10.1 Routine care and examination in the first few hours of life


Immediately and rapidly assess the infant’s condition so that resuscitation can be started, if needed (Section 10.2). The resuscitation equipment should be ready at hand and ready for use.

10.1.1 Clearing the airway

Wipe the nose and mouth to clear the airway.

Only suction the nose and mouth if there is obvious obstruction. Do not enter the larynx/trachea (there is a risk of bradycardia or laryngeal spasm). Preferably use a suction bulb (Penguin).

10.1.2 Cord clamping and cord care

Wait at least 2 minutes before clamping the cord in all infants who are crying vigorously (and especially those weighing less than 2500 g).
For optimal transfusion, keep the infant on the mother’s chest.

Clamp the cord with two Kocher forceps 10 cm from the umbilicus and cut between the two forceps. Use sterile blade or scissors – a different pair than were used for episiotomy, if performed.

Tie off the cord with a Barr clamp or sterile thread (double ligature), leaving a 2- to 3-cm stump.

Disinfect the umbilicus with a sterile compress soaked in 7.1% chlorhexidine (or, if not available, 10% polyvidone with a maximum of 3 applications total).

10.1.3 Apgar score

The Apgar score is evaluated at 1 and 5 minutes after complete delivery of the infant and recorded in the medical chart and the infant’s health record.

The score is a tool for monitoring the infant’s adaptation to extra-uterine life. It is not used to determine whether resuscitation is indicated; this should be evaluated at birth, based on whether or not there is spontaneous respiratory effort, without waiting for the 1-minute assessment.

In case of resuscitation, the Apgar score is determined retrospectively.

If the Apgar score is ≤ 4 at 1 minute or ≤ 6 at 5 minutes, the midwife should call the doctor and should initiate necessary steps based on infant’s needs. Once stabilised, the infant should be kept under observation for at least 24 hours.

Table 10.1 - Apgar score

Items evaluated/score

0

1

2

Skin colour*

Extreme pallor

Cyanotic extremities
No central cyanosis

Totally pink

Respiration

None

Abnormal (slow, shallow, apnoea, etc.)

Normal

Heart rate

0

≤ 100/minute

> 100/minute

Muscle tone

Absent

Hypotony
Incomplete flexion of extremities

Good
Complete flexion of extremities

Responsiveness
(after stimulation)

Nil

Grimace

Good, vigorous cry

* A healthy infant is usually born cyanotic but turns pink within 30 seconds after breathing starts. For infants with dark skin, assess skin colour by the soles of the feet, palms of the hands and mucous membranes.

Table 10.2 - Significance of the Apgar score

1-minute score
5-minute score

0 - 4

Asphyxia


0 - 6 Asphyxia

5 - 7

Difficulty adapting


7 - 8 Difficulty adapting

8 - 10

Good adaptation


9 - 10 Good adaptation

10.1.4 Clinical examination

The birth attendant should perform a complete examination of the newborn as soon as possible and preferably within 2 hours. The examination should be done under a warmer for infants.
All observations are recorded on a monitoring sheet.

The first priority is to look for danger signs: e.g. abnormal temperature, abnormal colour, difficulty breathing, neurological signs, severe abdominal distension, or symptomatic hypoglycaemia (Section 10.3.1 and Section 10.3.5).

Assess the risk factors for neonatal infection (Section 10.3.4) for all infants, whether the examination reveals danger signs or not.

The examination includes:
– Respiratory rate (normal values for infants 0-1 month are 30-60 breaths/minute)
– Heart rate (normal values for infants 0-1 month are 100-160 beats/minute)
– Temperature
– Weight (weigh the infant naked on an appropriate scale, calibrated beforehand).
– Examination of the skin and mucous membranes, oral cavity, palate, eyes, ears, fontanelles, abdomen, spine, genital organs, anus, feet, hands; neurological examination (posture, tone and reflexes, including sucking, grasp, response to stimulation).
– Check if the infant urinates and produces stools.

10.1.5 Thermoregulation

– At birth, dry the infant with a clean, dry cloth. Then, wrap the infant in another clean, dry cloth. Cover the head with a cap to reduce heat loss.
– Keep the infant in a warm room (at least 25°C).
– Place the infant skin-to-skin against the mother’s (dried) body and cover with a dry cloth or blanket.
– Do not bathe the infant for 6 to 12 hours after birth.

The axillary temperature should be kept between 36 and 37°C, and the infant should have pink, warm feet.

10.1.6 Feeding

– Exclusive breastfeeding is the best option (Appendix 3).
– Put the infant to the breast as soon as possible within an hour of birth.
– Encourage breastfeeding on demand day and night (at least 8 times/24 hours, i.e. every 3 hours).
– If the mother is HIV-infected, see Appendix 3, Section 3.7.

10.1.7 Preventive treatments

Routine prophylaxis for gonococcal ocular infection

For all infants:
Apply 1% tetracycline eye ointment: a 1-cm strip in each eye as soon as possible, preferably within an hour of birth.

Note: if the mother has a symptomatic genital infection at the time of delivery, see Section 10.4.

Routine prophylaxis for haemorrhagic disease of the newborn

phytomenadione (vitamin K1) IM in the anterolateral aspect of the thigh within the first few hours of life:
Infant weighing more than 1500 g: 1 mg as a single dose (0.1 ml if 2 mg/0.2 ml ampoule)
Infant weighing less than 1500 g: 0.5 mg as a single dose (0.05 ml if 2 mg/0.2 ml ampoule)

Note: open ampoules of phytomenadione should be used immediately or discarded. Do not store open ampoules, even in the refrigerator.

Prevention of mother-to-child HIV transmission

All infants of HIV-infected mothers should receive antiretroviral treatment as soon as possible.
See the specific PMTCT protocol.

10.1.8 Vaccinations

The monovalent Hepatitis B and BCG vaccines are recommended as soon as possible after birth for all newborns, including low birth weight and premature infants. The oral polio vaccine is recommended at birth in endemic areas or areas at risk of poliovirus importation.

For the Hepatitis B and oral Polio vaccines, the dose administered at birth is an extra dose (called and recorded as “Dose 0”). It does not count as one of the 3 doses required by the Expanded Programme on Immunization during the postnatal period.

The purpose of Hepatitis B Dose 0 is to prevent mother-to-child transmission of the disease. It should be administered as soon as possible, preferably within the first 12 hours of life. While it may still be administered after that time, the later the vaccine is administered, the less effective the protection1,2. In principle, this vaccine should be administered in the delivery room.

Table 10.3 - Neonatal vaccination

Vaccine

Contra-indications

Dose/route of administration

Hepatitis B
monovalent Dose 0

No contra-indication, but use only the monovalent vaccine (Hepatitis B only)

One dose = 10 micrograms

IM injection, anterolateral aspect of the thigh

BCG

Newborn whose mother has active TB as long as she is contagious (Section 10.4.6)*

One dose = 0.05 ml

Intradermal injection, deltoid region (at the junction of the lower 2/3 and upper 1/3 of the lateral aspect of the upper arm)

Polio oral
Dose 0

No contra-indication

One dose = 2 drops

Oral route

* Start the infant on isoniazid preventive therapy, and administer the BCG vaccination when the isoniazid therapy is completed.

Note: to perform an IM injection in newborns:
– Disinfect the skin beforehand (risk of abscess and other infections).
– Use the anterolateral aspect of the thigh (quadriceps muscle). Never inject into the gluteal or deltoid muscle (arm).
– Use the appropriate needle: 26G if < 2500 g; 23G if > 2500 g.
– The maximum amount to inject is 1 ml if < 2500 g; 2 ml if > 2500 g.

10.1.9 Daily monitoring

Newborn (and maternal) mortality is the highest in the first 24 hours after birth. Women are encouraged to stay for 24 hours in the maternity.
Routine monitoring and care includes:
– Temperature, heart and respiratory rate, twice daily.
– Cord disinfection once the first day (use the available antiseptic, Section 10.1.2). After that, keep it clean, dry and exposed to the air (no dressing).
– Support to breastfeeding.
– Urination and stool production.

Record the observations on the newborn’s monitoring sheet.

For the discharge criteria: see Section 10.6.