ESSENTIAL DELIVERYROOM CARE

Basic delivery room care begins even before the birth. Important components of essential delivery room care are as follows:

Step I. Pre-delivery review of antenatal health records: Although the need for neonatal resuscitation may arise unexpectedly, it is possible to identify many high-risk pregnancies (Table 12.2) by review of antenatal records and refer them to adequately equipped centers.

Step II. Pre-delivery preparations in labor room to receive the baby and resuscitate, if needed. These include: • All normal deliveries should be attended by a trained medical or health attendant. However, an expert pediatrician should always be stand-by, in case of unexpected emergencies.

• Labor room temperature should be ~25-28°C, to avoid sudden heat loss at birth. A commercial or indigenous-made warmer should be switched-on at least 15 minutes before the expected delivery.

• A pre-warmed baby receptacle (tray), lined with clean linen should be available to receive the baby after delivery, along with enough supply of extra linens.

• Availability of essential resuscitation equipment and drugs (Table 12.10) should be ensured, and in working condition.

• Universal safety precautions for infection control are necessary to protect not only the baby but also the health-staff. 6 Cs to ensure minimal asepsis during the delivery include—Clean hands with quality hand washing and use of gloves, Clean surface to receive the baby, Clean perineum, Clean blade to cut the cord, Clean clamp/ tie to tie the cord, and Clean, dry cord with no local application.

Step III. Intra-partum interventions include:

• Clamping of the umbilical cord. Normally, the cord should be cut after 30-60 seconds of delivery by a sterile blade, leaving at least 2-3 cm of umbilical stump and tied properly to avoid slipped-ligature and bleeding.

Delayed cord clamping is recommended in all stable term and preterm babies, who cried immediately after birth to improve hemoglobin status and iron stores.

Early cord clamping is recommended in asphyxiated newborns in need for immediate resuscitation, Rhesus isoimmunization and in first-born twin to minimize twin-to-twin transfusion.

• Collection of cord blood sample for grouping/cross matching and screening investigations for intrauterine infections or metabolic disorders, as per local protocol.

• Early skin-to-skin contact and breast-crawl to promote early breastfeeding and reduce the risk of hypothermia.

• Inform the mother about baby's gender and well­being.

Step IV. Receiving the newborn: Prevention of sudden hypothermia at birth is the most important component of immediate newborn care. As soon as the cord is cut, baby should be received in the pre-warmed tray, transferred under the warmer and wiped gently to clean and dry. No extra efforts should be made to remove the vernix, which protects against hypothermia. Wet linen, after wiping the baby should be discarded and changed.

Step V Ensuring the airway patency, by:

• Cleaning of oral cavity for mucus, blood, meconium, etc. manually, by clean gauze piece;

• Oropharyngeal suction is not recommended in newborns who start breathing on their own after birth, while in others a low-pressure suction with an Delee's oral mucus extractor (Fig. 31.9) may be used to clean the airways. Vigorous suction must be strictly avoided to prevent trauma and reflex bradycardia/apnea.

• Positioning the baby in supine position with a rolled towel under the shoulders to prevent hyperextension/ flexion of neck (Fig. 12.2).

Step VI. Stimulating the breathing: While most newborns cry immediately after birth or as soon as the air-passage is cleaned, gentle physical stimulation by flicking on soles/rubbing the body may be necessary in others to stimulate first cry. Inverting the baby or vigorous back-slapping should never be attempted.

Step VII. Quick clinical assessment for resuscitation needs, Apgar score, lethal congenital anomalies, birth injuries, gestational age and other complications.

Orifice counting and patency check—congenital anomalies tend to concentrate around natural orifices, e.g. nose, oral cavity, anus, urethral meatus and ears. Since many of them are serious or associated with internal malformations, it is advisable to quickly check these orifices for external abnormality, though there is no need to check the patency routinely with catheter. Esophageal patency must be checked before first feed in high-risk newborns with polyhydramnios, single umbilical artery, other congenital anomalies or frothing.

Stomach wash is recommended only in babies with- (a) cesarean delivery, (b) severe asphyxia, (c) meconium staining.

Step VIII. Cleaning of the baby must be limited to drying with a clean sterile cloth and gentle removal of blood and meconium. Vernix protects the skin and helps to maintain body temperature and hence, should not be removed.

Step IX. Weighing, tagging (identification) and gender assignment.

Step X. Initiation of breastfeeding: In all normal newborns, breastfeeds should be started as early as possible, usually within frac12; hour of delivery and in the labor room itself. Though milk output at this time may be negligible, early feeding ensures successful lactation and emotional mother-baby bonding.

Step XI. Examination of umbilical cord and placenta: Essential delivery room care is not complete without examination of umbilical cord and placenta (Table 12.6). Single umbilical artery (normally two), is associated with congenital malformations in 10-20% cases.

12.4.2