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 practice 1  Step 4 in the 10 steps of the BFHI policy 2,3 1. 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).

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 Factors 1  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 1. 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 Statistics 1,2  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 1 st 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 1. 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.

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 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

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 1 st 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