10.1 Routine care and examination

10.1.1 In the first hours of life

  Anticipate the need for resuscitation at every birth. The necessary equipment should be ready at hand and ready for use.

Initial assessment

At birth, dry thoroughly and rapidly assess the neonate’s condition:

The neonate

• Is not breathing spontaneously or has difficulty breathing

• Has poor muscle tone

• Has a heart rate less than or equal to 100 beats/minute

• Has persistent central cyanosis at 1 minute


• Is breathing or crying spontaneously

• Has good muscle tone and responds when stimulated

• Has a heart rate above 100 beats/minute

• Becomes pink rapidly

Commence resuscitation
Section 10.2


Proceed to routine care

Note: if the amniotic fluid is meconium-stained but the neonate is breathing spontaneously, wipe the face and start routine care as below.                                                                               

Thermoregulation

– At birth:
 • dry the neonate with a clean, dry cloth;
 • wrap the neonate in another clean, dry cloth;
 • place the neonate against the mother’s (dried) body and cover with a dry cloth or blanket.
– Perform a full clinical examination with the neonate under an infant warmer.
– Cover the head with a cap to reduce heat loss. 
– Axillary temperature should be kept between 36 and 37 °C, and the neonate should have pink, warm feet.
– Keep the neonate in a warm room (between 23 and 25 °C).
– Delay bathing the neonate until 24 hours after birth. If it is not possible for cultural reasons, delay for at least 6 hours.

For low birth weight neonates, see Section 10.5.

Cord clamping and cord care

– Wait at least 1 to 3 minutes before clamping the cord (especially neonates weighing less than 2500 g). 
– 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 those used for episiotomy.

– Tie off the cord with a Barr clamp or sterile thread (double ligature), leaving a 2 to 3 cm stump.
– Disinfect the umbilicus: apply 7.1% chlorhexidine digluconate (delivering 4% chlorhexidine) to the tip, stump and base of the cord. If not available, disinfect with 10% povidone iodine. Put a single application at birth.

Apgar score

The Apgar score is evaluated at 1 and 5 minutes after birth and recorded in the neonate's medical chart and health record.
The score is a tool for monitoring the neonate’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 the neonate’s needs. 

Table 10.1 - Apgar score

Items evaluated/score

0

1

2

Skin colour*

Extreme pallor
or central cyanosis

Cyanotic extremities
No central cyanosis

Totally pink

Respiration

None

Abnormal (slow, irregular, etc.)

Normal

Heart rate

0

≤ 100/minute

> 100/minute

Muscle tone

Absent

Hypotonia
Incomplete flexion of limbs

Good
Complete flexion of limbs

Responsiveness
(after stimulation)

Nil

Grimace

Good, vigorous cry

A healthy neonate is usually born cyanotic but turns pink within 30 seconds after breathing starts. In neonates with dark skin, it may be more difficult to assess skin colour change. If so, look at the soles of the feet, palms of the hands and mucous membranes to assess for the change from blueish to pink.

Table 10.2 - Significance of the Apgar score

1-minute score
5-minute score

0 - 4

Asphyxia


0 - 6Asphyxia

5 - 7

Difficulty adapting


7 - 8Difficulty adapting

8 - 10

Good adaptation


9 - 10Good adaptation

Feeding

– Put the neonate to the breast as soon as possible within an hour of birth.
– Breastfeeding on demand day and night (at least 8 times per 24 hours, i.e. every 3 hours).
– For more information, see Appendix 3.
– In the event of maternal HIV infection, see Appendix 3, Section 3.7.

For low birth weight neonates, see Section 10.5.

Clinical examination and assessment of risk factors

A full clinical examination of the neonate should be completed in the delivery room as soon as possible, under an infant warmer, by the birth attendant. 
The priority is to recognise danger signs that may indicate severe illness (Section 10.3.1) and to assess for risk factors for infection and hypoglycaemia. 
Record all observations on a monitoring sheet.

A. Routine clinical examination
– Vital signs:
 • respiratory rate: normal range 30 to 60 breaths/minute
 • heart rate: normal range 100 to 160 beats/minute
 • temperature: normal range ≥ 36 °C and < 37.5 °C
– Weight (weigh the neonate naked on an appropriate scale, calibrated beforehand)

– Skin: see danger signs, Section 10.3.1.
– Head: fontanelles, eyes, ears, oral cavity (palate, mucous membranes)
– Chest: respiratory effort, heart sounds, breath sounds
– Abdomen: shape, size, umbilicus, genital organs, anus, spine
– Extremities: limbs, feet, hands
– Neurology: posture, tone, reflexes (sucking, grasp, response to stimulation)

B. Assessment for risk factors for neonatal infection
Prophylactic antibiotics for 48 hours (Section 10.3.3) is indicated if the neonate presents with: 
– 1 major risk factor (except if, for PROM ≥ 18 hours or for maternal fever, the mother received adequate antibiotic therapy i.e. at least 2 doses of IV ampicillin administered 4 hours apart with the last dose administered within 4 hours prior to birth)
OR
– 3 minor risk factors (or more)

Major risk factors

Minor risk factors

Maternal fever (≥ 38 °C) before or during labour in preterm

Preterm or birth weight < 2000 g

Prolonged rupture of membranes (PROM) ≥ 18 hours

Resuscitation at birth

Foul-smelling, cloudy amniotic fluid

Meconium stained amniotic fluid

Twin with clinical signs of infection

Home delivery (Chapter 11, Section 11.3.3)

C. Assessment for risk factors for hypoglycaemia
– Check blood glucose within one hour of birth in neonates with one of the following risk factors:

 • Birth weight < 2500 g or > 4000 g
 • Maternal diabetes
 • Mother treated with labetalol 
 • Difficulty breastfeeding (difficulty with sucking or attaching to the breast)
– If blood glucose is normal (≥ 2.5 mmol/l or ≥ 45 mg/dl), observe that the neonate is breastfed at least every 3 hours. Check blood glucose before each meal until there are 3 consecutive normal results. 
– If blood glucose is < 2.5 mmol/l or < 45 mg/dl, see hypoglycaemia, Section 10.3.4.

D. Assessment for mother-to-child transmissible diseases 
If not done prior to birth, check if the mother may have any disease transmissible to the neonate (Section 10.4).

Preventive treatments

Gonococcal conjunctivitis 
As soon as possible, preferably within an hour of birth: apply a 1 cm strip of 1% tetracycline eye ointment in each eye.
Note: if the mother has a symptomatic genital infection at the time of delivery, see Section 10.4.

Haemorrhagic disease of the newborn
Administer phytomenadione (vitamin K1) IM in the anterolateral aspect of the thigh within the first few hours of life:
Neonate weighing 1500 g or more: 1 mg single dose (0.1 ml if 2 mg/0.2 ml ampoule)

Neonate weighing less than 1500 g: 0.5 mg single dose (0.05 ml if 2 mg/0.2 ml ampoule)

Rickets and vitamin D deficiency
Neonates particularly at risk (preterm, low birth weight, maternal malnutrition, contexts with prevalence of vitamin D deficiency) and if possible all neonates should receive vitamin D for 6 months: 
colecalciferol (vitamin D3) or ergocalciferol (vitamin D2) PO:
Preterm or neonates living in contexts of high risk vitamin D deficiency: 600 to 1200 IU once daily
Term neonates: 400 to 800 IU once daily
Note: the number of IU per drop of oral solution varies according to manufacturers. Check instructions for use.

Mother-to-child HIV transmission
All neonates of HIV-infected mothers should receive antiretroviral treatment as soon as possible.
See the specific PMTCT protocol.

Vaccinations

The monovalent Hepatitis B and BCG vaccines are recommended as soon as possible after birth for all neonates, including low birth weight and preterm neonates. The oral polio vaccine is recommended at birth in endemic areas or areas at risk of poliovirus importation.
For the oral Polio vaccine, 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 hepatitis B birth dose is to prevent mother-to-child transmission of the virus. It should be administered as soon as possible, preferably in the delivery room, or at least within the first 24 hours of life. While it may still be administered after that time, the later the vaccine is administered, the less effective the protection1,2.

Table 10.3 - Neonatal vaccination

Vaccine

Contra-indications

Dose/route of administration

Hepatitis B
monovalent 

None but use only the monovalent vaccine 

One dose = 5 to 10 micrograms (follow manufacturer's instructions)
IM injection, anterolateral thigh

Polio oral
bivalent (poliovirus types 1 and 3)
Dose 0

None


One dose = 2 drops (approximately 0,1 ml)
Oral route

BCG

Neonate whose mother has active tuberculosis (Section 10.4.6)*

One dose = 0.05 ml
Intradermal injection, deltoid region (junction of lower 2/3 and upper 1/3 lateral aspect of upper arm)

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

10.1.2 After the first hours of life

Neonatal (and maternal) mortality is the highest in the first 24 hours after birth. Women are encouraged to stay for 24 hours in the maternity.

For the first 24 hours (or more if the mother stays in maternity longer than 24 hours), monitor the neonate and record observations in the neonate's monitoring sheet:
– Monitor:
• Danger signs

• Temperature, heart and respiratory rate 2 times daily
 Weight once daily
• Urine and stool

– Keep cord clean, dry and exposed to the air (no dressing).
– Observe breastfeeding.

For low birth weight neonates, see Section 10.5.

For the discharge criteria of the neonate, see Section 10.6.