonatology)
Paramitha children's hospital, The Cradle, An Apollo Hospital Army Hospital (R&R)
Hyderabad Initiative, SCO 1&2, Sec 14, Dhaula Kuan
drsreeraman@yahoo.co.in Gurgaon, Haryana. Delhi Cantt – 110010
swazir21@gmail.com docvvt_13@hotmail.com

Dr Nalinikant Panigrahy Dr Kishore Sanghvi Dr Anjali Kulkarni

MD, DNB (Neo) MD, Fellowship in HOD Pediatrics and
Consultant Neonatology Neonatology (Australia) Neonatology, Sir HN Reliance
Rainbow children's hospital Jaslok Hospital, Saifee Foundation Hospital, Mumbai
Banjara hills, Hyderabad. Hospital, Masina Hospital, dr.kulkarnianjali@gmail.com
nalini199@gmail.com Mumbai.
kpsanghvi@hotmail.com
Dr Manisha Bhandankar Dr. S. Indu Nair Dr Sumitha Nayak
MD, PhD, MRCPCH DCH, DNB, Fellowship in MD, DNB,PGDMLS, PGDGC
Professor, Dept of Pediatrics Neonatology, Senior Consultant Pediatrician, The
JN Medical College Consultant, Pediatrics and Children’s Clinic, Bangalore
Consultant Neonatolgist & Neonatology,Sakra world snayak1011@gmail.com
Pediatrician, KLES Hospital & MRC, hospital, Bangalore
Belgaum. drindu_nair2000@yahoo.co.in
manishabhandankar@yahoo.com
Dr. Maneesha P.H. Dr Rajesh Kumar Dr LS Deshmukh
Consultant Neonatologist MD, DM(Neo) MD, DM(Neo)
Meenakshi Hospitals, Bangalore Director, Rani Children Prof, Dept of Neonatology,
maneeshadr@yahoo.com Hospital, Ranchi. Govt Medical College &
drrajeshranihospital@gmail.com Hospital, Aurangabad.
deshmukhls@yahoo.com

Dr Pradeep Sharma Dr VC Manoj Dr Vinay Joshi

MD , DM (Neo) Head, Dept of Neonatology, MD, DM (Neo)
Senior Consultant Jubilee Mission Medical Neonatologist & Pediatric and
SPS Apollo Hospitals, Ludhiana College, Thrissur. Cardiac Intensivist
psaiims@yahoo.co.in manojvaranattu@gmail.com Kokilaben Hospital, Mumbai
vjhanamesh@yahoo.com

Dr. K. Sankaranarayanan Dr Preetha Joshi Dr Ranjan Kumar Pejaver

CCT (Neo), CCT; (Ped), MRCPCH, DNB, FCCM (Australia and FRCP, FRCPCH(UK), FIAP, FNNF
DM (Neo), MD,DNB(Paed), DCH Canada) Chief of Neonatology,
Senior Consultant Neonatologist Neonatal, Pediatric and Meenakshi Hospitals,
Kanchi Kamakoti Childs Trust Cardiac Intensivist, Hon Professor of Neonatology
Hospital, Chennai Kokilaben Hospital, Mumbai KIMS. Bangalore
shankarnk@yahoo.com preethadoc@hotmail.com rpejaver@yahoo.com
Dr Sailesh Gupta Dr Ruchi Nanavati Dr Somashekhar Nimbalkar
MD, DCh Prof & Head, Dept of Head, Neonatal Intensive Care
Advisor, IAP Neonatology Chapter, Neonatology, KEM Hospital, Unit, Shree Krishna Hospital
Secretary General IAP 2012-13 Mumbai and Pramukhswami Medical
Senior Pediatrician, Mumbai drruchinanavati@gmail.com College, Karamsad-Anand-
guptasailu@gmail.com Gujarat.
somu_somu@yahoo.com

Dr Jayashree Mondkar Dr SR Daga Dr Rhishikesh Thakre

Prof & Head, Prof, Dept of Pediatrics DM(Neo), MD, DNB, DCh, FCPS
Dept of Neonatology, LTTMC & MIMER Medical College, Director, Neo Clinic & Hospital,
LTMGH, Sion, Mumbai. Talegaon Dabhade. Aurangabad
jayashreemondkar@rediffmail.com subhashdaga@yahoo.com rptdoc@gmail.com

Dr Rajath Pejaver Dr Srinivas Murki Dr Ashwani K Sood

Department Of Pediatrics, MD, DNB, DM(Neo) MD FIAP
Division of Neonatology, Senior Consultant, Professor of Pediatrics,
Basaveshwara Medical College Fernandez Hospital, IGMC, Shimla
Hospital,Chitradurga , Karnataka Hyderabad
rajath.pejaver@gmail.com srinivas_murki2001@yahoo.com doc.aksood@gmail.com
Mrs Rimple Sharma Ms Rekha Samant Dr Arjit Mohapatra
Lecturer, College of Nursing, All Project Coordinator, FBNC MD, DM (Neo)
India Institute of Medical Sciences, Project, Director, Jagannath Hospital,
New Delhi. KEM Hospital, Bhubaneswar.
reemapawankumar@gmail.com Mumbai arjitm@yahoo.com

Dr Naveen Bajaj Dr Suman Rao PN Dr Sandeep Kadam

MD, DM(Neo) MD, DM(Neo) MD, DM(Neo)
Neonatal Fellow, UWO, Canada, Prof & Head, Dept. of Senior Neonatal Consultant
Consultant Neonatologist, Neonatology KEM Hospital, Ratna Hospital,
Deep Hospital, Ludhiana St. John's Medical College Pune
Hospital, Bangalore drsandeepkadam@yahoo.com
bajajneo@yahoo.com raosumanv@rediffmail.com
Dr Tushar Parikh Dr Leslie Lewis Dr Reeta Bora
DNB, DM(Neo), Fellowship in Professor Pediatrics, Neonatal MD,DM(Neo)
Neonatal Perinatal Medicine division, department of Associate Professor & In
(Australia) Pediatrics, KMC Manipal charge Neonatal Unit, Dept of
Neonatologist, KEM Hospital, leslielewis1@gmail.com Pediatrics, Assam Medical
Columbia Asia Hospital, Pune College, Dibrugarh
drtusharparikh@gmail.com rbora_amc@yahoo.co.in

Dr Pradeep Suryawanshi Dr Deepak Chawla Dr Raktima Chakrabarti

MD, DCH ( Sydney), Fellowship in MD, DM(Neo) Consultant Neonatologist
neontal perinatal medicine Assoc. Prof, Dept of Pediatrics, Columbia-Asia Hospital,
(Australia), Head & Asso. Govt Medical College, Gurgaon
Prof. Dept. of Neonatology, BVU Chandigarh dr_raktima@yahoo.com
Medical college pune drdeepak.chawla@gmail.com
drpradeepsuryawanshi@gmail.com

Dr Swarup Kumar Dash Dr Bonny Jasani Dr Hemant Parakh

Surya Hospital, Mumbai MD, DM (Neo) MD, DM (Neo)
docswarup@gmail.com Dept of Neonatology, KEM Consultant Neonatologist,
Hospital, Mumbai Hyderabad
bonnyjasani@gmail.com drhemantparakh@gmail.com

Dr Ashish Mehta Dr Naveen Jain Dr Sanjay Aher

MD, Fellowship in Neonatology MD,DNB,DM(Neo) MD,DM(Neo), Fellowship in
(Australia) Senior Neonatologist Neonatology(Canada)
Director, Arpan Hospital, KIMS Hospital, Trivandrum Director, Neocare Hospital,
Ahmedabad naveen_19572@hotmail.com Nashik
amehta63@hotmail.com ahersm@gmail.com
Dr Sachin Shah Dr Asim Mallick Dr Piyush Jain
MD, DM (Neo) Professor & Incharge Neonatal MD, DM(Neo)
Director, Neonatology and unit, Dept of Pediatrics, N.R.S Assoc. Prof., MGM Medical
Pediatric intensive care, Surya Medical College &Hospital, College, Navi Mumbai.
Hospital for women and children, Kolkata docpiyush@yahoo.com
Pune asim_mallick2004@yahoo.com
sshahdoc@gmail.com
Dr Jaikrishan Mittal Dr Nandkishor S Kabra Dr Kumar Ankur
MD, DM (Neo) MD, DM (Neo), MSc (Clinical MD, DNB (Neonatology)
Asst. Professor Neonatology Epidemiology) Consultant In-Charge NICU
SMS Medical College, Jaipur Neonatologist, Surya Children BLK Superspeciality Hospital,
mittal_jaikrishan@yahoo.com Hospital, Santacruz West, Delhi
Mumbai. sahankur@gmail.com
nskabra@gmail.com

Dr Rohit Arora Dr Snehal Thakre Dr Dinesh Chirla

Clinical / Research Fellow Neonatal MS (Ophth), DNB MD, DM(Neo), Fellowship in
Perinatal Program Canada, Professor, Dept of Neonatal Perinatal
Simulation Scholar ,Texas Ophthalmology, MGM College Medicine(Australia), Director,
Children’s Hospital Houston & Hospital, Aurangabad Rainbow Hospital, Hyderabad
Consultant Neonatologist, Saket tsnehal73@gmail.com dchirla@gmail.com
City Hospital, New Delhi,
dr.rohitarora78@gmail.com

Dr Anu Thukral Dr Archana Kadam Ms Sashikala

MD,DNB,MNAMS, DM (Neo) MD (Ped), DNB Head Nurse
Asst. Prof; Dept. of Pediatrics Developmental Pediatrician, Fernandez Hospital
Kalawati Saran Children's Hospital, KEM Hospital & Jehangir Hyderabad
Lady Hardinge Medical College Hospital, Pune
New Delhi dr.archana.ped@gmail.com
dranuthukral@yahoo.com
Dr Viraj Sathenahalli Ms Shradha Palekar Ms. Vimala Peter
M.D.(Pediatrics), Senior Staff Nurse, Nurse Mentor,
Assistant Professor, NICU, KEM Hospital, St. John’s College of Nursing,
Bapuji child health institute & Mumbai Bangalore
J.J.M.M.C., Davanagere
virajbs.hb@gmail.com
Ms Hebsiba L.D Ms Ankita Raj Dr Jyothi Prabhakar
NICU Nurse, NICU Nurse, Associate Consultant,
Fernandez Hospital, Fernandez Hospital, Neonatology Department,
Hyderabad Hyderabad KIMS Hospital, Trivandrum
jyothimeloor@gmail.com
 SECTION 1
FUNDAMENTALS OF NEWBORN CARE

1. Classification of new born babies

 Dr Veeraraja B Sathenahalli Dr Ashish Jain

Learning objectives:

1. Understand classification of newborn babies.

2. Assess the gestational age of newborn.

3. Assess the fetal growth according to gestational age.

Introduction:

New born care depends on the gestational age and fetal growth of the baby. Different

clinical problems develop in babies with different gestational age and different fetal growth

status. Hence, a classification system using gestational age and birth weight information has

been evolved. Every year an estimated 15 million pre term babies are born with 1 million babies

dying annually. With a rising incidence, pre term birth leading cause of death among new

born. Majority of these deaths can be prevented with current, cost effective interventions.

India accounts to leading country with greatest number of pre term births. Hence, it is advised

that all health care personnel should be able to identify pre term baby at birth and manage

accordingly. Asia accounts to more than 75% of IUGR babies, the peculiarity and increased risk

of immediate and long term complications of these babies makes identification and appropriate

management an area of importance. Thus, classification of babies helps in identification of

babies at high risk and management. Nursing personnel be well acquainted with this

classification system so that proper coding can be done.

Classification of new born babies:

New born can be classified according to

a. Gestational age

b. Birth weight

c. Fetal growth.

Gestational age wise classification:

New born is classified into pre term, term and post term according to gestational age. Various

methods have been evaluated for gestational age assessment. Gestational age assessment can

be done by a. menstrual dates, b. USG assessment, c. assessment in early neonatal period. We

will be discussing gestational age assessment in early neonatal period in this chapter. Over a

period, many scoring methods were evolved to assess gestational age assessment using

physical and neuromuscular findings as tool. Dubowitz came up with first scoring system to

assess gestational age, followed by Ballard scoring system which was modified later to include

extremely pre mature babies and has been followed worldwide uniformly. New Ballard score

assesses physical and neuromuscular maturity. Skin, lanugo, plantar surface, breast, eye/ear,

genitals are assessed in physical maturity. Posture, square window, arm recoil, popliteal angle,

scarf sign and heel to ear are assessed in neuromuscular maturity.

Depending on the gestational age, newborn babies are divided into

a. Pre term: gestational age less than 37 weeks

b. Term: 37 weeks gestation age to 42 weeks

c. Post term: more than 42 weeks

Birth weight wise classification:

Birth weight wise babies are classified into

a. Low birth weight: birth weight less than 2500 gms.

b. Very low birth weight: birth weight less than 1500 gms.

c. Extremely low birth weight: birth weight less than 1000 gms.

Fetal growth wise classification:

On plotting birth weights of babies, a frequency distribution is obtained. According to the

classification, they are classified into

a. Small for gestational age (SGA):refers to weight below the 10th percentilefor gestational

age, corrected for parity and gender, as per the population growth charts.

b. Appropriate for gestational age (AGA):refers to weight between 10th to 90thpercentile

for gestational age.

c. Large for gestational age (LGA): refers to birth weight above 90th percentile for

gestational age.

Small for gestational age can be further classified into moderate (3rd to 10th percentile), severe

(< 3rd centile).

Intrauterine growth restriction (IUGR) is defined as fetal growthless than the normal growth

potential of a specific infant because ofgenetic or environmental factors. The terms IUGR and

Small forGestational Age (SGA) are often used to describe the same problem,although there are

subtle differences between the two. SGA isdiagnosed as birth weight less than (less than 10%
for that particulargestational age, parity and gender) the population norms on thegrowth chart.

IUGR is a clinical definition and applied to neonateswith clinical evidences of malnutrition.

Ponderal Index (PI) is also used to determine the degree of fetalmalnutrition. It is defined as the

ratio of body weight to lengthexpressed as (PI=[weight (in g) x 100]÷[length (in cm)3]). PI of

lessthan 10 percentile reflects fetal malnutrition; PI of less than 3percentile indicates severe

fetal wasting.

There are three types of IUGR.

a. Symmetrical IUGR ( hypoplastic small for date):

a. Begins early in gestation.

b. Cell number is reduced.

c. Cause: Intrinsic factors such as congenital infections orchromosomal

abnormalities.

d. Have reductions in allparameters including weight, length and the head

circumference.

e. There will be less than 3 cm difference between the head andthe chest

circumference.

f. PI is more than 2

b. Asymmetrical IUGR (malnourished babies):

a. Typically begins in the late second or third trimesters.

b. Cell numbers are normal but cell size is reduced.

c. Reductions in fetal nutrients that limit glycogen and storage,caused usually

due to placenta disorders.

 d. Reduction in the weight and length occurs due to Brain sparing.

e. Features of malnutrition are pronounced in the form of loose skinfold, loss of

buckle fat, featuring aged people.

f. Ponderal Index (PI) is less than 2

c. Mixed IUGR:

a. Decrease in the number of cell and cell size.

b. Occurs mostly when IUGR is affected further by placental causes inlate

pregnancy.

c. Represents the clinical features of both symmetrical andasymmetrical IUGR.

d. Infants with the normal cell numbers experience better andimmediate neonatal

and long term growth with improved neurodevelopmentaloutcomes.

Fig 1. Battaglia FC, Lubchenco LO: A practical classification of newborn infants by weight and

gestational age.J Pediatr 1967; 71:159-163.

Implications:

After birth, every baby should be classified using above methods, birth weight should be

plotted on the chart by the attending nurse or doctor. Baby at high risk as defined by hospital

authority. The classification and identification of high risk babies will help in better

management and thus reducing neonatal mortality rate.

Suggested reading:

1. Battaglia FC, Lubchenco LO: A practical classification of newborn infants by weight and

gestational age. J Pediatr 1967; 71:159-163.

2. Murki S and Sharma D (2014).Intrauterine Growth Retardation - A Review Article. J

Neonatal Biol 3: 135. doi: 10.4172/2167-0897.1000135.

3. Ballard JL, Khoury JC, Wedig K, Wang L, Eilers-Walsman BL,Lipp R. New Ballard Score,

expanded to include extremely premature infants.J Pediatr. 1991;119:417-423.

4. Blencowe H, Cousens S, Oestergaard M, Chou D, Moller AB, Narwal R, Adler A, Garcia

CV, Rohde S, Say L, Lawn JE. National, regional and worldwide estimates of preterm

birth. The Lancet, June 2012. 9;379(9832):2162-7

 Nursing Etiquettes
Ms Hebsiba L.D Ms Ankita Raj

Before round

• Hand washing prior to entering the unit

• Ensure all personnels in nursery have short nails
• Written hand over of all assigned newborns and related ents from the relieving
nurse
• Check identity of the patients and their mother/parent status
• Check all IV lines and central line functioning and insertion sites
• Cross check the medications administered (dosage, timing and preparation)
• If there is any sick baby (on CPAP, Ventilator, Multiple medications)
o Maintain the newborn in correct position
o Check for contents and functioning of emergency tray
o Check all the equipments and their functionality
o Check for water in humidification chamber of all CPAP and ventilators
• Collect all the relevant reports (investigations) which were sent and to be collected
• Talk to the resident for the need of any emergency int tions or medications
• Check availability of all emergency drugs and resuscitation equipments in the unit.
• Check for the TPN room and fridge temperature
• Ensure the cleanliness of the nursery
• Dispose the biomedical waste according to its nature
• Ensure all equipments are in functional order. If not, place requisition for repairs
immediately
During rounds

• Ensure that all the persons attending the rounds are following the aseptic precautions
• Attend the rounds with case sheets and notebook for taking notes
• Contribute to the patient by highlighting the nursing issues, medication administration and
family concerns
• Listen to the discussion done during the rounds and write down the important points
• Participate in decision making with the team
• Monitor and address the emergencies during rounds
• To follow the orders (in case of stat medication order given during the rounds)
• To ask about queries related to management and disease of the patient to the consultant

After rounds

• To go through the instructions from the rounds

• Prioritize the work according to the urgency and sickness of the newborn
• Recheck and discuss the orders written by the doctors
• To administer the medications as per the written instructions.
• Avoid medication errors. Confirm the dosing and administration of medications such as
heparin, insulin, analgesics, sedatives (morphine or fentanyl), amphotericin, IVIG and so
on. All medications administered should be signed
• If in doubt re-confirm with the consultant
• Record vitals, input and output variables
• Sent the relevant samples for investigations as advised
• To collect all the pending investigation and enter the reports in patient case sheet at the
designated place
• Communicate with the infant’s parents briefly about the present condition and try to
answer the queries
• Assist the mothers in milk expression, pain relief and develop cordial relation
• To see for any shifting of the babies is required and advised by the doctors
• Bring to the notice of the consultant all issues in the unit
• Indent the medications and disposables from the pharmacy or from the parents
• Assist the attending residents/doctors in procedures
• Communicate with the colleague sisters all relevant issues and maintain cordial working
atmosphere
• Involve in teaching activities for educating juniors and other paramedical personal
• If possible attend the follow up clinics or at-least know the outcomes of sick newborns
treated
• Enjoy the work being done
• Follow up regarding non functional equipments
• Note and rotate position of baby, probes, tubes, iv sites periodically
 NICU Housekeeping Practices
Ms Sashikala Dr Srinivas Murki

To minimize the transmission of microorganisms from equipment and the environment,

adequate methods for Cleaning, disinfecting and sterilizing must be in place.

Definitions

Cleaning

Removing foreign material (soil, organic matter, microbes) from an object. It is best done with
clean and cold running water. Sometimes mild disinfection with 0.5% chlorine is required
before cleaning. Most environmental objects (floors, walls, sinks) require only mild disinfection
and then cleaning. All objects in the NICU require cleaning.

Disinfection

Disinfection is removing all pathogenic microbes except spores. All objects must be cleaned
before disinfection. This is required for all objects come in contact with baby (warmers,
equipment, linen, cotton, gauze, baby belongings etc.). Disinfection is done with moist heat (70
to100° c) or with chemicals (2% glutaraldehyde, 6% Hydrogen peroxide, 0.2 -0.3% peracetic
acid). When using chemicals for disinfection, these sh not come in contact with the
newborn

Sterilization

This is removal of all living microbes including spores. This is required for all objects that invade
the body (orogastric tube, catheters, and ventilator circuits). Sterilization is done with
autoclave/dry heat/ethylene oxide gas

Decontamination

It involves Cleaning, Disinfection and Sterilization

Table 1: Time schedule for cleaning and disinfection
Table 2: The preferred order of Housekeeping practices
The Formula for Making a Dilute Chlorine Solution From Any Concentrated Hypochlorite
Solution Is:

• Check concentration (% concentrate) of the chlorine product you are using

• Determine total parts water needed using the formula below
• Total parts (TP) water = [%concentrate ] - 1 % dilute
• Mix 1 part concentrated bleach with the total parts water required.
Example: Make a dilute solution (0.5%) from 5% concentrated solution

STEP 1: Calculate TP water: [ 5.0% ]/0.5% - 1 = 10 – 1 = 9

STEP 2:Take 1 Part Concentrated solution and add to 9 parts water.

The formula for making a dilute solution from a powder of any percent available chlorine is:

Formula for making Chlorine Solution from Dry Powders:

• Check concentration (% concentrate) of the powder you are using.

• Determine grams bleach needed using the formula below.
• Grams/liter = [ % Dilute ] X 1000 / % Concentrate
• Mix measured amount of bleach powder with 1 litre of water.
Example: Make a dilute Chlorine-releasing solution (0.5%) from a Concentrated Powder (35%).

STEP 1: Calculate grams/litre: x 1000 = [ 0.5% ] X 1000 = 14.2 g / l

35%

STEP 2: Add 14.2 grams (Approximately 14 g) to 1 litre of water.

Cleaning Methods of Housekeeping Surfaces

Cleaning should start with the least soiled area and move to the most soiled area and
from high to low surfaces.

Wet Mopping

• Is the Most Common and Preferred Method to Clean Floors.

Double-Bucket Technique

• Two different buckets are used, one containing a cleaning solution and the other
containing rinse water. The mop is always rinsed and wrung out before it is dipped into
 the cleaning solution. The double-bucket technique extends the life of the cleaning
solution (fewer changes are required), saving both labor and material Costs.
Dusting

• Most Commonly Used for Cleaning walls, Ceilings, Doors, Windows, Furniture and Other
Environmental Surfaces
Cleaning strategies for spills of blood and body substances

• Clean spills with a 0.5% chlorine solution.

• Clean spills of blood, body fluids and other potentially infectious fluids immediately
For Small Spills

• While wearing utility or examination gloves, remove visible erial using a cloth
soaked in a 0.5% chlorine solution, then wipe clean with a disinfectant cleaning
solution.
For large spills

• While wearing gloves, flood the area with a 0.5% chlorine solution, mop up the
solution and then clean as usual with detergent and water

Suggested reading

1. Checklists, Bundles and Infection Control:

http://fernandezresearch.files.wordpress.com/2013/01/checklist-bundles-infection-
control.pdf
2. Prevention of Hospital acquired Infections. A Practical guide
http://www.who.int/csr/resources/publications/whocdscsreph200212.pdf
3. Prevention of HAI http://www.cdc.gov/hai/