2 Care of the newborn baby

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Contents

• Objectives
• Size at birth
• Care of normal babies after birth
• Common problems in newborn babies
• Important danger signs in newborn babies
• Supporting mothers of newborn babies
• Registering newborn babies
• Case studies

Objectives

When you have completed this chapter you should be able to:

1. Explain why it is important to weigh all babies at birth
2. Describe the management of babies immediately after birth
3. Provide routine care to newborn babies
4. Identify common problems which need treatment at the clinic
5. Recognise danger signs
6. Support mothers of newborn babies
7. Register newborn babies

Size at birth

2-1 Should all newborn babies be weighed after birth?

Yes. It is very important that all newborn babies be weighed after birth. The birth weight must be carefully recorded.

All newborn babies must be weighed after birth.

2-2 Do all newborn babies weigh the same at birth?

No. Most newborn babies weigh between 2500 g and 4000 g at birth. However some are smaller than normal and weigh less than 2500 g while others are larger than normal and weigh more than 4000 g.

Babies that weigh less than 2500 g are called low birth weight babies.

Low birth weight babies weigh less than 2500 g at birth.

2-3 Why is the birth weight important?

Birth weight is important to identify low birth weight babies as they are at risk of increased of problems in the first few days after delivery. As a result they may need admission to hospital or need extra care at home.

2-4 Why do some babies have a low birth weight?

There are two important causes of low birth weight:

• Some low birth weight babies are born too soon
• Other babies have not been born too soon but have grown slowly during pregnancy. They are therefore underweight for age and often look thin and undernourished. Many of these babies are underweight because the mother is undernourished, smokes cigarettes or drinks alcohol. Therefore not all low birth weight babies are born too soon.

2-5 Which babies are born too soon?

When counting from the first day of the mother’s last menstrual period to the day of birth, most infants are born between 37 weeks and 42 weeks. The length of pregnancy is called the gestational age. Babies who have a normal gestational age (37 to 42 weeks) are called term babies. Babies born before 37 weeks (259 days) are born too soon and are called preterm or premature babies.

A normal pregnancy lasts 37 to 42 weeks.

2-6 Why do low birth weight babies have many problems?

• Because preterm babies are born too soon many of their organs, such as their lungs and liver, are still immature and not ready to function normally after birth.
• Because underweight for age babies are often undernourished at birth they often get cold and have a low blood sugar level.

Low birthweight babies often have problems after delivery and therefore need extra care.

2-7 What should be done if a baby is born with a low birth weight?

The baby should be carefully examined by a nurse or doctor to decide whether the mother can care for the baby at home or whether the baby needs to be admitted to hospital to gain weight and receive extra care.

Care of normal babies after birth

2-8 Do all newborn babies start breathing by themselves?

Most newborn babies will start breathing as soon as they are born and will be breathing well within a minute after delivery. Usually they will also start crying loudly. Drying babies soon after birth helps to stimulate breathing.

About 10% of newborn babies, especially if they are low birth weight, will not start breathing well and may need some help. Bag and mask ventilation is the best way of helping these babies to start breathing.

The baby’s clinical condition is assessed at one minute after birth and given an Apgar score. A normal Apgar score is seven or more out of ten. Babies with a low score need some resuscitation or special care.

2-9 When should babies be given to the mother?

It is best if the baby is placed on the mother’s abdomen immediately after birth. In this position the baby should be well dried and then covered with a dry towel.

If at all possible the mother and baby should be kept together after delivery.

2-10 When should the umbilical cord be cut?

It is best to wait two minutes after the birth of the baby so that pulsations can stop before clamping and cutting the umbilical cord. This gives the baby extra blood from the placenta which provides iron that reduces the risk of anaemia during the first year of life. When the cord has been cut and clamped the baby can be moved to lie between the mother’s breasts. This is called the kangaroo care position.

2-11 When should the newborn baby be put to the mother’s breast?

If the baby is moving actively, breathing well and the umbilical cord has been cut the baby can be put to the breast. If placed in the kangaroo care position, most newborn babies will try to find the mother’s nipple. Even though there will be little milk, sucking at the breast helps to speed up delivery of the placenta.

The baby should be put to the breast as soon as possible after birth.

2-12 What needs to be done routinely after the baby is born?

After the baby is dried and placed on the mother’s chest, and after the placenta has been safely delivered, a number of tasks must follow:

• Injection of vitamin K
• Identifying the baby
• Eye care
• Umbilical cord care

There is no need to bath the baby after birth as the baby may get cold. If the baby is covered with blood from the delivery this can be wiped away with a warm towel.

2-13 Which babies need vitamin K?

The nurse should give all babies an intramuscular injection of vitamin K to prevent bleeding during the first week of life. In newborn infants injections must always be given into the upper outer thigh and never into the buttocks.

2-14 How are babies identified?

Usually plastic bands with the mother’s name and clinic number are placed around the baby’s wrist and ankle.

2-15 What is eye care?

After delivery antibiotic drops or ointment (usually Chloromycetin) should be placed in both the baby’s eyes to prevent infection (conjunctivitis) caused by germs from the mother’s vagina. Preventing infection of the eyes is called eye prophylaxis.

2-16 What is umbilical cord care?

The umbilical cord should be cleaned with surgical spirits (alcohol) or a 4% solution of chlorhexidine. This helps to prevent infection of the cord and should be repeated once a day until the cord falls off. It is very important not to put anything else onto the cord. Never put aspirin, soil or cow dung on the cord.

Some health facilities recommend just keeping the cord clean and dry and not covering the cord with the nappy.

Common problems in newborn babies

2-17 What problems are common in newborn babies?

Problems which are common in newborn babies, especially if they are low birth weight babies, are:

• Not starting to breathe well at birth
• Difficulty breathing
• Getting cold easily
• Feeding problems
• Infection of the eyes
• Infection of the umbilical cord
• Infection of the skin
• General infection
• Jaundice.

Each of these common problems may present with a danger sign. It is important for the community healthcare worker to look out for danger signs.

2-18 What is a danger sign?

A danger sign is something that the family or health carer sees or notices which indicates that the baby is sick and may die if not urgently treated. If one or more danger signs are present there will usually be a clinical problem. All mothers and healthcare workers should know the danger signs and always look out for them when handling or examining a newborn baby.

It is important to always look for danger signs

2-19 What are the danger signs of difficult breathing?

• Fast breathing with more than 60 breaths per minute. Normal babies have about 40 breaths per minute.
• Periods of no breathing lasting more than 20 seconds. This is called apnoea. Some healthy low birth weight babies may stop breathing for only a few seconds. This normal and is called periodic breathing.
• Marked in-drawing of the lower ribs when the baby breathes in.
• Blue hands, feet and tongue due to a lack of oxygen. Some normal babies may have blue hands and feet if they are cold. Their hands and feet become pink when they are warmed. All these signs of breathing difficulties are danger signs. These babies usually need oxygen and should be moved urgently to a healthcare facility.

2-20 When is a baby too cold?

Feeling the temperature of a baby’s hands and feet is a good way of deciding if a baby is getting cold. Normally the baby’s hands and feet should be warm. The baby’s temperature can be taken by gently placing a digital thermometer under the baby’s arm in the armpit for one to two minutes. A normal temperature is about 36.5 degrees. A temperature below 35 degrees is a danger sign. Never place the thermometer in the baby’s mouth or anus.

Cold babies should be placed skin to skin in the kangaroo care position to warm up. The baby should only wear a woollen cap and nappy and should be covered with a blanket. These babies should be taken to the clinic to be assessed as getting cold may be a sign of severe infection.

2-21 What are common feeding problems?

• Some low birth weight babies feed poorly because they are too weak and immature to suck well.
• Feeding problems in term infants are usually due to incorrect latching at the breast. It is important for all mothers to learn how to latch their baby to the breast correctly.
• Poor feeding in a baby who fed well before is a danger sign of severe infection.

Babies that feed poorly must be urgently taken to the nearest clinic or hospital.

2-22 What are the signs of a mild eye infection?

A mild eye infection (conjunctivitis) presents with a clear, sticky discharge of the eye. The eye lids may stick together. There is no swelling of the eyelids and no pus.

Both eyes should be wiped with a cotton wool ball and clean water. If the infection does not clear or if it gets worse the baby should be referred to the clinic as a few days of antibiotic ointment into both eyes may be needed.

2-23 When is an eye infection a danger sign?

A severe eye infection is a danger sign. With a severe eye infections there will be:

• Pus in the eye
• The eyelids will be swollen and it may be difficult to open the baby’s eye.

These are important danger signs. If there is pus in the eye the baby must be taken to the clinic or hospital urgently for an injection of antibiotics and for the eye to be carefully cleaned. An untreated severe eye infection can cause blindness.

Severe eye infection is an important danger sign

2-24 What are the signs of infection of the umbilical cord?

Signs of cord infection are:

• The cord may be wet or covered in pus
• The cord may smell bad
• The skin around the base of the cord may be red.

Babies with an umbilical cord infection should be referred to the clinic. Treatment is usually good cord care with 4% chlorhexidine or surgical spirits every 4 hours until the signs of cord infection are gone.

Normally the umbilical cord will come off between one and two weeks after delivery. Never pull or cut the cord off.

2-25 When is umbilical cord infection a danger sign?

With severe umbilical cord infection there will be signs of severe general infection.

2-26 What are the signs of severe general infection?

These are very important danger signs:

• The baby may move very little or not wake up when handled
• The baby is very irritable or having fits
• The baby may appear unwell, feed poorly or vomit repeatedly
• The abdomen may be swollen.

These babies are very ill and must be taken to the clinic or hospital urgently for treatment with antibiotics.

Babies with danger signs of severe general infection must be taken to the clinic or hospital urgently.

2-27 What are the signs of skin infection?

Babies with a skin infection have small yellow blisters full of pus. These are usually seen around the base of the umbilical cord. Babies with a skin infection should be taken to the local clinic. A mild infection can be treated with an antiseptic soap but a severe infection will need antibiotics.

2-28 What is jaundice?

Jaundice is a yellow colour of the skin cause by a yellow pigment called bilirubin which is deposited in the skin. Normally the kidneys and liver remove the bilirubin from the baby’s body. However in newborn babies these organs do not function well for the first 2 weeks. As a result mild jaundice is very common and causes no problems. These babies have a yellow face, chest and abdomen but their hands and feet are not yellow.

However some newborn babies may have severe jaundice because they are preterm or due to problems with their blood or liver. This is dangerous and may result in brain damage.

2-29 When is jaundice a danger sign?

Jaundice is dangerous when it is severe. Danger signs of severe jaundice are:

• It is present in the first 2 days (48 hours) after birth
• If the baby appears very yellow
• If the palms of the hand and soles of the feet are also yellow
• If the baby is sick or appears unwell.

All these babies must be urgently referred to the nearest clinic or hospital. A blood test will measure how much bilirubin is present in the body. Most very jaundiced babies will be treated with phototherapy (“the lights”).

Important danger signs in newborn babies

2-30 What are the common danger signs?

• Difficulty breathing: apnoea, a blue colour, breathing fast, chest in-drawing
• A cold baby with a temperature below 35 degrees
• Poor feeding or repeated vomiting especially if the baby fed well before
• Severe eye infection with swelling of the eyelid and pus
• Severe cord infection with signs of general infection: little movement, swollen abdomen, poor feeding, pale skin, bleeding, very irritable
• Severe jaundice with yellow hands and feet

Every time a community healthcare workers visits the home these danger signs must be looked for. Identifying babies with a danger sign and getting these babies to a clinic or hospital for treatment can save the lives of many babies. Mothers should also be taught the danger signs.

Babies with any important danger signs must be taken to the nearest clinic or hospital immediately.

Supporting mothers of newborn babies

2-31 When should the mother and her baby be visited after delivery?

If a healthy mother has a normal vaginal delivery and the baby is normal, she and her baby may be discharged home from the clinic or hospital after 6 hours. Before discharge the baby should be carefully examined to make sure there are no problems.

After discharge the baby should be seen at home or at the clinic on days 1, 3, 7 and 14 after birth. These postnatal visits are very important as they should be used to screen for problems in the mother and baby.

Postnatal visits are an essential part of good newborn care.

2-32 What should be done at each postnatal visit?

The community healthcare worker should visit the home and assess both mother and baby. The important steps are:

• Introduce yourself and explain why you are visiting
• Give her your contact details in case there are problems
• Have a look at any documentation which the mother has from the clinic or hospital where she delivered
• Ask whether the mother has any problems
• Assess the mother
• Assess the baby
• Give the mother any advice needed and answer her questions
• Support her in caring for herself and her baby, especially breastfeeding
• Make sure she can keep her baby warm
• Arrange further visits
• Refer the mother or baby to the clinic if you have any problems or if there are any danger signs.

At the first visit the mother may need help with bathing the baby and cleaning the umbilical cord. If the baby has been HIV exposed the mother should also be shown how to give her baby the antiretroviral (ARV) medication. At the 14 day visit the mother must be told when and where to go for the baby’s immunisations at 6 weeks.

2-33 How should the baby be assessed?

There should be a list of things that need to be checked at each visit. This is best done with a visiting card that lists what should be checked at each visit. The important items to check are:

• General appearance: Does the baby appear well and active?
• Feeding: Is the baby feeding well and are the mother’s breasts normal?
• Breathing: Any fast or slow breathing and any chest in-drawing?
• Colour: Is the baby pink, blue, pale, or jaundiced (yellow)?
• Eyes: Is there any discharge from the eyes?
• Umbilical cord: Is there any sign of infection of the umbilical cord?
• Skin: Are there any signs of skin infection?
• Are there any danger signs?

A careful record should be kept at each visit. Looking for danger signs at every visit is very important. It is helpful if the baby can be weighed on days 7 and 14 to make sure there is weight gain.

It is important to look for danger signs at every visit.

Registering newborn babies

2-34 When should newborn babies be registered?

All newborn infants must be registered at any Department of Home Affairs office within 30 days of birth. The following documents are needed to register a newborn baby:

• Proof of birth or clinic card from the hospital or clinic
• Both the parent’s identification documents
• A copy of their marriage certificate if they are legally married
• If the parents are not married they must both go to the Home Affairs office with their identification documents.

The community healthcare worker can help parents by informing them where to go and what documents to take with them. Once the birth is registered a birth certificate will be issued.

Case study 1

A young mother delivers a baby weighing 2000 g at a local clinic. She says she is only 36 weeks pregnant and admits that she smokes 20 cigarettes a day.

1. Is this a low birth weight baby?

Yes. The baby weighs less than 2500 g. Most babies weigh between 2500 g and 4000 g at birth.

2. Why does this baby only weigh 2000 g?

Because it is a preterm baby as it was born too soon at 36 weeks. Most babies are born between 37 and 42 weeks after the mothers last period. The mother says she smoked heavily so the baby may also be undernourished and underweight for age.

3. Should this baby receive normal care only?

No. This baby needs extra care as there is a risk of problems such as getting cold, poor feeding and infection.

4. What should the Community Healthcare Worker do if this baby was born at home?

The mother and her baby must be taken to the local clinic or hospital so that the baby can be examined. Then it can be decided whether the mother can care for her baby at home or whether the baby should be admitted to hospital.

Case study 2

A normal baby is delivered at a clinic. The umbilical cord is cut immediately and the baby is dried and placed in a cot next to the mother. After the placenta is delivered the mother is shown how to bath the baby.

1. When is the best time to cut and clamp the umbilical cord?

The umbilical should not have been cut and clamped immediately after delivery. It is best to wait about 2 minutes after birth so that the baby can get some extra blood from the placenta. The iron in the extra blood helps prevent anaemia during the first year of life.

2. Should the baby have been placed in a cot after delivery?

No. It would have been much better if the baby had been placed in the kangaroo care position.

3. When should the mother put her baby to the breast?

As soon as possible after birth. The sooner she puts the baby to the breast the better is the chance that she will successfully breastfeed.

4. Do babies need a bath after delivery?

There is no need to bath the baby after delivery as this may cause the baby to get cold. The mother can be shown how to bath her baby after a few days.

Case study 3

When a community healthcare worker visits a mother on day 3 after delivery she notices that the baby has sticky eyes and is also mildly jaundiced. The baby is active and feeds well.

1. What is the cause of sticky eyes?

A mild eye infection called conjunctivitis. This is common and usually settles if the eyes are gently wiped with a cotton wool ball and clean water.

2. Can sticky eyes be dangerous?

Yes. If the eye infection becomes severe with swollen eyelids and pus these are danger signs and the baby needs urgent treatment with an injection of antibiotics. If not correctly treated severe conjunctivitis can cause blindness.

3. What is jaundice in a newborn infant?

Jaundice is a yellow colour of the skin due to the presence of bilirubin. In a newborn infant jaundice is usually mild due to the baby’s liver not yet functioning fully.

4. How can you tell if newborn jaundice is severe?

If it presents in the first 48 hours after birth, if the baby looks very yellow with yellow hands and feet or if the jaundiced baby appears to be ill with poor feeding. These babies must be urgently taken to a clinic or hospital.

5. How is a baby with jaundice treated?

With mild jaundice there is no need to treat the baby. Severe jaundice is usually treated with phototherapy in a hospital.

Case study 4

When a community healthcare worker does a postnatal visit on day 7 the mother says that the baby has not been feeding well that day and has vomited twice. She also says that the umbilical cords has been wet and smells bad. She has not cleaned the cord with surgical spirits as instructed as the granny said she must put ash on the cord. On examination the baby looks ill and has a distended abdomen.

1. What do you think is the problem with this baby?

The baby has a number of important danger signs of poor feeding, repeated vomiting, looking ill and a distended abdomen. These signs suggest severe general infection.

2. What do you think is the cause of the problem?

The baby has a severe infection of the umbilical cord.

3. How could this problem have been avoided?

The mother should have given daily cord care with surgical spirits or 4% chlorhexidine or kept it clean and dry. She should not have put ash on the cord.

4. What should the community healthcare worker do?

The baby must be taken urgently to the local clinic or hospital as treatment with antibiotics is needed.