CARE AFTER DELIVERY:
OBSERVATION OF NEWBORNS IN
THE FIRST FEW HOURS OF LIFE
Alexandra Wallace
On behalf of the
Neonatal Encephalopathy Working Group
June 2012
Background – Normal Newborns


Most term newborns adapt rapidly to life ex utero and
require no resuscitation
Early skin to skin contact and initiation of breastfeeding are
integral to obstetric and neonatal best practice1

Step 4 in the 10 steps of the BFHI policy2,3
Moore, E. R. et al. Cochrane database of systematic reviews(2): CD003519. (2009)
2. World Health Organization/UNICEF: Ten Steps to Promote Successful Breastfeeding
(1989).
3. Saadeh, R. and J. Akre (1996). Birth (1996).
1.
Background – when things go wrong….

Some newborns require assistance to initiate or
maintain normal cardiorespiratory function
following delivery
 Problems
may be apparent immediately after delivery
or develop in the first few hours of life
 May be expected or unexpected

Therefore…..
 Normal
cardiorespiratory function cannot be assumed
 All newborns require assessment:
 at
birth
 intermittently over the first few hours of life
Potential Newborn Problems



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
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Failure to adapt to ex utero environment
Birth asphyxia
Meconium aspiration
Birth trauma
Sepsis
Congenital heart disease
Other congenital anomalies
Newborn vulnerability
 Thermoregulation
 Glucose homeostasis
 Immature respiratory control
Potential Maternal Factors

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Fatigue
Pain +/- immobility
Ongoing interventions or management of obstetric
problems
Effects of medication
Body habitus
Example: Compounding Maternal and
Newborn Factors1


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Primigravida, increased BMI
Long labour, normal delivery
Big baby but well, no resuscitation required
Skin to skin soon after delivery with attempts to latch
At 2 hours of age – Mum sleeping
Baby prone on Mum’s chest, apnoeic, blue, cold
 Required resuscitation, ventilation, inotropic support


1.
Developed severe hypoxic-ischaemic encephalopathy and
died at 15 days of age
Andres et al. Pediatrics, 2011.
SUDI vs SUPC vs SUEND



SUDI: Sudden Unexpected Death in Infancy
 Clinically unexpected deaths in infants less than 12
months of age
SUPC: Sudden Unexpected Postnatal Collapse
 Clinically unexpected collapse in apparently healthy
term infants in the first hours of life
SUEND: Sudden Unexpected Early Neonatal Death
 Does not include babies who collapse but do not die
SUPC

Incidence varies from 2.6 to 5 per 100,000 live births

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1,2
Statistics
Death results in up to 50% of cases
Over half of the events occur in 1st 2 hours of life
Identifiable cause found in up to 30% of cases
Remainder due to accidental airway obstruction
3 commonly identified risk factors:
Primiparous mother
 Skin-to-skin in prone position with mouth and nose occluded
 Mother and baby unattended by clinical staff

Becher, J-C et al Archives of Diseases in Childhood Fetal Neonatal Ed, 2012.
2. Fleming, PJ. Archives of Diseases in Childhood Fetal Neonatal Ed, 2012.
1.
What is Required?

Awareness of the issues
 What
can go wrong?
 Newborn and maternal factors that increase risk

Development of recommendations for observation
of the WELL newborn that:
 Do
NOT impinge on initiation of skin to skin contact and
breastfeeding
 DO keep babies safe by identifying unexpected
problems
DHB Survey


18 responses from 21 DHBs
Of the 18 that responded:
2 have specific policy on observation of the newborn
 Variety of other policies submitted including:
 Examination of the newborn
 Early discharge
 Breastfeeding
 Hypoglycaemia guidelines
 Care of low birth weight babies
 Treatment of narcotic depression
 Safe sleeping/SUDI prevention

Mother and Baby Observations in the Immediate
Postnatal Period: Consensus Statements Guiding Practice
1. Active assessment for ALL babies in the early
postnatal period, regardless of birth context
2. Minimum assessment time of 1 hour

Longer if increased risk
3. Early skin-to-skin contact and breast feeding is
facilitated and supervised


Monitoring of colour, tone, respiration ongoing
Ensure nose and mouth are not occluded
4. Family/Whanau may be involved in process

Must know what to check for and who to call for help
Newborn Observations
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Colour
Heart rate
Respiratory rate
Temperature
Airway patency
Tone and activity
Ability to feed
Overall condition
Any concerns require referral for Paediatric review
Summary

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Well newborns usually remain well
A few newborns develop problems soon after birth
All apparently well newborns require observation in the
1st few hours of life


This can be done without compromising early initiation of
skin to skin contact and breast feeding
Health care providers must:
 Be
aware of the problems a newborn may encounter
 Understand the observations required
 Know what to do if a newborn becomes unwell