Essential Care for Every Baby - Helping Babies Survive Facilitator Flip Chart

Page created by Ricardo Chapman
 
CONTINUE READING
Essential Care for Every Baby - Helping Babies Survive Facilitator Flip Chart
Helping Babies Survive
Essential Care for Every Baby
         Facilitator Flip Chart
Essential Care for Every Baby - Helping Babies Survive Facilitator Flip Chart
Helping Babies Survive
                                                                  Essential Care for Every Baby

Explain and demonstrate                                        Keeping babies warm, feeding breast milk early and                                             Learners in this course should have completed
                                                               exclusively, helping families practice good hygiene and                                        training in care provided at the time of birth.
Begin with a story.                                            recognize Danger Signs can be lifesaving. Providers of                                         This should include how to help babies who
Have each learner place one hand on the                        newborn care must be prepared to deliver this essential                                        do not breathe.
manikin. Then say to the learners:                             care to every baby and teach families to provide this
Imagine that a baby is separated from his mother soon                                                                                                         Show the Action Plan and learner materials.
                                                               care at home.
after birth. He is placed on a cot. An hour later he feels                                                                                                    Describe the time scale and the color coding.
cold to touch and cannot be awakened to feed. There is                                                                                                        Identify actions that are performed at particular
no one who knows how to help. The baby dies.                   Invite discussion                                                                              times and those that are required only if
                                                                                                                                                              particular needs are observed.
Pause, and then say:                                           1.		    Have any of you had experience with a baby
Now imagine you dry the baby immediately after birth           		      who dies soon after birth?
and place him skin-to-skin with the mother. You help           2.		    Who provides care for mothers and babies                                               Facilitate practice
the mother begin breastfeeding. Over the next day, you         		      immediately after birth? Until discharge
monitor for signs of illness, provide essential care for the   		      from the birth facility?                                                               Ask learners to organize themselves in groups
baby and teach the family how they can continue this           3.		    How are these individuals prepared for                                                 of six and identify pairs of participants for
care at home. The baby survives and thrives.                   		      this responsibility?                                                                   cooperative learning.
(Pause for a moment.)

                                                                      Background                                                                              Educational advice
                                                                      Care of babies after birth by health workers and mothers, often called Essential        Begin with a story to encourage learners to believe that ENC can really save lives.
                                                                      Newborn Care (ENC), promotes health and can increase newborn survival. Many             Invite participants to share their experiences.
                                                                      babies die during the first day and first week, some because they do not receive this
                                                                      care. The Essential Care for Every Baby program aims at giving providers the know-      Introduce and explain the use of the Action Plan and Flip Chart. Each step in
                                                                      ledge and skill to provide most elements of ENC and assist mothers and families         the Action Plan is presented on the Facilitator Flip Chart. The front is viewed by
                                                                      in providing this care.                                                                 the learner. The back, viewed by the facilitator, is organized into to three steps
                                                                                                                                                              to support learning:
                                                                      This program is based on recommendations in the 2006 WHO Pregnancy, Child-              1. Explain and demonstrate
                                                                      birth, Postpartum and Newborn Care guidelines, the 2010 WHO Essential New-              2. Invite discussion
                                                                      born Care Course and other guidelines developed by the World Health Organi-             3. Facilitate practice
                                                                      zation. The recommendations of local health authorities or ministries may vary
                                                                      slightly from the recommendations in this program. You should be familiar with          Facilitators should: EXPLAIN the key points for understanding and DEMON-
                                                                      these differences, and these variations should be highlighted for the learner.          STRATE skills correctly. INVITE DISCUSSION to identify barriers and find solu-
                                                                      Essential Care for Every Baby begins after immediate care at birth. It assumes that     tions for incorporating knowledge and skills into practice. The discussion can also
                                                                      initial care of the newborn, including drying, cutting the cord and resuscitation is    highlight important local practices. FACILITATE PRACTICE by providing materi-
                                                                      taught using another program; the Helping Babies Breathe program is recommended.        als for practice of the skill in pairs or by giving clear instructions for a role play by
                                                                      Some elements of the Helping Babies Breathe curriculum are not repeated in              the paired learners. Role plays give learners practice in communicating important
                                                                      this program, e.g. hand washing.                                                        messages to mothers and fathers. Organize learners into pairs for cooperative
                                                                                                                                                              learning. Each facilitator should assist 3 pairs of learners.
                                                                      Some steps of ENC should be provided at specific times, e.g. by 90 minutes after
                                                                      birth. Others should follow observations, e.g. low body temperature. These times
                                                                      and observations are shown in the Action Plan.

                                                                                                                                                                                                                                                          1b
Essential Care for Every Baby - Helping Babies Survive Facilitator Flip Chart
Helping Babies Survive
Essential Care for Every Baby

                                                 38

                                            37
                                       36

                                  35
                             34

                 0   1
            12
       10                2
       9                 3                            38   37

                                                                36   35

       8                 4                                                34

            7        5
                 6

                                                                               1
Essential Care for Every Baby - Helping Babies Survive Facilitator Flip Chart
After immediate care at birth

                                      Continue skin-to-skin care and monitor breathing

Explain and demonstrate                        Monitor for rapid breathing (>60 breathes/                                                Invite discussion
                                               minute) and chest indrawing every 15 minutes
Continued skin-to-skin care keeps babies       until first complete exam.                                                                1.    Are babies separated from mothers during
warm. Monitoring breathing helps identify      • Many babies who breathe fast but without 		                                             		    the first hours after birth? Why?
problems early.                                  increased effort gradually improve.                                                     2.    Who monitors a baby’s breathing during
                                                                                                                                         		    the first hour after birth?
Continued skin-to-skin care                    • Babies with severe breathing problems or
• Prevents heat loss                             babies with mild breathing problems who
• Avoids low body temperature                    do not improve need advanced care.
• Promotes early breastfeeding and bonding
                                                                                                                                         Facilitate practice
                                               Monitor the baby’s body temperature about                                                 Combine practice of this action with Initiate
To continue skin-to-skin care                  every 15-30 minutes during skin-to-skin care                                              breastfeeding (see next page).
• Remove wet towels and other cloths           by feeling the baby’s skin (foot or forehead) to
• Place baby naked between breasts             estimate temperature. If the baby ‘s skin feels
• Cover with clean, dry drape or cloth,        cool, measure temperature (see page 8b).
  and cover the head
• Continue for at least one hour
• Interrupt only for essential care

                                                 Background                                                                              Educational advice
                                                 Immediately after birth, the most common problems are low temperature and               Explain to learners that they will practice this action with the next action, Initiate
                                                 rapid breathing.                                                                        breastfeeding, because these actions occur at the same time.

                                                 A baby begins to lose heat immediately after birth. Heat loss can be prevented
                                                 and low temperature can be avoided by drying the baby immediately after birth
                                                 and removing wet towels or clothing. The baby should be placed naked between
                                                 the mother’s breasts, and the mother and baby should be covered with a clean,
                                                 dry drape or cloth. The baby’s head should be covered. Monitor the baby’s tem-
                                                 perature about every 15-30 minutes by feeling the skin. Measure the tempera-
                                                 ture if the skin is cool.

                                                 Skin-to-skin care should begin at birth and should continue for at least one hour.
                                                 If a mother is not well, other family members can provide skin-to-skin care.

                                                 Rapid breathing after birth often occurs because of delay in absorption of lung fluid
                                                 and usually resolves rapidly. However, rapid breathing may persist or be caused by
                                                 a more serious problem that would require advanced care. Breathing in all babies
                                                 should be monitored every 15 minutes for rapid breathing (>60/min) and chest
                                                 indrawing (see Danger Signs) until the time of the first complete exam. This can
                                                 be done by observation alone without handling if the baby appears well.

                                                                                                                                                                                                                                  2b
Essential Care for Every Baby - Helping Babies Survive Facilitator Flip Chart
After immediate care at birth
34
     35
          36
               37
                    38

                         Continue skin-to-skin care
                          and monitor breathing

                          To keep babies warm and identify problems early

                                                                            2
Essential Care for Every Baby - Helping Babies Survive Facilitator Flip Chart
Within one hour after birth

                                                               Initiate breastfeeding

Explain and demonstrate                         Help mother recognize when the                                                                     3.		 What other liquids are fed to the baby?
                                                baby is ready to breastfeed                                                                        		 How can mothers be encouraged to
Breast milk is the best food                    • Opens eyes                                                                                       		 give only breast milk?
for all babies because it                       • Seeks breast
• Is highly nutritious                          • Head back slightly
• Protects against infection                    • Tongue down and forward                                                                          Facilitate practice
• Prevents some deaths                          • Opens mouth wide                                                                                 Ask learners to role play
                                                • Licks                                                                                            • Positioning the baby skin-to-skin
Early breastfeeding                                                                                                                                • Covering the baby’s body and head
• Helps establish successful and exclusive 		   Some babies will not latch and feed during
                                                the first feeding.                                                                                 • Monitoring breathing
  breastfeeding                                                                                                                                    • Communicating findings with mother
• Helps the uterus contract to decrease         Give no liquids other than breast milk
  bleeding after birth                          (or colostrum) even if the baby does not feed.                                                     Ask learners to role play assisting the mother with
• Encourages maternal-baby bonding                                                                                                                 • Positioning herself comfortably
                                                Invite discussion                                                                                  • Positioning the baby near the breasts
To encourage early breastfeeding, position                                                                                                         • Recognizing the signs of readiness
the baby near the mother’s breasts, where       1.		    In your facility, are healthy babies encouraged                                              to breastfeed
the baby can latch when ready to feed.          		      to breastfeed soon after birth?
                                                2.		    Do babies receive colostrum? Do mothers
                                                		      understand its importance?

                                                       Background                                                                                  Signs that the baby is ready to feed include: the baby is awake and seeks the breast;
                                                                                                                                                   the head is back slightly, with the mouth wide open; the tongue is down and forward;
                                                       Breast milk is easy to digest and contains antibodies that protect against infec-           the baby may lick. Mothers should know how to recognize these signs and how to
                                                       tion. Colostrum, milk that is produced by the breast during the first several days          encourage the baby to latch onto the breast.
                                                       after birth, is often yellow in color and contains large amounts of antibodies. It is       Some babies who are preterm, small, neurologically unwell, or have cleft lip and
                                                       very important that the baby is fed colostrum. Babies who receive other food or             palate may not be able to breastfeed. Use alternate feeding methods (see page 21)
                                                       liquids before six months of age are more likely to develop diarrhea and may have           to feed these babies.
                                                       growth problems. Early and exclusive breastfeeding will lower the risk of serious
                                                       infections and death. The benefits of breastfeeding should be discussed during
                                                       antenatal visit.
                                                                                                                                                   Educational advice
                                                       Early breastfeeding increases the likelihood of successful and exclusive breast-
                                                       feeding, promotes mother/baby bonding and helps contract the uterus, which may              Have learners role play with one acting as the mother and the other as the provider
                                                       decrease uterine bleeding.                                                                  who will counsel the mother. The provider should describe his or her actions to the
                                                                                                                                                   mother. The person playing the role of the mother can raise commonly asked ques-
                                                       Although a baby may not feed successfully during the first hour after birth, it is impor-   tions. Reverse the roles and repeat the skill practice.
                                                       tant to encourage breastfeeding during this time. To encourage early breastfeeding,         Materials for practice:
                                                       keep mother and baby together unless a problem separates them. Babies are often             - Clean, dry drape or cloth
                                                       alert immediately after birth and will move and turn toward the mother’s breast but         - Head covering for infant
                                                       may not suck.                                                                               - Newborn manikin

                                                                                                                                                                                                                                           3b
Essential Care for Every Baby - Helping Babies Survive Facilitator Flip Chart
Within one hour after birth
34
     35
          36
               37
                    38

                         Initiate breastfeeding

                          To increase the success of breastfeeding

                                                                     3
Essential Care for Every Baby - Helping Babies Survive Facilitator Flip Chart
Within 90 minutes after birth

                                                                    Provide eye care

Explain and demonstrate                            Invite discussion                                                                       Facilitate practice
Early eye care can prevent serious infections      1.		 Do health care providers routinely treat all 		                                    Ask learners to practice with role play
and blindness.                                     		 babies’ eyes with medicine?                                                          • Applying medication to the eye of a
                                                                                                                                             doll of manikin
Provide eye care                                   2.		 What eye medicine is recommended by your
• Wash hands with soap and water.                  		 health authority?                                                                    • Communicating to the family why
• Pull down the lower lid of the eye.                                                                                                        antibiotics are used in the eyes
• Place a portion (usually about 1 cm long if 		   3.		 Are there reasons parents do not want eye
  using ointment) of the locally approved 		       		 treatment with medicine after birth or do
  medication inside the length of the lower lid,   		 they put something else in the eyes?
  beginning from the side closest to the nose
  and extending to the opposite side of the lid.
• Repeat for the other eye.

                                                     Background                                                                            Educational advice
                                                     Infections can pass from the mother to the baby during birth. Infections of the eye   Ask learners to demonstrate eye care. To avoid injury to the eye, encourage them to
                                                     with bacteria such as gonococci and chlamydia can lead to blindness. Treatment of     administer the medicine inside the eyelid without touching the eye. Ideally, medi-
                                                     the eyes with medicine soon after birth may prevent these infections.                 cations should be single use and the same tube not reused on other babies. If medi-
                                                                                                                                           cations are reused a clean technique for application must be emphasized.
                                                     There are three medications recommended by the WHO: 1% silver nitrate eye
                                                     drops, 2.5% polyvidone iodine eye drops and 1% tetracycline ointment. Any are         Use a doll or manikin or make a model of an eye from local materials that allows
                                                     acceptable for the prevention of eye infections. Your health authority may recom-     the lower eyelid to be pulled down. A doll whose eyes do not open may be used by
                                                     mend one of these. Silver nitrate is used less frequently because it often causes     applying ointment or drops along the lower lid and saying that the eyelid should
                                                     swelling of the eyelids and drainage. Customs of placing other substances into the    be pulled down.
                                                     eyes should be discouraged as they may cause eye irritation or infection.
                                                                                                                                           Learners should practice using an ointment or drops that are similar to the
                                                     Many providers delay eye care until they perform the first exam and after the first   medication used in their facility. Eye drops can be given in a manner similar
                                                     breastfeeding, but eye care should be done within 90 minutes after birth. Eye care    to ointment.
                                                     may be provided while a baby remains skin-to-skin.
                                                                                                                                           Materials for practice:
                                                                                                                                           - Ointment or drops
                                                                                                                                           - Doll or manikin
                                                                                                                                           - Cloth for clean-up

                                                                                                                                                                                                                                 4b
Essential Care for Every Baby - Helping Babies Survive Facilitator Flip Chart
Within 90 minutes after birth
34
     35
          36
               37
                    38

                          Provide eye care

                         To help prevent serious eye infections

                                                                  4
Essential Care for Every Baby - Helping Babies Survive Facilitator Flip Chart
Within 90 minutes after birth

                                                                      Provide cord care

Explain and demonstrate                               Invite discussion                                                                        Facilitate practice
Proper care of the umbilical cord can prevent         1.		 What cord care practices are recommended                                            Ask learners to role play giving guidance
serious infections.                                   		 by your health authority?                                                             to the mother about cord care.
                                                      		                                                                                       • Keeping the cord dry
Cleansing the baby after birth                        2.		 What traditions exist around cord care?                                             • Cleaning the cord
• Remove blood or meconium by wiping.                 		 How can parents be encouraged to put 		                                               • Stopping bleeding
• Delay the first bath for at least six hours after   		 nothing on the cord?
  birth. If the baby is premature, has a low birth                                                                                             OR

  weight, has a low body temperature or is ill,                                                                                                Ask learners to practice cord care as
  bathing should be delayed even longer.                                                                                                       recommended by local health authorities.
Cord care
• The cord should remain exposed.
• Nothing should be placed on the cord unless
  a medicine (for example, chlorhexidine) is
  recommended by the health authority.
• If the stump is soiled, wash it with clean
  water and dry with a clean cloth.
• If bleeding, put an extra tie tightly around
  the cord.

                                                        Background                                                                             Following a home birth in areas where neonatal mortality is high, cord care with
                                                                                                                                               7.1% chlorhexidine digluconate (4% chlorhexidine) solution or gel saves lives. If the
                                                        Proper hygiene may help prevent infections in babies. Hygiene includes frequent        health authority recommends this or another treatment, the technique for applica-
                                                        hand washing, bathing the baby periodically, and proper care of the cord.              tion should be discussed, demonstrated and practiced.

                                                        Cleansing the baby after birth: Soon after birth, remove blood or meconium by
                                                        wiping. Vernix should not be removed. Do not bathe the baby until at least 6 hours     Educational advice
                                                        after birth, and then only if the baby has no serious problems. Small babies may
                                                        require further delay of bathing. Babies of mothers with HIV should be bathed after    Have learners role play with one acting as the mother and the other as the provider.
                                                        normal breathing and temperature have been established. Until the cord detaches,       The provider should give guidance to the mother about cord care and bathing.
                                                        it should not be submerged under water.
                                                                                                                                               Materials for practice:
                                                        Cord care: Proper care of the cord may prevent infection. The cord should be kept      - Doll or manikin with umbilical cord
                                                        exposed and dry. DO NOT apply anything to the cord, including herbs, animal dung       - Clean water
                                                        or other substances, except for medications recommended for cord care. Do not          - Clean cloth
                                                        place a bandage, diaper or a tight covering over the cord. If soiled, wash the cord.   - Umbilical cord tie

                                                                                                                                                                                                                                       5b
Within 90 minutes after birth
34
     35
          36
               37
                    38

                         Provide cord care

                           To help prevent infections

                                                          5
Within 90 minutes after birth (may be deferred until later during the first day)

                                                                            Give vitamin K

Explain and demonstrate                               Encourage mothers to breastfeed their baby                                                    Facilitate practice
                                                      during the injections for comfort.
Vitamin K will protect babies from serious                                                                                                          Ask learners to practice with role play
bleeding.                                             Remind providers to use a new syringe and                                                     • Explaining to the mother the need for
                                                      needle for each baby.                                                                           vitamin K and how it will be given
Give vitamin K by intramuscular (IM) injection                                                                                                      • Drawing up correct dose
• Wash hands with soap and water.                                                                                                                   • Identifying the correct injection site on
• Use gloves if available.                            Invite discussion                                                                               the doll or manikin
• Draw up 1 mg Vitamin K (0.5 mg for
Within 90 minutes after birth
                         (may be deferred until later during the first day)

                                 Give vitamin K
                    38

               37
          36

     35
34

                            To prevent bleeding that can cause death

                                                                              6
Within 90 minutes after birth

                                                                         Examine the baby

Explain and demonstrate                              Every examiner should                                                                      Facilitate practice
                                                     • Explain the exam to the mother
A complete examination should be performed           • Advise the mother to continue to observe                                                 Ask learners to practice with role play
within about 90 minutes after birth                    for abnormalities in the exam                                                            • Describing and documenting the
• Count the number of breaths during                                                                                                              physical exam
                                                     • Advise the mother to report abnormalities
  one minute.                                                                                                                                     - breathing
                                                       to a provider immediately
• Observe the movement of the limbs when 		                                                                                                       - movement, position and tone of
  awake, their position when not moving              • Record observations and findings of exam
                                                                                                                                                		 arms and legs
  and their tone.                                                                                                                                 - skin color
• Observe the skin color.                            Invite discussion                                                                            - cord appearance
• Inspect the following body areas for                                                                                                            - other features of a general exam
  abnormalities: head, face, mouth and palate,       1.		    When are babies usually examined?
  chest, abdomen, genitalia, anus, limbs and skin.   		      Who examines them?                                                                 • Communicating the features of the physical
A well baby should                                   2.		    How do you record the findings of the 		                                             exam to the mother and advising her to
• Breathe easily at 40-60 breathes/minute            		      physical exam?                                                                       monitor the baby’s exam during the
• Move arms and legs equally when active and         3.		    Are parents routinely present for the exam 		                                        hospitalization
  rest with limbs flexed                             		      or informed of findings?
• Have pink skin
• Have no bleeding or drainage from the
  umbilical cord

                                                            Background                                                                          The examination should be performed while skin-to-skin care is continued if pos-
                                                                                                                                                sible. Explain the exam to the mother, particularly the features listed above. Ask her
                                                            A complete exam should be performed within 90 minutes of birth, or whenever a       to continue to observe for abnormalities in these features and to notify a provider
                                                            baby appears unwell. During the exam, providers should evaluate a baby by look-     immediately is she identifies a problem.
                                                            ing, listening and feeling. This exam should focus on the following features:
                                                                                                                                                The results of the exam should be documented, even if all findings are normal.
                                                            Breathing: A baby should breathe effortlessly between 40-60 times a minute. To
                                                            obtain a respiratory rate, a baby’s breathing should be counted for one minute
                                                                                                                                                Educational advice
                                                            Movement and tone: When active, well babies have spontaneous movements
                                                            of arms and legs that are equal on both sides. Limbs are flexed at rest. The tone   Have learners practice how to examine a newborn systematically and describe
                                                            should be neither floppy nor rigid.                                                 normal findings. Have each learner tell the group how to document one part of
                                                                                                                                                the exam.
                                                            Skin color: The normal skin color of a newborn is pink, but hands and feet
                                                            may still look pale or blue soon after delivery. The pink color may be difficult    Materials for practice:
                                                            to detect in dark-skinned babies. The inside of the mouth should be pink in         - Doll or manikin
                                                            all babies. Babies with jaundice may have yellow skin. Recognizing jaundice         - Paper or local recording form for physical exam
                                                            is important because severe jaundice may cause serious health problems (see         - Pen
                                                            page 26b).                                                                          - Watch or other timing device
                                                            In addition to looking for these features, the baby’s entire body should be in-
                                                            spected for abnormalities.

                                                                                                                                                                                                                                         7b
Within 90 minutes after birth
34
     35
          36
               37
                    38

                          Examine the baby

                         To tell if a baby is well, or has a problem

                                                                       7
Within 90 minutes after birth

                                                                 Measure temperature
Explain and demonstrate                                • Hold the arm against the side for the                                                  Facilitate practice
                                                         recommended time.
Abnormal temperature may cause death.                    Digital thermometers can be read very soon                                             Ask the learners to practice
• 36.5°C - 37.5°C is a normal temperature.               (see manufacturer’s recommendations);                                                  • Measuring temperature on the manikin or
• 35.5°C - 36.4°C requires improved thermal care.        hold a mercury thermometer in the armpit                                                 doll with all thermometer types available in
• A temperature below 35.5°C is a Danger Sign.           for 5 minutes.                                                                           the community
• A temperature above 37.5°C not due to excess                                                                                                  • Reading high and low temperatures after
  warming is a Danger Sign.                                                                                                                       immersion in hot and cold water or on a
                                                                                                                                                  simulated thermometer
Using a thermometer to measure temperature             Invite discussion                                                                        • Classifying the temperature as normal,
is more exact than feeling the skin to estimate                                                                                                   abnormal and requiring improvement of
if a baby is too hot of too cold.                      1.		 What types of thermometers are available
                                                       		 locally? Do they measure temperatures                                                   thermal care, or showing a Danger Sign
Measure temperature                                    		 below 35.5°C
• Clean the thermometer.                               2.		 How do you clean and store a thermometer?
• Position the baby on the side or back.
• Put the tip of the thermometer high in the armpit.

                                                         Background                                                                             thermometer in the armpit. Practice reading the thermometer by simulating
                                                                                                                                                different temperatures. Dip the thermometer in hot water and have learners read
                                                         Keeping a baby’s body temperature normal improves outcomes and can avoid               high temperatures. Then reset the thermometer and simulate a low temperature
                                                         the death of some babies. Low body temperature is common in the first hours            using cold water.
                                                         after birth, especially among premature and low-weight infants. A temperature
                                                         below 35.5 that does not improve is a Danger Sign. Low temperature can be pre-         If water is not available, you may use adult hands or armpits for temperature source.
                                                         vented, or corrected, with changes in care. It is better to prevent low tempera-       Practice with the thermometer usually used. If not available, make a set of drawings
                                                         ture than try to warm a baby who is cold. Temperature can be taken while               to practice reading the temperature. Ask learners to classify babies and state the
                                                         the baby is skin-to-skin. If the baby needs to be separated from the mother,           actions they would take on the basis of temperatures from each of the four ranges,
                                                         other methods should be used to keep the baby warm.                                    for example:
                                                                                                                                                36.8°C - normal, maintain temperature
                                                         Babies can also become too warm, either because of an infection (causing fever) or     36.2°C - problem (low), improve thermal care
                                                         from over-warming. A temperature of 37.5°C which is not due to over-warming is a       37.9°C - Danger Sign (high), improve thermal care, treat and refer
                                                         Danger Sign.                                                                           35.0°C - Danger Sign (low), improve thermal care, treat and refer
                                                         An axillary (armpit) temperature should be measured in all babies within approx-       Danger sign        ( Improve thermal care, treat and refer )

                                                                                                                                                                                                                    38
                                                         imately 90 minutes after birth. Feeling the skin of the face, abdomen, or foot can                                                                                   37.5°C
                                                         estimate the temperature. Measuring the temperature is more exact. Measuring           Normal range       ( Maintain normal temperature )

                                                                                                                                                                                                                         37
                                                         axillary temperature is safer than measuring rectal temperature.                                                                                                     36.5°C
                                                                                                                                                Cautionary range   ( Improve thermal care )

                                                                                                                                                                                                                    36
                                                         Two common types of thermometers are 1) mercury or gallium and 2) digital. For                                                                                       35.5°C
                                                                                                                                                Danger sign        ( Improve thermal care, treat and refer )
                                                         use in measuring the temperature of a baby, the thermometer must be capable of

                                                                                                                                                                                                                         35
                                                         measuring temperatures below 35.5°C.                                                   Equipment for practice:

                                                                                                                                                                                                                    34
                                                                                                                                                - Doll or manikin
                                                                                                                                                - Thermometer (type used locally)
                                                         Educational advice                                                                     - Form to record temperature
                                                         Prepare locally available solutions (alcohol, soap and water) for cleaning a ther-     - Pen
                                                         mometer or discuss these with the learners. Practice with all types of thermome-       - Hot and cold water or simulated thermometer(s)
                                                         ters that are used locally. Use a manikin or doll to show the proper position of the   - Solution for cleaning

                                                                                                                                                                                                                                        8b
Within 90 minutes after birth
34
     35
          36
               37
                    38

                         Measure temperature

                                                                       38
                                                                                 37.5°C

                                                                            37
                                                                                 36.5°C

                                                                       36
                                                                                 35.5°C

                                                                            35
                                                             38
                                                        37
                                                   36
                                              35
                                         34

                                                                       34
                         To identify babies who require special care

                                                                                          8
Within 90 minutes after birth

                                                                   Weigh the baby

Explain and demonstrate                         • Resume skin-to-skin care or ask the mother                                              Facilitate practice
                                                  to dress the baby promptly after weighing.
Weighing helps identify babies at a higher      • Record the birth weight in the baby’s record.                                           Ask learners to practice how to
risk of death.                                                                                                                            • Balance the scale to zero
• < 2500 grams may require special care to 		                                                                                             • Weigh a baby (manikin or doll)
  prevent low body temperature
• < 2000 grams should receive prolonged         Invite discussion                                                                         • Record the weight
  skin-to-skin                                  1.		 What devices are available for weighing
• < 1500 grams should receive advanced care     		 babies in your community?
                                                2.		 How are these scales cleaned and maintained?
Weigh the baby                                  3.		 Are birth weights recorded?
• If possible, take the scales to the baby.     		 Who keeps these records?
• Clean the scale.                              4.		 How can you ensure that every baby is
• Put a clean cloth or towel on the scale.      		weighed?
• Balance the scale to “zero.”
• Wash hands with soap and water.
• Quickly place the baby on the scale naked
  (no diaper, clothing or blanket).

                                                  Background                                                                              Educational advice
                                                  Birth weight helps identify babies at higher risk, provides a baseline for monitoring   Have learners practice how to obtain an accurate birth weight on a manikin or doll
                                                  growth and may also be necessary for calculating drug doses.                            that must be unwrapped and undressed. Have learners document the weight.

                                                  Babies should be weighed within 90 minutes of birth. However, weighing should           Materials for practice:
                                                  be deferred if an infant is cold unless needed for calculating antibiotic doses. Use    - Doll or manikin
                                                  scales designed for weighing babies. Zero the scales before each use to test that       - Baby scale
                                                  they function properly. Clean the scales with dilute bleach solution or other safe      - Baby clothing or blanket
                                                  cleaning product before each use to prevent infection.                                  - Cleaning solution for scale
                                                                                                                                          - Soap and water or hand cleaner
                                                  Babies with birth weights under 2500 grams may require special care to prevent          - Forms to record birth weight
                                                  low body temperature. Babies with birth weight under 2000 grams should receive          - Pen
                                                  prolonged skin-to-skin care (see page 20b). These babies may need alternative
                                                  feeding methods (see page 22b) and more frequent assessment to identify prob-
                                                  lems and Danger Signs. Babies with birth weights under 1500 grams should be
                                                  referred for advanced care when possible.

                                                  Always document birth weights. Use established regional or national forms and
                                                  guidelines for documenting birth weight, for example on an antenatal card, baby’s
                                                  medical history, and/or the immunization record.

                                                                                                                                                                                                                               9b
Within 90 minutes after birth
34
     35
          36
               37
                    38

                          Weigh the baby

                                                    0   1
                                               12
                                          10                2
                                          9                 3
                                          8                 4
                                               7        5
                                                    6

                         To help identify babies at higher risk

                                                                  9
By 90 minutes after birth

                                                                  Classify the baby

Explain and demonstrate                         Classification should be delayed if a baby                                                  Facilitate practice
                                                • Has a normal exam but did not feed during
Classify babies by 90 minutes                     the first 90 minutes after birth.                                                         Ask learners to practice with role play
• Based on their exam, temperature and weight                                                                                               • Classifying a baby who
• To define further care                        All babies should be classified by 4 hours.                                                   - is breathing 55 times/minute at 90 minutes
                                                                                                                                            		 of age, temperature 36.8°C, and weight
Classify babies as NORMAL if                                                                                                                		 2100 grams (green)
• Breathing normally and normal exam
• Temperature 36.5 to 37.5°C                                                                                                                  - has a normal exam, temperature of 36.2°C,
                                                Invite discussion                                                                           		 and weight 2500 grams (yellow)
• Weight >2000 grams
                                                1.		 Who is responsible for identifying babies                                                - has blue hands and feet but pink lips,
Classify babies as HAVING A PROBLEM if          		 who have a problem or a Danger Sign?
• Temperature 35.5 to 36.4°C                                                                                                                		 temperature 36.5°C, and weight
• Weight 1500 to 2000 grams                     2.		 Which babies are difficult to classify?                                                		 2600 grams (green)
• Feeding poorly                                                                                                                              - is breathing 80 times/minute with severe
Classify babies as NEEDING ADVANCED CARE if                                                                                                 		 chest indrawing at 60 minutes, temperature
• A Danger Sign ( page 24b)                                                                                                                 		 36.9°C, and weight 2700 grams (red)
  or severe jaundice (page 26b) present
• Birth weight
34
     35
          36
               37
                    38

                           By 90 minutes after birth
                         Classify the baby

                           To determine further care

                                                       10
Exercise: Essential care during the first 90 minutes (pages 2-10)                                                                                 Case scenario:
                                                                                                                                                  A baby was born vaginally at 39 weeks gestation. The baby cried at birth.
                                                                                                                                                  The placenta has been delivered and mother is well.

                                                                                                                                                  Checklist

                                                                                                                       38
                                                                                                                                                      Wash hands

                                                                                                                  37
                                                                                                             36
                                                                                                        35
                                                                                                   34
                                                                                                                                                      Explain why it is important to wash hands before touching the baby.
                                                                                                                                      0   1
                                                                                                                                 12
                                                                                                                            10
                                                                                                                            9
                                                                                                                            8
                                                                                                                                              2
                                                                                                                                              3
                                                                                                                                              4
                                                                                                                                                      Monitor breathing
                                                                                                                                 7        5

                                                                                                                                                      Describe fast, difficult, noisy breathing.
                                                                                                                                      6

         Continue                                Provide treatments   Assess and Classify                                                             Continue skin-to-skin care
   skin-to-skin care and                         to prevent disease                                                                                   Explain that skin-to-skin care helps the baby stay warm and begin breastfeeding.
    monitor breathing.                                                                                                                                Initiate breastfeeding
  Initiate breastfeeding
                                                                                                                                                      Describe the signs that a baby is ready to breastfeed and how to position a baby.

                                                                                                                                                  Provide treatment to prevent disease and assess the baby
                                                                                                                                                  (steps can be done in any order between 60-90 minutes)
                                                                                                                                                       Examine the baby
 Work in pairs. Demonstrate and describe                                                                                                               Breathing, skin color, movements, activity, cord appearance, other physical features
 care of a baby for the first 90 minutes                                                                                                               Describe the findings to the mother.
 after birth. One person takes the role of the                                                                                                         Measure temperature
                                                                                                                                                       Tell mother if temperature is normal, low, or high.
 mother. The other person takes the role of
                                                                                                                                                       Weigh the baby
 the health worker who performs the actions
                                                                                                                                                       Tell mother the baby’s weight.
 (black text) and communicates with the                                                                                                                Documents results of exam, weight and temperature.
 mother (green text). Switch roles and repeat
 the exercise with a different case scenario.                                                                                                         Provide eye care
                                                                                              38

                                                                                         37
                                                                                    36

                                                                               35
                                                                          34

                                                                                                                                                      Explain that eye care prevents infections.
                                                                                                                                                      Provide cord care
                                                                                                                                                      Explain that cord care prevents infections.
 Materials for practice:                                                                                                                              Give vitamin K
 - Manikin                                                                                                                                            Explain that vitamin K prevents serious bleeding.
 - Soap, basin and water                                                                                                                              Classify the baby as being Normal, having a Problem, or showing a Danger Sign
 - Thermometer
 - Cleaning solution
                                                                                                                                                    Educational advice
 - Scale
                                                                                                                                                    The purpose of this exercise is to assist the learner in understanding how to integrate essential
 - Ointment or drops for eyes                                                                                                                       actions and assessments while maintaining contact between mother and baby. The facilitator
 - 1.0 mL syringe                                                                                                                                   will demonstrate the actions that are performed during the first 90 minutes after birth, and de-
                                                                                                                                                    scribe explanations and advice given to the mother. The six actions to provide preventive treat-
 - Vial of vitamin K or water to simulate                                                                                                           ments and assess can be performed in any order. Practice begins with the facilitator reading the
 - Documents for recording results of exam, 		                                                                                                      case scenario.
   weight and temperature                                                                                                                           Learners will work in pairs. One person will play the role of the provider who performs the actions
                                                                                                                                                    (black) and communicates with the mother (green). The other will play the role of the mother.
 - Pen                                                                                                                                              Roles will switch after one person successfully completes the exercise. Learners may review the
                                                                                                                                                    Action Plan during the exercise.

                                                                                                                                                                                                                                                          11 b
34
              35
                   36
                        37
                             38
                                           Exercise:
                                        Essential care
                                  during the first 90 minutes

                                                                                              38
                                                                                         37
                                                                                    36
                                                                               35
                                                                          34
                                                                                                             0   1
                                                                                                        12
                                                                                                   10                2
                                                                                                   9                 3
                                                                                                   8                 4
                                                                                                        7        5
                                                                                                             6

 Continue skin-to-skin care,             Provide treatments   Assess and Classify
monitor breathing, and initiate          to prevent disease
        breastfeeding

                                                                                                                         11
After skin-to-skin care with a well, normal weight baby

                                                     Maintain normal temperature

Explain and demonstrate                             Prevent over-heating                                                                         Facilitate practice
                                                    • Do not place babies close to heat sources
Even normal, well babies need care to avoid           or in direct sunlight.                                                                     Ask learners to practice with role play
becoming too cold or too hot.                                                                                                                    • Selecting or describing appropriate clothing
                                                    Assess temperature every four hours during                                                     and head covering for the region
Prevent heat loss                                   routine care by touching the foot or forehead.                                               • Wrapping the manikin to prevent heat loss
• Continue initial skin-to-skin care for at least   • If the skin feels too cool or too hot, measure
  one hour after birth whenever possible.             a temperature.
• Do not bathe prior to six hours after birth.
• Avoid drafts and contact with wet or
  cold surfaces.
                                                    Invite discussion
Maintain normal temperature when
skin-to-skin care is not being used                 1.		 What clothing and wraps are used locally
• Clothe and wrap in a clean, dry blanket,          		 to keep babies warm?
  and cover the head.
• Wrap securely but not tightly.                    2.		 What ways are babies kept warm at home?
                                                    		 Are these safe ?

                                                       Background                                                                                Babies may become too hot if placed in direct sunlight, or if placed too close to
                                                                                                                                                 heaters or stoves. Babies may also become too hot in medical devices with heaters
                                                       A baby begins to lose heat even before the body temperature falls. For this reason,       (for example incubators or radiant warmers). The baby’s temperature should be
                                                       preventing heat loss should begin with skin-to-skin care at birth. Whenever possible,     monitored closely when these devices are used.
                                                       skin-to-skin care should continue for at least one hour after birth. If illness in the
                                                       mother prevents skin-to-skin care with her, another adult may be able to provide
                                                       skin-to-skin care.                                                                        Educational advice
                                                       Avoid heat loss by keeping the environment warm. Avoid drafts and contact with            Prepare clothing and wraps that are used locally for learners to practice. Show how
                                                       wet or cold surfaces. Do not bathe a baby prior to six hours after birth, or longer if    a wet cloth, a cold surface, and a draft can cause a baby to lose heat by exposing the
                                                       the baby is low birth weight or small. (Exception: babies of HIV mothers should be        learners’ bare skin to each one. Have learners demonstrate correct clothing, head
                                                       bathed as soon as possible.)                                                              covering, and wrapping for babies in the region.
                                                       After skin-to-skin care, wrap the baby in a clean, dry blanket or cloth. Wrap securely,   Materials for practice:
                                                       but not so tightly that breathing is difficult. Babies may also be dressed in a diaper    - Doll or manikin
                                                       and shirt. The head should be covered. The amount of clothing should be appro-            - Clothing, head covering, blankets
                                                       priate for the temperature around the baby. This usually means 1-2 layers of clothes
                                                       more than is required for adults to be comfortable.

                                                                                                                                                                                                                                          12b
After skin-to-skin care with a well, normal weight baby
34
     35
          36
               37
                    38

                                  Maintain
                              normal temperature

                         To prevent a baby becoming either too cold or too hot

                                                                                   12
During the first day after birth

                                                          Support breastfeeding

Explain and demonstrate                          Advise mother about                                                                        Invite discussion
                                                 • Signs of good attachment
Support of breastfeeding after birth will          - mouth wide open                                                                        1. What policies in your facility encourage early
improve the chances of success.                    - lower lip turned downward                                                              		 and exclusive breastfeeding?
• Keep mother and baby together unless it is       - chin touching breast                                                                   2. Who helps new mothers with breastfeeding?
  absolutely necessary to separate them.           - most of dark portion of the nipple in the mouth                                        3. Are there any local practices that interfere with
• Encourage breastfeeding whenever the 		                                                                                                   		 exclusive breastfeeding
  baby shows signs of readiness (see page 3b).   • Signs of poor attachment
                                                   - only nipple in mouth
Assist mother with positioning for feeding         - baby pulls on nipple
• Head and body in a straight line                                                                                                          Facilitate practice
                                                 • Alternating the side on which the baby
• Face opposite nipple
                                                   feeds first                                                                              Combine practice of this action with Advise about
• Neck not flexed
                                                                                                                                            breastfeeding problems (see next page).
• Whole body supported                           Provide advice about signs that a baby is
                                                 adquately fed.
Options for positioning for feeding:             • softening of the breast with feeding
                                                 • swallowing sounds heard during feeding
                                                 • feeds every 2-4 hours (8-12 times per day)
                                                 • baby sleeps well between feedings

                                                   Background                                                                               The side on which the baby feeds first should be alternated. The baby may benefit
                                                                                                                                            from burping periodically during feeding.
                                                   Breastfeeding often is not easy, especially for the first-time mother. Advice and sup-
                                                                                                                                            Signs of adequate feeding. The breast will soften during feeding if the breast
                                                   port from a health care provider will increase a mother’s chance of successful and
                                                                                                                                            is emptied. The mother may hear sounds as the baby swallows. Healthy babies
                                                   exclusive breastfeeding.
                                                                                                                                            should feed every 2-4 hours and 8-12 times per day. Babies who are getting
                                                   Good positioning during breastfeeding increases the likelihood of success. This          enough milk sleep well between feedings.
                                                   occurs when the baby is positioned properly and the mother is comfortable.
                                                   Advise the mother to place the baby with the head and body in a straight line with
                                                   the face opposite the nipple, and the neck not flexed. The whole body should be          Educational advice
                                                   supported. This can be done by holding the baby in several positions.
                                                                                                                                            Have learners practice correct position for breastfeeding using a manikin or doll.
                                                   Good attachment occurs when 1) the mouth is open wide, 2) the lower lip is               One learner should take the role of the mother and a second should act as the
                                                   turned downward, 3) the chin is touching the breast, and 4) most of the dark             provider. The provider should both assist and advise the mother.
                                                   portion of the nipple is in the baby’s mouth.
                                                                                                                                            Demonstrate incorrect and correct attachment on a model, by referring to the
                                                   Poor attachment occurs when the baby pulls at the nipple and only the nipple is in       illustrations or by using a volunteer mother.
                                                   the mouth. Poor attachment may cause the baby to take in air and have abdominal
                                                   distention and pain. Mothers may experience severe nipple pain with poor attach-         Materials for practice:
                                                   ment. Poor attachment can lead to engorgement, cracked nipples and mastitis.             - Doll or manikin
                                                   These problems may be prevented by supporting breastfeeding early.                       - Head cover and blanket
                                                                                                                                            - Breast model (optional)

                                                                                                                                                                                                                                 13b
During the first day after birth
34
     35
          36
               37
                    38

                             Support breastfeeding

                         Good attachment            Poor attachment

                             To improve the success of breastfeeding

                                                                       13
Before discharge

                                              Advise about breastfeeding problems

Explain and demonstrate                           Mastitis                                                                                2.		   How are the common breast problems
                                                  • Painful, red and firm area, usually in one                                            		     managed in your community?
Inverted nipples may interfere with                 breast only                                                                           3.		   How do mothers increase their breast
successful breastfeeding by making good           • Ill feeling often with fever                                                          		     milk supply?
attachment more difficult. To improve             • Feed frequently, or express milk to ensure emptying
attachment
• Stimulate nipple before feeding
                                                  • Seek medical attention                                                                Facilitate practice
• Shape breast by supporting underneath with      Advise mothers about how to improve                                                     Ask learners to practice with role play
  the fingers and pressing above with the thumb   flow of milk                                                                            • Positioning a manikin or doll
Teach mothers how to recognize and manage         • Apply warm compresses                                                                 • Pointing out the features of good and poor
other common problems that may prevent            • Massage the back and neck                                                               attachment
successful breastfeeding.                         • Massage the breasts and nipples                                                       • Describing the signs that a baby is adequately fed
Breast engorgement                                To improve supply of milk                                                               • Communicating this information to the mother
• Swelling and shininess of both breasts          • Increase maternal fluid intake                                                        Ask learners to role play advising
• No tenderness or redness                        • Increase frequency of feedings                                                        mothers about
• Feed often, express milk                                                                                                                • Inverted nipples
Sore or cracked nipples                           Invite discussion                                                                       • Breast engorgement
• Nipple tenderness and pain during feeding                                                                                               • Cracked nipples
• Cracks or fissures may be visible               1.		 Who helps new mothers with breast 			                                              • Mastitis
• Ensure good attachment                          		problems?                                                                             • Low milk supply
• Avoid irritation from clothing
• Apply drops of milk                               Background                                                                            Mastitis may occur when blocked ducts limit drainage of milk or may result from
                                                                                                                                          infection. It typically occurs in one breast only, and is present when there is a
                                                    Problems with the breasts during the first week or two following delivery are         well-defined, red, sore and swollen or hardened area. The goal of care is to promote
                                                    common, and may prevent successful breastfeeding. Providers should understand         the immediate resumption of milk flow by frequent breastfeeding or expressing
                                                    the causes of these problems and strategies to prevent or treat them. Because the     milk. If a mother has a temperature of > 38°C, feels ill or does not improve in 2 days,
                                                    problems most commonly occur after discharge from the birth facility, providers       she should seek medical care promptly. Further treatment may include antibiotics.
                                                    should advise mothers about prevention, recognition and treatment.
                                                                                                                                          Improve milk supply by increasing maternal fluid intake and the frequency of feedings.
                                                    Inverted nipples are relatively common and can interfere with breastfeeding be-       Flow of milk during a feeding may be increased by applying warm compresses to the
                                                    cause they make good attachment more difficult. Mothers with inverted nipples         breast, back and neck, massaging breasts and nipples.
                                                    may need extra help when learning to breastfeed. Encourage mothers to stimulate
                                                    the nipples before feeding and to shape the breast before attachment.                 Educational advice
                                                    Breast Engorgement is a sign that the breasts are not being emptied adequately.
                                                                                                                                          Use the illustrations on the front to enhance discussion of breast problems. Have
                                                    When the breasts are engorged both breasts are swollen, shiny and patchy red,
                                                                                                                                          learners role play advising a mother about the management of breast problems.
                                                    but the mother will not have fever. Mothers with engorgement should feed more
                                                    often, and/or express milk prior to attachment.                                       Materials for practice:
                                                                                                                                          - Doll or manikin
                                                    Sore or cracked nipples may result from poor attachment or a skin infection.
                                                                                                                                          - Head cover and blanket
                                                    Ensure good attachment and continued breastfeeding or expression of milk.
                                                                                                                                          - Breast model (optional)
                                                    Advise mothers to wash their breasts at least once a day and avoid soaps, medicated
                                                    lotions, and ointments. Treat cracked nipples by applying the last drops of breast
                                                    milk to the skin.

                                                                                                                                                                                                                                    14b
Before discharge
34
     35
          36
               37
                    38

                                      Advise about
                                 breastfeeding problems

                         Engorgement                  Cracked nipples            Mastitis

                                       To improve the success of breastfeeding

                                                                                            14
Within one day after birth

                                                     Begin immunizations
Explain and demonstrate                   Invite discussion                                                                          Facilitate practice
Review the dose and how to give each      1.		 What immunizations are recommended 		                                                 Ask learners to practice with role play
immunization recommended by the health    		 in your community?
                                                                                                                                     • Explaining to the mother the need for
authority.
                                                                                                                                       immunizations and how they will be given
                                          2.		 How are they stored and who gives them?
Demonstrate how to give the recommended                                                                                              • Drawing up oral, IM, and intradermal
immunizations, which might include:                                                                                                    medications (use air or water for simulation)
                                          3.		 Where is immunization recorded for
• Hepatitis B – 0.5 mL IM                                                                                                            • Identifying the correct injection site on the
                                          		 each baby?
• BCG (tuberculosis vaccine) – 0.05 mL                                                                                                 doll or manikin
  intradermal in the arm                                                                                                             • Cleaning the site of injection
• Oral polio – 2 drops on the tongue                                                                                                 • Recording immunizations in the baby’s record
                                                                                                                                     • Demonstrating the technique for safe disposal
Remind providers to use a new syringe                                                                                                  of syringes and needles
and needle for each baby.

                                            Background                                                                               Educational advice
                                            Specific immunizations differ from one region to another. Follow the recommenda-         Have learners work in pairs with one playing the role of the mother and the other
                                            tions of your health authority. Common immunizations include the following:              acting as the provider. Have learners demonstrate all the steps in performing IM
                                                                                                                                     and intradermal injections as well as oral administration while they explain to the
                                            Hepatitis B vaccine is given IM usually within 24 hours after birth.                     mother what they are doing.

                                            BCG is given intradermally in the shoulder. If mother is HIV positive, BCG is often      Review the importance of prior storage of medications.
                                            deferred until the baby is known to be HIV negative.
                                                                                                                                     Materials for practice:
                                            Polio vaccine is given orally, and is often given at the same time as hepatitis B        - Doll or manikin (to show injection site only)
                                            vaccine and BCG.                                                                         - Alcohol and swabs
                                                                                                                                     - A container with a lid to dispose of syringes.
                                            Remind mothers that additional doses of hepatitis B and polio vaccine will be required   - Recording form and pen or pencil
                                            later. Immunizations against other diseases will also be needed later in infancy.

                                            Providers are not routinely required to wear gloves during the administration
                                            of vaccines (hands must be washed). Sterility during administration is essential.
                                            Needles, with or without attached syringes, should be placed in a solid container
                                            with a lid to avoid needle injury and infection.

                                                                                                                                                                                                                           15b
Within one day after birth
34
     35
          36
               37
                    38

                                     Begin immunizations

                         Hepatitis                      BCG                        Oral polio

                                     To help prevent serious childhood illnesses

                                                                                                15
When considering discharge

                                             Reassess the baby and breastfeeding

Explain and demonstrate                        Invite discussion                                                                             Facilitate practice
Assessment breastfeeding                       1.		    How long do mothers and babies usually stay                                           Combine practice of this action with Give
• Baby feeds every 2-4 hours and feeds at      		      in the birth facility?                                                                guidance for home care (see next page).
  least 8 times per day. 		                    2.		    Are there written criteria for discharge of
• Baby suckles effectively.                    		      babies from your facility?
• Baby settles with each feeding.              3.		    Is the discharge of babies who have breathing
• Mother has little breast or nipple pain.     		      or temperature problems soon after birth
                                               		      delayed? For how long?
If problems with breastfeeding are present,
observe breastfeeding, looking for signs of
poor attachment.
Perform a complete examination of the
baby, with particular attention to signs
of severe jaundice and infection of the
umbilical cord.

                                                      Background
                                                      When possible, discharge from the birth facility should not occur until 24 hours       A second complete exam of the baby should be performed prior to discharge from
                                                      after birth. A longer period of hospitalization should be considered for infants who   the birth facility. The provider should look for signs of severe jaundice. The umbilicus
                                                      have had problems such as low birth weight, low temperature or breathing prob-         should be examined for redness and swelling at the base of the umbilicus and drain-
                                                      lems. Prior to discharge, preparedness for home care is established by assessment      age of pus from the cord. These are signs of infection of the cord. When present, the
                                                      for potential problems in both the mother and the baby.                                cord should be cleaned with soap and clean water. If these signs do not improve
                                                                                                                                             within 2 days, or if a Danger Sign is also present at any time, antibiotics should be
                                                      Signs of successful breastfeeding should be present prior to discharge. The            given. During the exam, abnormal signs should be explained to the mother.
                                                      baby should feed every 2-4 hours and at least 8 times per day, The baby should
                                                      settle between feedings and should suckle effectively with slow, deep sucks
                                                      and occasional pauses. If successful breastfeeding has not been established,
                                                      a feeding should be observed for signs of poor attachment.

                                                                                                                                                                                                                                        126bb
When considering discharge
34
     35
          36
               37
                    38

                         Reassess the baby
                         and breastfeeding

                         To make sure discharge is appropriate

                                                                 16
When discharge is appropriate

                                             Give parents guidance for home care

Explain and demonstrate                          Identify the place and time for follow-up care.                                                Facilitate practice
                                                 • Record follow-up appointment on Parent
Parents will continue essential newborn            Guide or local document.                                                                     Ask learners to practice with role play
care at home. They must                                                                                                                         • Completing a pre-discharge assessment of
• Understand how to keep a baby healthy          Discuss any other guidance from the local                                                        breastfeeding and examination of the baby
• Be able to recognize problems                  health authority (e.g., birth registration).                                                   • Identifying the baby who cannot be discharged
• Know to seek immediate care for Danger Signs   Prior to taking the baby home, parents should                                                  • Discussing key messages for home care
  and other serious medical problems.            be able to demonstrate knowledge about                                                           with parents
                                                 their responsibilities.                                                                        • Assessing the family’s knowledge of
Discuss with the family the following                                                                                                             essential care
key messages                                                                                                                                    • Identifying the place and time for
                                                 Invite discussion                                                                                follow-up care
• Breast feed exclusively
• Manage common breast problems                  1.		    How do you know that parents understand
• Wash hands before touching the baby            		      advice about home care?
• Put nothing on the cord                        2.		    What resources are available for families who
• Complete all immunizations                     		      may have difficulty delivering essential care?
• Seek immediate care for Danger Signs or        3.		    What printed information or records are
  severe jaundice                                		      given to the parents?

                                                        Background                                                                              Parents should demonstrate their knowledge of the key messages. This can be
                                                                                                                                                done by asking parents to repeat key messages. Additional efforts to prepare par-
                                                        Prepare parents for caring for their baby by helping them understand the key            ents for home care should focus on gaps in their knowledge about key messages.
                                                        messages about home care.
                                                                                                                                                Advise parents about other healthy practices that are recommended in
                                                        Key messages:                                                                           your setting. This might include advice regarding prevention of malaria, well-
                                                        Exclusive breastfeeding for at least 6 months provides the best nutrition for           child visits, and family planning.
                                                        babies, and helps protect against infection. Healthy babies feed every 2-4 hours
                                                        or 8-12 times per day and sleep well between feedings. From around day six after        Advise parents about the time and place of the first follow up appointment.
                                                        birth, well-fed babies urinate 6-8 times per day.                                       Record these details in the Parent Guide or similar document.

                                                        Recognition and management of common breastfeeding problems, includ-
                                                        ing engorgement, cracked nipples, and mastitis (see Advise about breastfeeding          Educational advice
                                                        problems, page 14b). This can help improve rates of exclusive breastfeeding. Advise
                                                        mothers that nipple pain should not be felt and is usually a sign of poor attachment.   Have learners role play with one acting as the mother and the other acting as the
                                                        If mothers with breastfeeding problems develop a fever, or in general feel unwell,      provider. The provider assesses the mother for successful breastfeeding and per-
                                                        they should seek health care.                                                           forms a complete examination of the baby. The provider discusses key messages
                                                                                                                                                for home care and explains the contents of the Parent Guide. Emphasize that the
                                                        Washing hands before touching the baby and putting nothing on the cord
                                                                                                                                                family’s understanding of the key messages is critical for effective home care.
                                                        helps prevent infection.
                                                                                                                                                Materials for practice:
                                                        Completion of all scheduled immunizations to ensure that the baby is protect-
                                                                                                                                                - Doll or manikin
                                                        ed from dangerous illnesses. Remind parents of the immunization schedule that is
                                                                                                                                                - Parent Guide or other appropriate document
                                                        recommended in your setting.
                                                                                                                                                - Pen
                                                        Recognition of Danger Signs, or severe jaundice, and seeking appropriate care
                                                        helps babies receive advanced care, which can be lifesaving.
                                                                                                                                                                                                                                    17b
17
     To help parents continue essential care and recognize problems
                                  Dang
                        Seek                        er Si
                               healt                      gn                             s
                                    h car
                                              e im
                                                             media
                                                                                    tely!
                                       Too
                                                                                                                                                                               DA NG
                                            hot or
                                       too cold                                                                                                                                        ER SIG
                                                                                                                                                                                              NS
                                                                                                                                                                                   Help
                                                                                                                                                                                        your         ESSE
                                                                                                                                                                                             baby         NTIAL
                                   Convuls                                                                                                                                                                      CA RE
                                          ions                                                                                                                                                    surv
                                                                                                                                                                                                       ive
                                                                                                  Baby
                                                                                                            ’s birth                      N OT
                                                                                            Date                           weig                      E
                                                                                         follo         and                          ht: ......... S
                                                                                                 w-up location
                                                                                                             appo                                   .........
                                                                                 Clini                                           of next                      .........
                                                                                                                       intm                                             . gram
                                                                                          c: .........                           ent:                                          s
                                                                                                       .........                          .........
                                                                        Heal                                     .........                          /.......                              OBS
                                                                                                                                                                                                E RVA
                                                                                                                           .........                         .../....
                                                                    ......... th worker                                              .........                         ......                           TIO
                                                                              .........                                                        .........                                                      NS A
                                                                                                                                                                                                                   ND
                                                                                        ......... contact:                                               .........                                                      A DV
                                                            Othe                                 .........            .........                                    ...
                                                                                                           .........            .........                                                                                      ICE
                                                       ......... r notes:                                            .........            .........
                                                                                                                               .........            ........
                                                   ......... .................. ..................                                       .........
                                               ......... .................. .................. ..................                                  .....
                                           ......... .................. .................. .................. ..................
                                       ......... .................. .................. .................. .........
                                                .........                                                                             .....
                                                          ......... .................. .................. ..............
                                                                   .........
                                                                             ......... .................. ..............
                                                                                      .........
                                                                                                ......... ..............
                                                                                                          .........
                                                                                                                    .....
                for home care
                                                                                                                                                                                                                                                         34
                                                                                                                                                                                                                                                    35
                                                                                                                                                                                                                                               36
                                                                                                                                                                                                                                          37
                                                                                                                                                                                                                                     38

            Give parents guidance
                    When discharge is appropriate
Exercise: Essential care for a well baby (pages 12-17)                                                                   Case scenario:
                                                                                                                         At 2 hours of age, a baby with a birth weight of 2900 grams has a
                                                                                                                         temperature of 36.7 oC and a normal physical exam.

                                                                                                                         Checklist
                                                                                                                             Wash hands
                                                                                                                             Reinforce why it is important to wash hands before touching the baby.
     Maintain                Support         Advise about       Begin                                 Reassess and            Maintain normal temperature
   temperature            breastfeeding      breastfeeding   immunizations                       give parents guidance       Explain ways to prevent heat loss and how to wrap a baby..
                                               problems                                              for home care
                                                                                                                             Support breastfeeding
                                                                                                                             Describe for mother good positioning and attachment at the breast.
                                                                                                                              Advise about breastfeeding problems
                                                                                                                             Advise mother about breast engorgement, sore or cracked nipples,
                                                                                                                             mastitis, and low milk supply.
Work in pairs. Demonstrate and describe                                                                                      Begin immunizations
care of a well baby following the first 90                                                                                   Explain each medication and complete the immunization record.
minutes after birth. One person takes the                                                                                    Reassess the baby and breastfeeding (temperature, feeding, breathing/ color,
role of the mother. The other person takes                                                                                   movements/activity, cord appearance, jaundice and adequacy of feeding)
the role of the health worker who performs                                                                                   Discuss any concerns with the family.
the actions (black text) and communicates                               34
                                                                             35
                                                                                  36
                                                                                       37
                                                                                            38

                                                                                                                             Give parents guidance for home care
with the mother (green text). Switch roles                                                                                   Review key messages in the Parent Guide and the plan for follow-up care.
and repeat the exercise with a different
case scenario.

  Materials for practice:                                                                                                  Educational advice
  - Manikin                                                                                                                The purpose of this exercise is to assist the learner in understanding how to integrate essential
  - Head cover and blanket                                                                                                 care that is required following the initial period after birth (the first 90 minutes) until preparation
                                                                                                                           for home care for a baby of normal weight who has no problems. The facilitator will demonstrate
  - Syringes                                                                                                               the actions that are performed during essential care of a well baby, and describe explanations
  - Parent Guide                                                                                                           and advice given to the mother and other family members. Practice begins with the facilitator
                                                                                                                           reading the case scenario.
  - Recording form for assessment
  - Pen                                                                                                                    Learners will work in pairs. One person will play the role of the provider who performs the actions
                                                                                                                           (black) and communicates with the mother (green). The other will play the role of the mother.
                                                                                                                           Roles will switch after one learner successfully completes the exercise.

                                                                                                                                                                                                                                     18b
34
           35
                36
                     37
                          38

                                               Exercise:
                                    Essential care for a well baby

  Maintain                        Support      Advise about       Begin             Reassess and
temperature                    breastfeeding   breastfeeding   immunizations   give parents guidance
                                                 problems                          for home care

                                                                                                       18
If the baby has an abnormal temperature

                                                           Improve thermal care

Explain and demonstrate                          Invite discussion                                                                       Facilitate practice
Warm a baby whose temperature is  37.5°C
• Check for too much clothing.
• Move baby from direct sunlight or away
  from a heat source .
Measure baby’s temperature hourly until
normal. For a temperature  37.5°C,
that does not improve after one hour of
warming or cooling, seek advanced care.

                                                   Background
                                                   If a baby’s temperature is below normal, make sure that the room is warm (25-         A temperature that is too high may also be dangerous. A high temperature may be
                                                   28°C) and without drafts. Make sure that the baby is dry, and is not wrapped in wet   caused by wrapping a baby in too many clothes, leaving a baby in direct sunlight, or
                                                   covers or clothing. Skin-to-skin care should be continued and improved, or            placing a baby too close to a heat source. Inappropriate use of a radiant warmer may
                                                   resumed if stopped. Dress the baby in a diaper, hat and socks, and place on the       also cause a high temperature. Use of radiant warmers requires special training, and
                                                   mother’s chest. Cover mother and baby with additional layers of warm, dry clothing    should include frequent temperature monitoring. A high temperature may also be a
                                                   and/or blankets. Check the temperature every hour until normal. Continue feeding      sign of infection. A temperature > 37.5°C that does not fall with appropriate thermal
                                                   during rewarming.                                                                     care is a Danger Sign.

                                                   Using these steps, 90% of babies with a low temperature will have a normal
                                                   temperature within 4 hours. A low temperature that does not rise after one hour
                                                   of attempts at warming is a Danger Sign. For these babies, seek advanced care
                                                   urgently. Maintain skin-to-skin care during this time.

                                                                                                                                                                                                                                 19b
You can also read