11.2

• Essential newborn care (ENC)

  • Comprehensive strategy designed to improve the health of newborns through interventions before conception, during pregnancy, at and soon after birth, and in the postnatal period

  
• ENC Protocol

  1. Immediate and thorough drying

  2. Skin-to-skin contact followed by properly timed cord clamping

  3. Non-separation of baby from mother for breastfeeding initiation
• Immediate drying

  Prevents hypothermia and stimulates breathing
• WHO recommends bathing be delayed after six hours of life
• Newborns may be exposed to hypothermia during washing hence bathing is best done after the infant's temperature has stabilized
• The vernix should not be washed off because it provides a protective barrier to bacteria such as E. coli and Group B streptococcus
• Washing removes the crawling reflex which is essential for breastfeeding initiation
• Skin-to-skin contact


  Prevents hypothermia, increases colonization with a protective family of bacteria and improves breastfeeding initiation and exclusivity
• Properly timed cord clamping

  Within 1-3 minutes or until cord pulsations stops, decreases anemia in 1 out of every 7 term babies
• Non-separation of the mother-infant dyad

  Ensures overall success in breastfeeding

  
• Breastfeeding within the first hour of life prevents hypothermia
• Properly timed cord clamping (within 1-3 minutes or until cord pulsations stops)

  • Decreases anemia in 1 out of every 7 term babies
• Suctioning can cause apnea, vagal induced bradycardia, slower rise in oxygen saturations and mucosal trauma with increased risk for infection
• APGAR score

  A practical method of systematically evaluating infants immediately after birth

  
• Apgar scores should not be used to determine need for resuscitation or to guide steps of resuscitation
• Changes in Apgar scores at sequential time points after birth can reflect how well the infant is responding to resuscitation

  
• (APGAR) If the 5 min score remains <7, additional scores should be assigned every 5 min for up to 20 min
• Factors like prematurity and drugs given to the mother during labor can result in low Apgar scores
• Gestational age

  The time elapsed between the first day of the last menstrual period (LMP) and the day of delivery

  
• Gestational age and birth weight classification help the neonatologist to categorize infants, guide treatment, and assess risks for morbidity and mortality

  
• Newborn classification based on birthweight

  • Extremely low birthweight
  • Very low birthweight
  • Low birthweight

  
• Newborn classification based on gestational age and birthweight

  • Small for gestational age (SGA)
  • Appropriate for gestational age (AGA)
  • Large for gestational age (LGA)

  
• Prenatal gestational age assessment

  • Determined by maternal history, clinical examination, and ultrasound examination

  
• Last menstrual period

  The first day of the last menstrual period is about 2 weeks before ovulation and about 3 weeks before blastocyst implantation

  
• Assisted reproductive technology

  In vitro fertilization pregnancies have a known date of conception and can accurately predict gestational age within 1 day

  
• Quickening


  Date of first reported fetal activity by the mother (18–20 weeks for a primigravida, 15–17 weeks for a multipara)

  
• Pelvic examination

  • Uterine size by bimanual examination in the first trimester can be accurate within 2 weeks

  
• Symphysis pubis fundal height

  • Accurate up to 28–30 weeks' gestation, 1 centimeter is equal to 1 week from the 18th to 20th weeks of gestation

  
• Ultrasound examination

  • First fetal heart tones by Doppler ultrasound heard at 8–10 weeks
  • Fetal heart motion/beat by ultrasound detectable at 5.5–6.5 weeks by vaginal ultrasound, and 6.5–7 weeks by fetal ultrasound
  • Gestational sac mean diameter accurate within 1 week
  • Crown-rump length accurate within 5 days
  • Biparietal diameter determines gestational age with 95% confidence within 7 days if done between 14 and 20 weeks of gestation
• Postnatal gestational age assessment

  • Physical criteria alone are more accurate than neurological criteria alone, with the combination being the best estimate of gestational age
  • Rapid assessment in the delivery room
  • New Ballard Score
  • Direct ophthalmoscopy examination

  
• Rapid assessment of gestational age in the delivery room

  Includes physical characteristics like skin texture, skin color, skin opacity, edema, lanugo hair, skull hardness, ear form, ear firmness, genitalia, breast size, nipple formation, and plantar skin creases

  
• New Ballard Score

  Spans from 10 (correlating with 20 weeks' gestation) to 50 (correlating with 44 weeks' gestation), best performed at <12 hours of age if the infant is <26 weeks' gestation

  
• New Ballard Score


  • Accurate whether the infant is sick or well to within 2 weeks of gestational age, overestimates gestational age by 2–4 days in infants between 32 and 37 weeks' gestation
  • Consists of 6 neuromuscular and 6 physical criteria, administered twice by 2 different examiners

  
• Direct ophthalmoscopy of the lens

  Reliable method for determination of gestational age at 27 to 34 weeks only, based on the normal embryologic process of the gradual disappearance of the anterior lens capsule vascularity
• Lens capsule vascularity disappearance

  1. Occurs between 27 and 34 weeks of gestation

  2. Before 27 weeks, cornea too opaque to allow visualization

  3. After 34 weeks, atrophy of the vessels of the lens occurs
• Method to assess gestational age

  Reliable to ±2 weeks

  
• Assessing lens vascularity

  1. Pupil must be dilated under ophthalmologist supervision

  2. Assessment must be performed within 48 hours of birth before vessels atrophy
• Grading system for lens vascularity

  • Grade 4 (27-28 weeks): Vessels cover entire anterior surface or meet in center
  • Grade 3 (29-30 weeks): Vessels don't meet in center but are close, central portion not covered
  • Grade 2 (31-32 weeks): Vessels reach only to middle-outer part, central clear portion larger
  • Grade 1 (33-34 weeks): Vessels only at periphery
• Newborn classification by gestational age

  • Preterm
  • Late preterm
  • Term (early or late)
  • Post term

  
• Birthweight classifications

  • Micropreemie: <800g
  • Extremely low birthweight (ELBW): <1000g
  • Very low birthweight (VLBW): <1500g
  • Low birthweight (LBW): <2500g
  • Normal birthweight (NBW): 2500-4000g
  • High birthweight (HBW): 4000-4500g
  • Very high birthweight (VHBW): >4500g