Essential Care for Every Baby - Helping Babies Survive Facilitator Flip Chart
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Helping Babies Survive
Essential Care for Every Baby
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
Helping Babies Survive
Essential Care for Every Baby
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1
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
After immediate care at birth
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Continue skin-to-skin care
and monitor breathing
To keep babies warm and identify problems early
2
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
Within one hour after birth
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Initiate breastfeeding
To increase the success of breastfeeding
3
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
Within 90 minutes after birth
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Provide eye care
To help prevent serious eye infections
4
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
5bWithin 90 minutes after birth
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Provide cord care
To help prevent infections
5Within 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 forWithin 90 minutes after birth
(may be deferred until later during the first day)
Give vitamin K
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To prevent bleeding that can cause death
6Within 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.
7bWithin 90 minutes after birth
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Examine the baby
To tell if a baby is well, or has a problem
7Within 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 )
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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 )
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axillary temperature is safer than measuring rectal temperature. 36.5°C
Cautionary range ( Improve thermal care )
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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
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measuring temperatures below 35.5°C. Equipment for practice:
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- 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
8bWithin 90 minutes after birth
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Measure temperature
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37.5°C
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36.5°C
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35.5°C
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To identify babies who require special care
8Within 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.
9bWithin 90 minutes after birth
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Weigh the baby
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To help identify babies at higher risk
9By 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 weight34
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By 90 minutes after birth
Classify the baby
To determine further care
10Exercise: 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
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Wash hands
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Explain why it is important to wash hands before touching the baby.
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10
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Monitor breathing
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Describe fast, difficult, noisy breathing.
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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
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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.
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Exercise:
Essential care
during the first 90 minutes
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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
11After 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.
12bAfter skin-to-skin care with a well, normal weight baby
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Maintain
normal temperature
To prevent a baby becoming either too cold or too hot
12During 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)
13bDuring the first day after birth
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Support breastfeeding
Good attachment Poor attachment
To improve the success of breastfeeding
13Before 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.
14bBefore discharge
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Advise about
breastfeeding problems
Engorgement Cracked nipples Mastitis
To improve the success of breastfeeding
14Within 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.
15bWithin one day after birth
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Begin immunizations
Hepatitis BCG Oral polio
To help prevent serious childhood illnesses
15When 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.
126bbWhen considering discharge
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Reassess the baby
and breastfeeding
To make sure discharge is appropriate
16When 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.
17b17
To help parents continue essential care and recognize problems
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......... ........
......... .................. .................. .........
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......... .....
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.........
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for home care
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Give parents guidance
When discharge is appropriateExercise: 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
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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.
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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
18If 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.
19bYou can also read
