Care after delivery: Observation of newborns in the First Few Hours of Life

1. 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

2. 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) • World Health Organization/UNICEF: Ten Steps to Promote Successful Breastfeeding (1989). • Saadeh, R. and J. Akre (1996). Birth (1996).

3. 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

4. Potential Newborn Problems • 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

5. Potential Maternal Factors • Fatigue • Pain +/- immobility • Ongoing interventions or management of obstetric problems • Effects of medication • Body habitus

6. Example: Compounding Maternal and Newborn Factors1 • 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 • Developed severe hypoxic-ischaemic encephalopathy and died at 15 days of age • Andres et al. Pediatrics, 2011.

7. 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

8. SUPC Statistics1,2 • Incidence varies from 2.6 to 5 per 100,000 live births • 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. • Fleming, PJ. Archives of Diseases in Childhood Fetal Neonatal Ed, 2012.

9. 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

10. 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

11. Mother and Baby Observations in the Immediate Postnatal Period: Consensus Statements Guiding Practice • Active assessment for ALL babies in the early postnatal period, regardless of birth context • Minimum assessment time of 1 hour • Longer if increased risk • 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 • Family/Whanau may be involved in process • Must know what to check for and who to call for help

12. Newborn Observations • Colour • Heart rate • Respiratory rate • Temperature • Airway patency • Tone and activity • Ability to feed • Overall condition • Any concerns require referral for Paediatric review

13. Summary • 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