NBSU Participants Module

CHILD HEALTH DIVISION
Ministry of Health and Family Welfare

Government of India
Newborn
StabiliZation Unit Training
PARTICIPANTS’ MODULE
2020
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Message
It gives me immense pleasure to commemorate the National Newborn Week from 15th to 21st
November, 2020 and launch the training module on "Newborn Stabilization Units (NBSUs)" for
optimal management of newborn care at First Referral Units (FRU).
The health of children including newborns continues to be of highest priority to our Government.
We are committed to reducing Neonatal Mortality Rate to single digit by the year 2030 - a target which
has been much appreciated globally and is more ambitious than the targets set under Sustainable
Development Goals.
I am also happy to note that to provide quality services to newborns at FRUs, my Ministry has
developed a training module for NBSUs. I am sure this will help doctors and nurses to acquire essential
knowledge and skills for optimal care of neonates thereby improving health status of newborns.
I wish all the best and hope this module will work as a good resource for capacity building of our
healthcare personnel.
(Dr. Harsh Vardhan)
348, - 110011 • Office: 348, A-Wing, Nirman Bhawan, New Delhi - 110011
Tele.: (0): +91-11-23061661, 23063513 • Telefax: 23062358 • E-mail: hfwminister@gov.in, hfm@gov.in
- 110011 • Residence: 8, Tees January Marg, New Delhi -110011
Tele.: (R): +91-11-23794649 • Telefax. 23794640
MINISTER OF STATE FOR
HEALTH & FAMILYMINISTER
WELFAREOF STATE FOR
HEALTH
GOVERNMENT OF INDIA& FAMILY WELFARE
GOVERNMENT OF INDIA
Ashwini Kumar Choubey
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MINISTER OF STATE FOR
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Message
The Ministry of Health and Family Welfare, Govt. of India has implemented a number of policies and programmes aimed at
ensuring universal access to health coverage and reducing child and neonatal mortality.
Under the umbrella of RMNCAH+N strategy in National Health Mission, Child Health have always been of high priority.
In 2014, the Government of India launched the India Newborn Action Plan (INAP) in order to intensify the efforts towards
improving newborn health. INAP has successfully brought a sharper focus on implementation of the existing and new
initiatives for the newborns both for their survival and subsequent growth and development.
To fulfill the role of providing quality service for newborn care in the health facilities, Ministry of Health and Family Welfare,
Government of India has developed training packages for Newborn Stabilization Units. Capacity building of the service
providers are of utmost importance as newborn care and survival necessitate knowledge and skills of high order in the
providers.
I would like to express my heartfelt appreciation to all those who contributed to the preparation of these documents. I am
sure that these packages will help in delivering newborn health services with quality care, all across the country.
(Ashwini Kumar Choubey)
Office : 250, ‘A’ Wing, Residence :

Nirman Bhawan, New Delhi-110 011 30, Dr. APJ Abdul Kalam Road,
Tel. : 011-23061016, 011-23061551 New Delhi – 110003
Telefax : 011-23062828 Tel. : 011-23794971, 23017049
E-mail : moshealth.akc@gov.in
Government of India
Department of Health and Family Welfare
RAJESH BHUSHAN, IAS

Secretary
Message
Childhood and infant mortality in India has reduced substantially during the last decade, but the rate of neonatal
mortality continues to remains high. Nearly two-thirds of infant deaths each year occur within the first four weeks of life
and about two-thirds of these occur within the first week itself. Thus, the first few days and weeks of life are extremely
critical for survival of a child. Therefore, newborns must be provided special attention during their birth for a healthy and
safe start to life.
India Newborn Action Plan envisages that the country will make all possible endeavors and attain the target of
single digit newborn mortality by 2030, a target which is more ambitious than even the corresponding global SDG target.
Effective and quality Newborn care is a critical challenge faced by every health care setting dealing in child birth and child
care. Building capacities of Doctors, Nurses and ANMs to improve quality of services in low resource settings remains a
challenge but is urgently required for our country.
Newborn Stabilization Units (NBSUs) are an important part of the facility based newborn care at the first referral units
to provide basic stabilization and feeding support to babies delivered at the facility and to sick and small babies referred to
the facilities from outside. The NBSU training package has been developed with an aim to empower the health care providers
with essential knowledge and skills for optimal management of any newborn presenting at NBSU. This aims to bring about
the desired changes in quality of services at these units established at the sub district level.
I am sure that the NBSU training package will act as an enabling tool for health care providers. Functionalization
of the NBSUs will result in effective utilization of resources and contribute in a significant way to reduce preventable
mortality in the country.
(Rajesh Bhushan)
Room No. 156, A-Wing, Nirman Bhawan, New Delhi-110 011

Tete: (O) 011-23061863,23063221, Fax: 011-23061252, E-mail: secyhfw@nic.in
Government of India
Department of Health and Family Welfare
Vandana Gurnani, I.A.S. Nirman Bhavan, New Delhi - 110011
Additional Secretary & Mission Director (NHM)
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Preface Government of India
1-23061398 Ministry of Health & Family Welfare
ndana.g@ias.nic.in Nirman Bhawan, New Delhi - 110011
A healthy start to life is vital for establishing the foundation of a healthy nation. During the last one and half decades, India
has made concerted efforts towards improvement of maternal and child health and has achieved significant reduction
in the maternal and child mortality. With significant gains in child mortality reduction, the contribution of newborn
mortality to child mortality has increased despite a decline in absolute number of neonatal deaths. This points to an urgent
need to accelerate efforts to improve newborn health.
As a part of the Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition (RMNCAH+N) strategy
of the National Health Mission, newborn health has always been at priority. A well-defined multi level care system for
newborn care at public health facilities has been scaled up massively and is supported by community level interventions.
Health systems strengthening over the last 15 years has brought about considerable improvement in the infrastructure,
availability of human resources, availability of drugs & equipment along with ancillary services.
Under facility based newborn care, “Newborn Stabilization Units” at the first referral units have been part of the care
system since 2011. However, these units continue to remain underutilized, one of the main reasons being the lack of
confidence and poor skills of healthcare providers working in these units. As a part of the strategy to revitalize these units,
a new “NBSU Training Package” for both doctors and nurses has been developed by the Child Health Division, GoI with
technical support from the Norway India Partnership Initiative (NIPI), technical experts and other development partners.
I do hope that this new package will be rolled out across the States and UTs to reinvigorate the facility based newborn care
system and pave way towards strengthening of timely and quality care for the newborns, closer to their homes.
(Vandana Gurnani)
Tele : 011-23063693, Telefax : 011-23063687 E-mail : vandana.g@ias.nic.in

Government of India
Dr. Manohar Agnani, IAS
Nirman Bhavan, New Delhi - 110011
Additional Secretary
Tele.: 011-23061723
e-mail: jsrch-mohfw@gov.in
Foreword
With the National Health Policy-2017 and the India Newborn Action Plan, India is committed to accelerate reduction in
the newborn deaths by more than half, by the year 2030. Newborn health occupies the centre-stage in the Reproductive,
Maternal, Newborn, Child Health, Adolescent Health and Nutrition (RMNCAH+N) strategy and inter linkages between
various components have a significant impact on the mortality and morbidity rates of a newborn.
Under the National Health Mission, newer interventions and improved service delivery platforms have been included in
the newborn health programme over a period of time. This mandates a review of existing training packages and strategies
in order to incorporate these new topics and skills sets emerging out of new evidences and technological advances which
will work towards improving the quality of care at the health facilities.
With this background, the Child Health Division along with the support of technical experts and development partners
including NIPI, has developed a “NBSU Training Package” for training of doctors and nurses working in the Newborn
Stabilization Units (NBSU). Until now, the Facility Based IMNCI package was being used for this purpose. This new
package equips both doctors and nurses to deliver interventions for management and stabilization of small and sick
newborns. It is further envisioned that these units will play a key role in scaling up Kangaroo Mother Care Services, one
of the most effective interventions , to save lives of preterm and low birth weight babies.
I do hope that by adopting this training package, a large number of babies will receive quality care at the sub district level
thus preventing referral and overburdening of district level facilities, resulting in improvement of neonatal survival to a
great extent.
(Dr. Manohar Agnani)
Talking about AIDS is taking care of each other

www.mohfw.nic.in
GOVERNMENT OF INDIA
MINISTRY OF HEALTH & FAMILY WELFARE
Nirman Bhavan, Maulana Azad Road,
New Delhi - 110108
DR. SUMITA GHOSH
Additional Commissioner
Telefax.: 011-23063178
E-mail: sumita.ghosh@nic.in
Acknowledgement
India witnessed a consistent and sharp decline in maternal and child mortality in comparison to global averages since
the inception of National Health Mission (NHM). India’s newborn mortality has reduced by more than one-third in the
last decade. With the National Health Policy 2017 in place and with sight on the Sustainable Development Goal agenda,
the opportunity now is to build upon the gains made in the last decade, accelerate and sustain the pace of improvement.
In order to scale up the implementation of the facility based newborn care programme, at New Born Stabilization Units
(NBSUs) at sub district level, it was a felt need that a training package should be designed exclusively for training of the
health care providers to deliver full set of services at the NBSUs. Accordingly, the Child Health Division along with the
technical support from the Norway India Partnership team has developed the “NBSU Training Package” for doctors and
nurses to equip them with the necessary technical knowledge and skills for provision of quality care to small and sick
newborns in these units.
I sincerely thank my colleagues Dr. Ajay Khera, Ex-Commissioner MCH & Dr. P. K. Prabhakar, Ex- JC, Child Health, for
starting the process. I specially acknowledge the efforts of Dr. Harish Kumar, Dr. Harish Chellani, Dr. Renu Srivastava,
Dr. Deepti Agrawal and NIPI team for their assistance in the development of this package.This was an intensive process that
required a lot of brainstorming and deliberations. I would therefore take this opportunity to thank all the academicians,
technical experts from NCC, State Programme officers, Child Health Division officers and consultants who participated
in the discussions and shared their valuable experiences and suggestions.
As a next step, I will urge the State / UTs, to roll out this package at the earliest. Concerted, consistent efforts of all
concerned stakeholders are solicited for achieving significant decrease in neonatal mortality.
(Dr. Sumita Ghosh)
Healthy Village, Healthy National
Talking about AIDS is taking care of each other

List of Contributors
NBSU
Ministry of Health and Family Welfare Child Health Division

Ms Vandana Gurnani Dr Kapil Joshi
Dr Manohar Agnani Mr Vishal Kataria
Dr Sumita Ghosh Mr Sharad Singh
Dr Sheetal Rahi Mr Vinit Mishra
Ms Sumitra Dhal Samanta
Editorial Team
Dr Harish Chellani Reviewers
Dr Sushma Nangia Dr Ashok Deorari
Dr Sadhana Mehta Dr Aditya Mahapatra
Dr Harish Kumar Dr Amrita Misra
Dr Deepti Agrawal
Dr Annapurna Kaul
Dr Renu Srivastava
Dr Arti Maria
Technical Experts Dr Misbah Samad
Dr Ajay Khera Dr Ashfaq Bhat

Dr P K Prabhakar Dr Vivek Singh
Dr S. Ramji Dr Nimisha Goel
Dr J Kumutha Dr Sachin Gupta
Dr Ruchi Nanavati
Mr Rajat Khanna
Dr Reeta Bora
Dr Prasant Kumar Saboth
Dr S Sitaraman
Dr Ashima Dabas Mr Gaurav Kumar
Table of Contents
CHAPTER 1
Assessment & Management of Newborns with Emergency Signs / 19
CHAPTER 2
Referral and Transport of Sick Babies & Communication with the Family / 47
CHAPTER 3
Assessment of Newborns for Admission in NBSU / 57
CHAPTER 4
Supportive Care / 67
CHAPTER 5
Management of Jaundice and Sepsis in Newborn / 83
5.1: Management of Jaundice / 85
5.2: Management of Sepsis in Newborn / 91
CHAPTER 6
Postnatal Care of the Newborn in the Health Facility / 97
SKILL STATIONS / 105
ANNEXURE
Annexure 1: Examination of Newborn from head to toes for Common Birth Defects / 144
Annexure 2: NBSU Stationery and Formats / 146
Annexure 3: Mentoring Checklist / 161
CHAPTER 1
Assessment & Management of
Newborns with Emergency Signs
INTRODUCTION
Under National Health Mission, facility based level care system for managing small and sick newborns is
implemented across the country and the newborn stabilization units (NBSU) play an integral and important
role. They have been established at the sub district level (First Referral Unit/Community Health Centre) in
order to provide facility based newborn care to babies delivered at the same health facility and to sick and
small babies delivered at other health facilities closer to FRU/CHC. The advantage of a functional NBSU
is that it adds to the total bed capacity available in the district for newborn care, while making provision
for newborn care closer to home for many sick and small babies. Current data shows that the mortality
is higher in babies referred from home/other health facilities (out born), as compared to the facility born
babies (inborn). This could be due to the fact that currently newborns are referred to Special Newborn
Care Unit (SNCU), without adequate pre referral management. This gap can be addressed at an optimally
functioning NBSU.
To fulfil your role as quality service provider for newborn care in the FRU/CHC, this course will help you
in acquiring essential knowledge and skills for optimal management of newborns presenting at NBSU.
Learning Objectives:
After completion of this module the participant should be able to:
1. Understand the process of identification of emergency signs requiring urgent attention.
2. Carry out Emergency Triage Assessment and Treatment (ETAT) of all sick neonates when they arrive
at a health facility
Group discussion
Activity 1.1:
• What are the common conditions for which newborns need hospitalization?
• Which skills would help you provide quality newborn services at your health facility?
• Expectations of the participants from the training
Activity 1.2:
• Facilitator will brief the group on the training methodology and agenda
1.1. Arrival & Rapid Assessment

Neonatal deaths can occur in seriously ill newborns, even after reaching the hospital. It is therefore
important to make immediate clinical assessment and initiate emergency treatment in these babies. Assess
every newborn for emergency signs, soon upon arrival, regardless of the place from where the newborn is
brought (another ward, another health care facility, or home).
Newborn Stabilization Unit Training Participants’ Module | 21

• The first step is rapid screening to identify life threatening conditions. This is known as triage or ‘sorting’.
A few of them may have emergency signs indicating that the problem is so serious that the newborn
may die within minutes, if not immediately treated.
• Assess all sick or small babies before doing any of the usual preadmission administrative procedures.
• Instruct staff to call a health care provider as soon as a newborn is brought to the facility. Do not keep
the newborn waiting to receive care.
• Ensure that the admission and reception area is organized, so that every newborn can be seen quickly
after arrival.
Sick newborns are triaged into following categories:
E Emergency
P Priority
N Non-urgent
Categories after Triage Action required

Emergency cases Need emergency treatment
Priority cases Need assessment and rapid action
Non-urgent cases Need assessment and counseling
22 | Newborn Stabilization Unit Training Participants’ Module

Signs of triage
Emergency Signs Priority Signs Non-urgent Signs

• Low body temperature (Temp • Tiny neonate (<1800 gms) • Jaundice
<35.5°C) • Temp 36.4°C-35.5°C • Transitional stools
• Apnoea or gasping • Respiratory distress (rate >60 but no or • Developmental
• Severe respiratory distress minimal retractions) peculiarities
(respiration rate >70, severe • Irritable/restless/jittery • Minor birth trauma
retractions, grunt) • Refusal to feed • Possetting
• Central cyanosis • Abdominal distension • Superficial infections
• Shock (cold periphery, CFT >3secs, • Severe jaundice (appears in <24 hours/ • Minor malformations
weak and fast pulse) stains palms and soles/lasts >2 weeks) • All cases not categorized
• Coma, convulsions or • Severe pallor as Emergency/Priority
encephalopathy • Bleeding from any site
• Major congenital malformations (Tracheo
esophageal fistula, Menigomyelocele,
Anorectal malformation)
• Large baby >3.8 kg or according to the
percentile charts
Action
Neonates with emergency signs are at Neonates with priority signs are sick and In neonates with no
high risk and require urgent intervention would need immediate assessment. They emergency or priority signs,
and emergency measures. These neonates should be attended to on a priority basis. proceed with assessment
with emergency signs after stabilization These will also need to be referred to SNCU and further treatment
are to be admitted or referred to the or admitted in NBSU. according to neonate’s
SNCU (Special Newborn Care Unit). requirement
Newborns are assessed using the TABC priority order so that no danger sign is missed.
T: Temperature
A: Airway
B: Breathing
C: Circulation/Convulsions/Coma
This order is also followed while stabilizing any sick newborn.
Emergency signs
• Low body temperature (Temp.<35.5°C)
• Not breathing at all "OR" gasping respiration
• Severe respiratory distress
• Central cyanosis
• Shock
• Convulsions/Unconsciousness

1.2. Clinical Assessment of Emergency Signs
Perform following 3 steps (RED) as soon as a baby arrives:
✓ Place the newborn on a warm surface under a Radiant warmer and under good light and record
temperature.
✓ Check for the Emergency signs and institute appropriate treatment while planning for referral to
SNCU/higher facility.
✓ If there is an emergency sign perform bedside diagnostics (check oxygen saturation & blood glucose ).
Give priority to stabilizing the sick or small baby before assessing and treating the underlying cause of
the problem.
✓ Place the newborn on a warm surface under a radiant warmer and under good light
Placing the baby on a warm surface under a radiant warmer and under good light is the first essential
step that you should perform in every baby irrespective of the underlying condition. This is important
as many sick babies are hypothermic and their survival chances increase, if hypothermia is taken care,
of even before initiating any resuscitation measure.
Key Messages:
• All newborns reporting to the hospital should be immediately assessed for emergency signs by the
service provider following the TABC priority order.
• Immediate life saving action is required to manage every emergency sign

ACTIVITY 1.3:
DRILL TO REVISE: WHAT STEPS TO TAKE ON RECEIVING A SICK OR SMALL NEWBORN?
1.
2.
3.
ACTIVITY 1.4:
DRILL TO IDENTIFY: WHICH CONDITIONS REQUIRE EMERGENCY MANAGEMENT?
Sign/Condition Emergency Treatment Needed: Yes or No

Jitteriness
Convulsions
Fast breathing (66/min)
Birth weight 1800 grams
Cyanosis of lips
Severe respiratory distress
Bleeding From umbilicus
Shock
Temperature 35°C
Diarrhoea
Skin rashes
Gasping for breath
Temperature 36°C
Refusal to feed

1.2.1. How to assess for emergency signs:
As soon as a neonate reports to the hospital, the first step is to assess for emergency signs. This is important
because a newborn baby with any emergency sign will require immediate treatment. It is equally crucial to
know how to assess each emergency sign and initiate prompt life saving measures.
Record temperature
Take axillary temperature using a digital thermometer. The digital thermometer needs to be switched on
for recording the temperature. Temperature is recorded by placing the tip of digital thermometer in roof of
dry axilla parallel to the trunk. Newborn's arm is held close to the body to keep the thermometer in place.
The temperature is read when the thermometer beeps. The recording should be noted after the beep. There
should be no addition or subtraction to the displayed temperature. Normal axillary temperature is 36.5°C
to 37.5°C.
Tactile assessment of temperature: Temperature of a baby can be assessed with reasonable precision by
human touch, the reliability of which can be enhanced by practice. Abdominal temperature is representative
of the core temperature and it is reliable in the diagnosis of hypothermia. The warm and pink feet of the
newborn indicate that the newborn is in thermal comfort, but when feet are cold and abdomen is warm,
it indicates that the newborn is in cold stress. In hypothermia, both feet and abdomen are cold to touch.
By Thermistor probe: In a newborn being nursed under a radiant warmer, temperature is usually recorded
by a thermistor probe. The thermistor probe is attached to the skin over upper right side of the abdomen.
The thermistor senses the skin temperature and displays it on the panel.
Hypothermia is graded as:
Cold stress : 36.4 – 36.0°C (97.5 – 96.8°F)
Moderate hypothermia : 35.9 – 32.0°C (96.2 – 89.6°F)
Severe hypothermia : < 32°C (89.6°F)
In hypothermia, the temperature is below 36.5°C. The common signs and symptoms in a hypothermic
newborn are lethargy, irritability, poor feeding and breathing difficulty (tachypnoea/apnoea).
Temperature below 35.5°C is an emergency sign
Ensure:
• Assessment for other emergency signs is started while recording temperature.
• Treatment is initiated immediately when an emergency sign is detected, while simultaneously
completing the assessment for other emergency signs.

Look at breathing & count respiratory rate:
Observe breathing effort and count the respiratory rate, for at least one minute, if the baby is not breathing;
or is gasping; or respiratory rate is less than 20 breaths per minute, initiate immediate management.
Check for severe respiratory distress

Observe for severe lower chest wall indrawing or use of the accessory muscles for breathing, which may
cause the head to nod or bob with every inspiration. Severe respiratory distress is present, if the newborn
has any of the following:
a. Respiratory Rate >70/min
b. Severe chest indrawing
c. Grunting
d. SpO2<91%
LOOK: Count the breaths in one minute. Repeat the count if elevated.
Count the breaths in one minute to decide if the newborn has fast breathing. Tell the mother you are going
to count her newborn's breathing. The newborn must be calm and quiet when you count the respiratory
rate. If the newborn is crying or agitated, you will not be able to obtain an accurate count of the newborn 's
breaths. If the newborn is sleeping, do not wake him. To count the number of breaths in one minute, use a
watch with a second’s hand or a digital watch. Look for breathing movement, anywhere on the newborn's
chest or abdomen. Usually you can see breathing movements even in a newborn who is clothed. If you
cannot see the movement easily, ask the mother to lift the newborn 's shirt. If the newborn starts to cry, ask
the mother to calm the newborn before you start counting. If you are not sure about the number of breaths
you counted (for example, if the newborn was actively moving and it was difficult to watch the chest, or if
the newborn was upset or crying), repeat the count.
LOOK for severe chest indrawing

If you did not lift the shirt when you counted the breaths, ask the mother to lift it now. Look for chest indrawing
when the infant breathes in. Look at the lower chest wall (lower ribs). The newborn has chest indrawing if
the lower chest wall goes IN when the infant breathes IN. Chest indrawing occurs when the effort needed
to breathe in, is greater than normal. In normal breathing, the whole chest wall (upper and lower) and the
abdomen move OUT when the infant breathes IN. When chest indrawing is present, the lower chest wall goes
IN as the infant breathes IN. If you are not sure about the presence of chest indrawing, look again. If the body
is bent at the waist, it is hard to see the lower chest wall move. Ask the mother to change the position, so that
the baby is lying flat in her lap. If you still do not see the lower chest wall go IN, when the baby breathes IN,
the newborn does not have chest indrawing. For chest indrawing to be present, it must be clearly visible and
present all the time. If you only see chest indrawing when the baby is crying or feeding, the newborn does not
have chest indrawing. If only the soft tissue between the ribs goes in when the infant breathes IN (also called
intercostal indrawing or intercostal retractions), the infant does not have chest indrawing.

Mild chest indrawing is normal in premature infants because the chest wall is soft. Severe chest indrawing
is very deep and easy to see. Severe chest indrawing is a danger sign and may be due to pneumonia.
LOOK and LISTEN for grunting

Grunting is the soft, short sound a young infant makes when breathing OUT. Grunting occurs when
newborn is having trouble breathing.
Check for Central Cyanosis

Central cyanosis occurs when there is an abnormally low level of oxygen in the blood. To assess for central
cyanosis, look at the mouth and tongue. A bluish or purplish discoloration of the tongue and the inside of
the mouth indicates central cyanosis.
Identification of central cyanosis can be difficult. Examine the lips, tongue or gums in natural light or the
light from an incandescent light bulb (even healthy people may look slightly blue under fluorescent light).
If unsure, compare the colour of the baby’s tongue with that of the mother’s. Bluish discoloration of the
nail-beds indicates peripheral cyanosis, which can occur with vasoconstriction as a result of hypothermia.
This is not central cyanosis and does not denote low oxygen level.
Assess circulation
Assess if a newborn has a poor circulation:
• Does the newborn have cold hands?
• Is the capillary refill time (CRT) longer than 3 seconds?
• Is the pulse weak and fast?
Feel the temperature of extremities. If the newborn’s hands feel cold, you need to assess the capillary refill.
Is the CRT ≥ 3 seconds?

Capillary refill is a simple test that assesses how quickly blood returns to the skin after pressure is applied
and indicates adequacy of tissue perfusion.
• CRT is checked on the central part of the body such as the chest. Gentle pressure is applied by the tip
of finger for 3-5 seconds e.g. by slowly counting from 1 to 5, this results in blanching of the underlying
surface. Observe how fast the blanched area refills and becomes pink after the tip of the finger is lifted
from the skin surface. Normal capillary refill time is < 3 seconds.
Is the pulse weak and fast?

The central pulse (a pulse nearer to the heart e.g. brachial pulse) should be felt. If this is strong and not
obviously fast, then the pulse is adequate and no further assessment is needed. Fast pulse is labelled when
the rate is more than 160 per minute.

Check for abnormal movements
The most common causes of abnormal movements in a newborn are convulsions and jitteriness.
Convulsions can be due to asphyxia, birth injury, or hypoglycaemia and could also be a sign of meningitis
or neurologic problems. Between the convulsions, the newborn may appear normal or may be unconscious,
lethargic, or irritable.
How to differentiate convulsions and jitteriness?
• Like convulsions, jitteriness is characterized by repetitive movements; however, in a jittery

newborn, these movements are at a faster pace than convulsions.
• Like spasms, jitteriness can be precipitated by sudden handling of the newborn or by loud noises,
but it is usually stopped by cuddling, change in position or restraining the newborn’s limb.
Jitteriness
Jitteriness must be differentiated from seizures in neonates.
1. Jitteriness is not associated with ocular deviation.
2. It is stimulus sensitive (e.g., triggered by stimulation or easily stopped with change in position or
restraining of the limb).
3. The movement resembles a tremor and no autonomic changes, such as tachycardia, are associated with it.
Seizures, often, are associated with ocular deviation and are not stimulus sensitive. Autonomic changes
frequently accompany them.
The assessment of a seizure is based on observation; convulsion must be witnessed by a health care worker
in the health facility. A convulsion can be recognised as sudden loss of consciousness, associated with
uncontrolled jerky movements of the limbs and/or the face. The same may be associated with stiffening of
the arms and legs or uncontrolled movements of the limbs.
Sometimes, in newborns, jerky movements may be absent, but there may be twitching (abnormal facial
movements)/abnormal movements of the eyes, hands or feet and the neonate may appear awake but
unresponsive. These are classified as subtle seizures.

Subtle seizures can be recognized by following features:
Subtle convulsion *
• Repetitive blinking, eye deviation, or staring
• Repetitive movements of mouth or tongue
• Purposeless movement of the limbs, as if bicycling or swimming
• Apnoea (spontaneous cessation of breathing for more than 20 seconds or less, if associated with
cyanosis and bradycardia)
* Also known as automatisms
Check for consciousness level

A newborn who is awake is, obviously, conscious. If the newborn appears asleep, ask the mother whether
the baby is sleeping. If there is any doubt, assess the level of consciousness by assessing response to sound
and if there is no response, then the infant can be gently shaken to elicit a response. A little shake to the
arm or leg should be enough to wake a sleeping newborn.
A newborn who does not respond to any of the above stimuli, may be lethargic or unconscious.
Lethargy is decreased level of consciousness from which the newborn can be aroused, but with difficulty.
Unconscious babies have profound sleep; are unresponsive to stimuli and may not respond to a painful
stimulus.
Video 1
Recognition of emergency signs
✓ If newborn has an emergency sign, perform bedside diagnostics
A. Check oxygen saturation

B. Check blood glucose levels
Check for oxygen saturation

Use pulse oximeter to check oxygen levels (see annexure for details). If a newborn has severe respiratory
distress or gasping respiration or apnoea or central cyanosis, the oxygen levels should be monitored.
Oxygen saturation (SpO2) should be maintained between 91-95%.
Video 2
Pulse Oximetry

Check blood glucose levels
• Perform blood glucose estimation using glucometer. The procedure is described in detail in skill station.
• Hypoglycaemia is described as blood glucose levels below 45mg/dl.
• Small (LBW and or premature) and sick babies are more prone to hypoglycaemia.
• Hypoglycemia may be symptomatic or asymptomatic. It is important to realize that even asymptomatic
hypoglycemia can cause brain damage and should be treated without delay.
Video 3
Glucose monitoring
Once the triaging process is complete and the bedside diagnostics are done the provider may proceed as
under.
• While looking for emergency signs, introduce yourself to the mother/attendant and ask:
 What is the problem with the newborn?
 When did the problem(s) first start?
 How old is the newborn?
• Details of any treatment received so far?
• Keep the newborn with the mother, if possible, and allow her to be present during the assessment and
for any procedures.
• Provide immediate management (as described in the section below) for any life- threatening
emergency signs, before continuing with the further assessment.
• While initiating the emergency management, prepare for referral.

Table 1.1: Assessing newborn for emergency signs
Assessment Emergency signs

• Place under radiant warmer and attach thermistor • Low body temperature (temperature<35.5°C)
probe. Record temperature using digital
thermometer
• Look at breathing & count respiratory rate: • Not breathing at all or gasping respiration
Not breathing at all, even when stimulated; or
gasping; or
 Slow breathing - Respiratory Rate <20/min
 Apnoea – Breathing with prolonged, intermittent
pauses lasting >20 seconds or less if associated
with bradycardia/cyanosis
• Check for severe respiratory distress • Severe respiratory distress

 Respiratory Rate >70/min
 Severe chest indrawing
 Grunting
• Check for central cyanosis • Central cyanosis

Blue skin/tongue and lips
• Assess circulation • Shock

Shock - If newborn has cold hands/peripheries with
capillary refill time (CRT) longer than 3 seconds and
weak and fast pulse (>160/minute).
• Check for abnormal movements • Convulsions/Unconsciousness

Convulsions - Repetitive jerking movements of limbs
or face, continuous extension or flexion of arms and
legs; may be generalized, focal or multifocal.
Many a times, convulsions in newborns are subtle
(e.g. staring, repetitive blinking of eyes, or repetitive
movement of mouth or tongue etc.)
• Check for consciousness level

Assess whether the baby is sleeping, lethargic or
unconscious
• Perform bedside diagnostics

Check SpO2 and blood glucose levels
Key Messages:
• A sick newborn can present with one or more emergency signs.
• Maintain temperature, airway, breathing and circulation (TABC), in addition to specific management
of the condition/emergency sign.

1.2.2. Management of newborn with emergency signs
Once emergency signs are identified, give prompt emergency treatment to stabilize the condition of the
newborn. The general management of each of the emergency signs is given below:
Low Body Temperature (Temp. <35.5°C)

a. Check axillary temperature.
b. Remove any wet clothing and rewarm the baby, under radiant warmer in servo control mode. Assess
temperature every half hour (in axilla).
c. If radiant warmer not available, place in skin to skin contact.
d. Keep the room warm (at least 26°C) using an external heating device, if needed.
e. Monitor temperature & capillary refill time during rewarming. Watch for apnoea and hypoglycemia
f. Check temperature regularly and ensure that the infant’s temperature is maintained in the range
36.5–37.5°C.
Not breathing at all "OR" gasping respiration

a. Position and Clear airway by suction,
b. Initiate bag & mask ventilation, if there is apnoea, gasping or respiratory rate too slow (<20/minute).
(The steps are described below).
c. In addition, all the common actions described above need to be taken.
How to administer Positive Pressure Ventilation (PPV) using self-inflating bag

Place the newborn on a firm, flat surface with head in the neutral position and place the face mask covering
the chin, mouth and nose, but not the eyes. Stand at the head end of the newborn and squeeze the bag 40-
60 times per minute using the dominant hand. Look for chest rise and check for effective PPV.
Check for heart rate after 30 seconds of effective ventilation:
a. If the heart rate is above 60 beats per minute (bpm), continue PPV.
• Ventilate for 30 seconds and check HR and breathing. If HR is more than 100 bpm, stop PPV and
quickly determine if the newborn is breathing spontaneously:
 If the respiratory efforts are good and rate is normal (40 to 60 breaths per minute), stop
ventilating;
• If the newborn is gasping or not breathing, or the respiratory rate is less than 20 breaths per minute,
continue ventilating. Monitor heart rate and breathing every 30 seconds during bag and mask
ventilation.
• If the newborn is not breathing regularly after 2 minutes of ventilation:
 Insert an oro-gastric tube to empty the stomach of air and secretions;
 Continue ventilation

b. If heart rate is less than 60 bpm after 30 seconds of effective bag and mask ventilation, initiate chest
compressions along with PPV with 100% oxygen. Rate is 90 chest compressions, coordinated with 30
breaths per min (ratio 3:1), three compressions and one breath to be delivered in 2 seconds. After one
minute of coordinated chest compression with PPV, monitor HR.
 If HR continues to be less than 60 bpm, administer inj. Adrenaline (Details of dose and route
will be discussed at the skill station) and continue chest compression with ventilation.
 Establish an IV line, if one is not already in place, and give a bolus of IV Normal saline 10 ml/kg
body weight over 5-10 minutes, while continuing ventilation and chest compression (until the
HR is above 60/bpm);
 Communicate with the family and organize transfer to the SNCU.
• When to stop resuscitation: If there is no sign of life (no breathing and no cardiac activity) even
after 20 minutes of resuscitation; inform the family and provide emotional support to the family
and with their approval resuscitation efforts can be discontinued.
Oxygen therapy: A source for oxygen supply and delivery devices are prerequisites for Oxygen therapy.
Efforts should be made to make the newborn comfortable and facilitate feeding.
Indications: All newborns who present with emergency signs and if the oxygen saturation is < 91%,
Oxygen delivery devices: Include nasal cannula/prongs and head box.
Nasal prongs/cannula: are the most preferred mode of providing oxygen and provide FiO2 between 25 to
45% with flow rates of 0.5-2 L/min. An appropriate neonatal size prongs should be selected from various
sizes available to fit inside the nostrils, without blanching the nares. Ends of prongs should be cleaned twice
daily with saline and checked to avoid plugging by mucous or secretions. Nasal prongs carry the advantage
of permitting breast feeding while newborn is on oxygen therapy.
Oxygen hood: The flow rates in the oxygen hood should be maintained between 2-3L/Kg/min. These are
capable of providing FiO2 between 30 to 90%. They have occludable portholes on the sides. With one port
hole opened it provides a FiO2 close to 40-50%, while with both opened it provides 30-40%. With both
port holes closed, 80-90% FiO2 can be achieved. Head box should allow for newborn’s head movement
within the box.
Monitoring: Meticulous monitoring of SpO2 and general condition should be ensured while the baby is on
oxygen therapy. Use a pulse oximeter to guide oxygen therapy. Oxygen can be discontinued once the infant
can maintain saturation > 90% in room air.

For standard flow oxygen therapy, humidification is not needed.
Figure 1.1: Oxygen delivery devices- Nasal prongs and head box
Figure 1.1: Oxygen delivery devices- Nasal prongs and head box
Video 4 Video 1
Oxygen delivery in neonates
Oxygen delivery in neonates

Shock
Shock
In additionIntoaddition
maintaining temperature,
to maintaining airway,
temperature, oxygen
airway, oxygensaturation, andglucose
saturation, and glucose levels:
levels:
a. Give IV fluid bolus 10 mL/kg normal saline over 20-30 minutes. Repeat bolus, if circulation does not
a. Give IV fluid bolus 10 mL/kg normal saline over 20-30 minutes. Repeat bolus if circulation
improve. This is described below in further detail.
does not improve. This is described below in further detail.
Administer IV fluids
Administer IV fluids
To administer IV fluids,IV superficial

To administer distal
fluids, superficial veins
distal veinover dorsum
site over dorsumofofhands
hands orandfeet
feetare preferred.
is preferred.
• Fluid may beFluid may be administered
administered using using a micro
a micro drip
drip setsetororan
aninfusion
infusion pump.
pump. Each mL ofml
Each micro drip drip set equals
of micro
set equals 60 micro drops; thus the amount of fluid required in mL/hour equals number of
60 micro drops; thus, the amount of fluid required in ml/hour equals number of drops per minute.
drops per minute.
• Always check thecheck
Always fluidthe
bottle
fluid for type
bottle for of
typefluid, bottle’s
of fluid, seal,
bottle’s date
seal, ofofexpiry
date andwhether
expiry and whether it it contains clear
fluid or not.contains clear fluid or not.
• Check the intravenous
Monitoring: site for
The clinical leakage
signs or displacement
that should be monitored duringof cannula.
treatment of shock include:
 Heart rate [decrease in heart rate by at least 10 beats per minute]

Monitoring: The clinical signs that should be monitored during treatment of shock to evaluate for response
 Respiratory Rate
to therapy include:
 Capillary refill time
• Heart rate
 (decrease in heart rate by at least 10 beats per minute)
Oxygen saturation
• Respiratory Rate (normalization puffiness
 Signs of over-hydration- of RR) of eyes and increasing liver size on per-abdomen
examination
• Capillary refill time (Improvement of CRT)
19
• Oxygen saturation (Improvement in SpO2)
Look for signs of over-hydration
• Puffiness of eyes
• Weight gain
• Increasing liver size on per abdomen examination
In case of excess fluid administration, further fluid bolus should be stopped and only maintenance
fluid therapy should be continued.
Video 5
IV access in newborns
Treatment of Hypoglycemia:
• If blood glucose <45mg/dl by glucometer (if possible get confirmation done by plasma blood sugar
levels), start treatment.
 Asymptomatic newborn: Provide one oral feed (direct breastfeed or EBM 20ml by spoon). Assess
blood sugar after an hour, if blood sugar remains below 45mg/dl, treat with IV dextrose as for
symptomatic newborn (given below).
 Symptomatic newborn (lethargy, limpness, sweating, respiratory distress, apnoea etc.): Give a bolus
of 10% Dextrose @2ml/kg slowly over a minute (If IV access is difficult, give the same amount through
OG tube) and follow by Dextrose infusion @6mg/kg/min. Start infusion of dextrose containing fluid
at the daily maintenance volume according to the baby's age so as to provide a glucose infusion rate
(GIR) of 6 mg/kg/min.(Refer to the table below)
 Repeat blood glucose after half an hour. Refer to SNCU for further management.
 In case, immediate referral is not possible , follow the algorithm and refer as soon as possible for
further management.

Management of Hypoglycemia
Hypoglycemia (blood glucose <45 mg/dl by Glucostix) Send blood sample to

lab for plasma glucose
Asymptomatic Symptomatic
Blood glucose 25-45 mg/dl Blood glucose < 25 mg/dl

Give one breastfeed and /or 10% Dextrose bolus: 2 ml/kg
20-30 ml EBM/top feed
Check blood glucose 1 hour Dextrose infusion @ 6 mg/kg/min

aer feeding
Check blood glucose aer 30 min

Blood glucose 25-45 mg/dl
Blood glucose ≥ 45 mg/dl Blood glucose ≥ 45 mg/dl Blood glucose < 45 mg/dl
Frequent Breastfeeding Begin oral feeding q 2 hourly GIR 2 mg/kg/min, as needed

Monitor blood glucose 6 hourly
GIR > 12 mg/kg/min Blood glucose > 45 mg/dl for 24 hr

GIR by 2 mg/kg/min every 6 hr

Oral feeding
Inj. Hydrocortisone 2.5 mg/kg iv stat & Refer
Table 1.2: Achieving appropriate glucose infusion rates for neonates with Birth weight ≥ 1500 gms
using a mixture of D10 and D25 Volume (ml/ kg/d)
Day Vol- Glucose Infusion Rate Glucose Infusion Rate Glucose Infusion Rate
of ume 6 mg/kg/min 8 mg/kg/min 10 mg/kg/min
Life (ml/
kg/d) Normal Distill Normal Distill Normal Distill
D10 D25 D10 D25 D10 D25
(ml/ (ml/ Saline Water (ml/ (ml/ Saline Water (ml/
(ml/kg/d Saline Water
kg/d) kg/d) (ml/ kg/d) kg/d) (ml/ kg/d) (ml/
(ml/kg/d) (ml/kg/d) (ml/kg/d)
kg/d) kg/d) kg/d)
1 60 42 18 - - 24 36 - - 5 55 - -
2 75 68 7 - - 49 26 - - 30 45 - -
3 90 60 10 20 - 40 30 20 - 20 50 20 -
4 105 85 - 20 - 65 20 20 - 45 40 20 -
5 120 86 - 20 14 88 12 20 - 70 30 20 -
6 135 86 - 20 29 115 - 20 - 95 20 20 -
7 150 86 - 20 44 115 - 20 15 120 10 20 -

Table 1.3: Achieving appropriate glucose infusion rates for neonates with Birth weight < 1500 gms
using a mixture of D10 and D25 Volume (ml/ kg/d)
Day Vol- Glucose Infusion Rate Glucose Infusion Rate Glucose Infusion Rate
of ume 6 mg/kg/min 8 mg/kg/min 10 mg/kg/min
Life (ml/
Nor- Distill Nor-
kg/d) D10 D25 D10 D25
Distill
D10 Normal Distill
mal Water mal Water D25
(ml/ (ml/ (ml/ (ml/ (ml/
(ml/kg/d Saline Water
kg/d) kg/d) Saline (ml/ kg/d) kg/d) Saline (ml/
kg/d)
kg/d) (ml/
(ml/kg/d)
(ml/kg/d) kg/d) (ml/kg/d) kg/d)
1 80 76 4 - - 55 25 - - 35 45 - -
2 95 87 - - 8 80 15 - - 60 35 - -
3 110 87 - 20 - 70 20 20 - 50 40 20 -
4 125 87 - 20 18 70 20 20 15 75 30 20 -
5 140 86 - 20 34 70 20 20 30 100 20 20 -
6 150 86 - 20 44 115 - 20 15 120 10 20 -
Convulsions/Unconsciousness
a. Maintain temperature under radiant warmer
b. Position the newborn to maintain airway
c. Clear the airway, if required
d. Maintain SpO2 between 91-95%
e. Check glucose levels; if blood glucose <45mg/dl, then treat with 10% dextrose as described above.
f. Give IV 10% Calcium gluconate at 2ml/kg (in equal dilution with distilled water), slowly over 5-10
minutes under cardiac monitoring after taking a blood sample for Calcium estimation preferably by an
infusion pump (withhold infusion if HR< 100/min).
g. If seizure persists, start Injection Phenobarbitone 20mg/kg loading dose (diluted with normal saline)
over 20 minutes prior to referral.
h. For newborns with any signs of serious bacterial infection or sepsis, give first dose of antibiotic before
referral.
Note that generalized and subtle convulsions are both managed in the same way.
Do not add calcium to maintenance IV Fluid
Administration of anticonvulsant:
Anticonvulsant drugs should be given if seizures persist, even after correction of hypoglycemia and
hypocalcemia. First line drug for newborns is Phenobarbitone which is given in the loading dose of 20 mg/
kg IV over 20 minutes (at the rate of 1mg/kg/min.). In case, immediate referral is not possible , follow the
algorithm and refer as soon as possible for further management.
If seizures persist after initial Phenobarbitone infusion, administer further boluses of 5mg/Kg, up to a total
of 40 mg/Kg.

Table 1.4: Dose of Phenobarbitone for newborns
Inj. Phenobarbitone Intravenous (200 mg/ml) 0.1 ml diluted with 0.9 ml saline (20 mg/ml)
Weight of Infant Initial dose Repeat dose
2 kg or less 2 mL 0.5 mL
2 to 3 kg 3 mL 0.75 mL
3 to 4 kg 4 mL 1 mL
Caution- Do not use Inj. Diazepam for control of convulsions in Neonates < 2 weeks
Phenytoin is used as a second line drug, when full dose of phenobarbitone fails to resolve seizures. If
used, it should only be mixed with saline and not with dextrose as it precipitates in dextrose.
Continue supportive management while preparing for referral to higher centre for further management.

Neonate with seizure
Ensure TABC, IV Access;

Blood glucose < 45 mg/dL
Check Blood glucose
Blood glucose normal (> 45 mg/dL)
Do Serum calcium if possible Ÿ 10% Dextrose 2 ml/kg bolus IV

or Ÿ Continuous infusion @ 6 mg/kg/min
Give 10% calcium gluconate
2 ml/kg IV over 5-10 minutes
Seizures persist
Seizures Controlled
Inj. Phenobarbitone 20 mg/kg IV Ÿ Do not start maintenance
over 20 min (@ of 1 mg/kg/min)
Seizures persist
Ÿ Start maintenance dose of
Give further 5 mg/kg bolus of Seizures Controlled Phenobarbitone 3-4 mg/kg/day,
Phenobarbitone over 5-10 minutes. once a day aer 12 hours of loading dose
Repeat if seizures not controlled up Ÿ Stop Phenobarbitone once
to a maximum of 40 mg/kg. seizure free for 48 hrs
Seizures persist
Ÿ Continue maintenance dose of
Give Phenytoin 20 mg/kg over
Seizures Controlled Phenobarbitone and Phenytoin
20 mins. (@ of 1 mg/kg/min)
3-4 mg/kg/day once a day
Assess aer 30 min
Ÿ Stop phenytoin once seizure
Seizures persist free for 48 hrs
Lorazepam 0.05 - 0.10 mg/kg,

IV infusion
Ÿ Continue on 3-4 mg/kg/day of
Seizures persist
Phenobarbitone
Ÿ Stop Phenobarbitone once
Consider referral to a higher centre seizure free for 48 hrs.

SUMMARY OF KEY ACTIONS FOR MANAGING EMERGENCY SIGNS
Table 1.5: Management of emergency conditions
Emergency Signs Actions

• Low Body Temperature (temperature <35.5°C) • Maintain temperature under radiant warmer in servo
control mode.(If warmer not available, put in skin to
skin contact). Monitor axillary temperature every ½
hour till it reaches 36.5°C
• Not breathing at all "OR" gasping respiration • If not breathing at all/gasping, maintain the airway by
positioning the head correctly by placing a shoulder
roll, suctioning the mouth and nose if required;
stimulate to breathe, administer positive pressure
ventilation with bag & mask.
• Severe respiratory distress ✓ Attach pulse oximeter and monitor oxygen
• Central cyanosis saturation – Provide oxygen if saturation is below
91%.
✓ Prevent and treat hypoglycemia. If not possible to
check blood glucose levels/if <45mg/dl give 10%
Dextrose bolus @2ml/kg slowly over one minute and
start Glucose Infusion Rate (GIR) @6 mg/kg/min
• Shock ✓ If in shock, give IV fluid bolus 10 mL/kg normal

saline over 20-30 minutes. Repeat bolus, if circulation
does not improve.
• Convulsions/Unconsciousness ✓ Check blood glucose levels, if <45mg/dl give 10%
Dextrose bolus @2ml/kg slowly over one minute and
start Glucose Infusion Rate (GIR) @6 mg/kg/min
✓ If convulsing, give IV 10% Calcium gluconate at 2ml/
kg in equal dilution with distilled water, slowly over
5-10 minutes, under cardiac monitoring.
If seizure persists, give Injection Phenobarbitone at a
dose of 20mg/kg (diluted with normal saline) slowly
over 15-20 minutes
✓ Dress the newborn in warm clothes and a cap, and cover with a warm blanket.
✓ Refer after administering pre-referral dose of antibiotics and provide IV fluids or oxygen support as required.
✓ Give Inj. Vit K1 if not given earlier, around birth.
A sick newborn can present with one or more emergency signs. They all require maintenance of
Temperature, Airway, Breathing and Circulation (TABC), in addition to specific management of the
condition/emergency sign.

Common actions for all newborns with any emergency sign:
1. Maintain temperature: Keep the newborn under a radiant warmer. Remove cold or wet clothing.
2. Position and clear airway, if required.
3. Oxygen: Check oxygen saturation using pulse oximeter. Maintain SpO2 between 91-95%. Give oxygen
to newborns with saturation value of 90% or less.
4. Prevent and treat hypoglycemia: Check blood glucose. If hypoglycemic (blood glucose <45 mg/ dl),
give 2 ml/kg body weight of 10% Dextrose, through IV route and start GIR @6mg/kg/min. If blood
glucose cannot be checked quickly, assume the baby to be hypoglycaemic and administer IV glucose.
If an IV line cannot be established quickly, provide 2 ml/kg body weight of 10% glucose or expressed
breast milk through an orogastric tube.
5. Refer all newborns with emergency signs after stabilization.
6. Give fluids if newborn is not able to feed.
7. Give pre-referral dose of antibiotics before referral. The antibiotics of choice to be given before
transport are - ampicillin and gentamicin.
Assess and manage where referral not possible

Referral of all cases may not be possible for various reasons (parents may refuse; transport may be
unavailable or the distance to higher facility may be more). In such cases, examine for emergency signs
(i.e. not breathing, gasping, respiratory rate less than 20 breaths per minute, bleeding or shock) and provide
immediate management. Continue to assess and monitor the newborn.
Table 1.6: Dose of pre-referral antibiotics
Give First Dose of Antibiotics

Give first dose of Ampicillin (or Oral Amoxicillin*) and Gentamicin intramuscularly
AMPICILLIN AMOXICILLIN GENTAMICIN
Dose: 50 mg per kg Dose: 30-50 mg per Kg Dose: 5 mg per kg
Add 1.3 ml sterile Oral syrup (contains 2 mL Vial containing 80mg Gentamicin
water to a vial of 250 125 mg in 5 ml) (For convenience, add 6 ml sterile water to 2 ml vial containing
mg=250 mg/1.5ml 80 mg = 8 ml at 10 mg/ml)
WEIGHT
< 1.5 kg 0.4 ml 2.0 ml* 0.5 ml
1.5 - 2.0 kg 0.5 ml 2.0 ml* 1.0 ml
2.0 - 3.0 kg 0.5 ml 2.5 ml* 1.0 ml
3.0 - 4.0 kg 1.0 ml 3.0 ml* 1.5 ml
4.0 - 5.0 kg 1.25 ml 4.0 ml* 2.0 ml
*Determine if the child is able to take orally

Table 1.7: Assessment & Management of emergency conditions
Assessment Emergency Signs Actions

• Record temperature • Low Body ✓ If temperature < 35.5°C, rewarm
temperature under radiant warmer in servo
(temperature mode with temperature setting at
<35.5°C) 36.5°C
Assess temperature every half hour
(in axilla). If warmer not available,
put in skin to skin contact
• Look at breathing & count • Not breathing ✓ If not breathing at all/gasping,
respiratory rate: at all or gasping position and clear airway, stimulate
 Not breathing at all, even when respiration to breathe, administer positive
stimulated; or gasping; or pressure ventilation with bag &
 Slow breathing - Respiratory Rate mask.
<20/min
 Apnoea – Breathing with prolonged
intermittent pauses lasting >20
seconds or less, if associated with
bradycardia (<100 bpm)/cyanosis
• Check for severe respiratory distress • Severe respiratory ✓ Give oxygen; attach pulse oximeter
 Respiratory Rate >70/min distress and monitor oxygen saturation.
 Severe chest indrawing
 Grunting
• Check for central cyanosis • Central cyanosis

Blue skin/tongue and lips
• Assess circulation • Shock ✓ If in shock, give IV fluid bolus 10
If newborn has cold hands/peripheries ml/kg normal saline over 20-30
with capillary refill longer than 3 seconds minutes. Repeat bolus, if circulation
and weak and fast pulse (>160/minute), improves but parameters have not
then classify as shock. become normal.
• Check for abnormal movements • Convulsions ✓ If convulsing, check blood glucose.
Repetitive jerking movements of limbs or /Unconsciousness
✓ (If <45mgs/dl, Give 10% Dextrose
face, continuous extension or flexion of
bolus @2ml/kg slowly over one
arms and legs; may be generalized, focal
minute and start GIR@6mgm/kg/
or multifocal convulsions.
min).
Many a times, convulsions in newborns
are subtle (eg staring, repetitive blinking ✓ If blood glucose is normal give IV
of eyes, or repetitive movement of mouth 10% Calcium gluconate at 2ml/kg in
or tongue etc.) equal dilution with distilled water,
slowly under cardiac monitoring.
• Check for consciousness level
Assess whether the baby is sleeping, ✓ If seizure persists, start Injection
lethargic or unconscious Phenobarbitone 20mg/kg loading
dose (diluted with normal saline).
• Perform bedside DIAGNOSTICS
a Check oxygen saturation ✓ Maintain SpO2 between 91 to 95%
b. Check blood glucose levels ✓ Prevent and treat hypoglycemia. If
not possible to check blood glucose
levels, Give 10% Dextrose bolus
@2ml/kg slowly over one minute
✓ Dress the newborn in warm clothes and a cap and cover with a warm blanket.
✓ Refer after pre-referral dose of antibiotics and on IV fluids and oxygen support
 Give Inj. Vit K1, if not given earlier around birth

Key Messages:
• Identification of emergency signs and prompt treatment is life saving.
• Neonate with emergency signs should be stabilized before referral (TABC priority order to be followed):
 Maintain temperature. Keep the newborn under a radiant warmer.
 Remove cold or wet clothing.
 Position and clear airway, if required, provide positive pressure ventilation in case baby is not
breathing
 Maintain SpO2 between 91-95%.
 Prevent and treat hypoglycemia.
 Manage shock/convulsions.
• Refer all newborns with emergency signs after stabilization.
• Give pre-referral dose of antibiotics before referral.

Activity 1.5:
DRILL TO REVISE THE CRITERIA FOR RECOGNISING VARIOUS SIGNS IN NEWBORNS
SIGN CRITERIA
Shock
Low Body Temperature
Cyanosis
Hypoglycemia
Severe Respiratory Distress
Jitteriness
Subtle convulsions
Apnoea
Activity 1.6:
CASE STUDIES
1. A 7 days old baby weighing 2.5 kg is admitted with refusal to feed, fast breathing, cold extremities and
CRT of 5 seconds. What are the steps for stabilization of this newborn?
2. A 7 days old baby girl with birth weight 2.8 kg is brought with the inability to breastfeed.
On examination you find that the newborn has subtle seizures, temperature is 36°C and respiratory
rate is 56/min.
Write down initial steps of management.

CHAPTER 2
Referral and Transport of
Sick Babies & Communication
with the Family

REFERRAL AND TRANSPORT OF
SICK BABIES & COMMUNICATION
WITH THE FAMILY
Babies who are seriously ill at the time of presentation and cannot be cared for at NBSU need to be
transferred to a special neonatal care unit (SNCU). In such instances, communication with the family
is important for ensuring that the referral to the SNCU is smooth and successful. It is also necessary to
arrange for timely transport and provide care during transfer.
Learning objectives:
After completion of this chapter the participant should be able to:
• Identify babies who need referral
• Provide pre referral stabilization
• Counsel and support the family
• Prepare and organize transport
• Ensure en route care
• Document the details and handover the baby
Components of Neonatal Transport
1. Assessment and stabilization of baby

2. Communication with the family
3. Communication with the referral facility
4. Pre-referral stabilization
5. Pre-referral antibiotics
6. Referral note
7. Arrange for a health care provider to accompany, where feasible
8. Arrange vehicle for transport
9. Enroute care
10. Confirm successful transport
1. Assessment and stabilization of baby

This has already been discussed in chapter 1.
2. Communication with the Family

Effective communication is crucial to make informed decisions. It maintains a healthy association between

the health care personnel and the parents, besides reducing parental anxiety also prevents conflicts.
Communication begins at the first contact with health facility, till the baby leaves after discharge or
treatment. Communication can be verbal which includes spoken language. Communication may also be
non-verbal which involves use of correct body posture, gestures and eye contact.
Dos Don’ts
• Always use simple language which the family can • Use technical jargon
understand easily • Be judgmental, rude or create panic
• Ensure appropriate and culturally sensitive behaviour • Rush the process of referral
• Preferably be done patiently by senior health personnel
or person with expertise
Communication at admission:
Parents are anxious when they bring their sick baby to the health facility. Assess the condition of the baby
and inform the family about the following:
• Whether the newborn needs admission
• Prognosis of the baby, treatment options and likely duration of treatment
• Inform the parent/ parent attendant about free entitelments to baby and mother under Janani Shishu
Suraksha Karyakram and Ayushman Bharat PM Jan Arogya Yojana (PM-JAY).
If the mother is medically fit she should also be allowed to stay along with the admitted baby. Counsel the
mother regarding care of her newborn including feeding which should be transitioned to spoon and finally
direct breastfeeding as baby improves. In addition, the healthcare provider should ensure communication
regarding the infant's condition.
Communication before referral and transport:

Few babies who are sicker may need specialized neonatal care which may not be available at FRU or NBSU.
Such babies will need to be referred to a higher centre. Ensure communication with the following:
• Parent/parent-attendant:
 Allow parents to see and touch their infant prior to transport.
 Explain the baby’s condition to the parents and the reason(s) why the baby needs to be sent to SNCU/
higher centre. Answer any questions they may have.
 Explain where to go and indicate whom to contact along with care to be provided during transport.
 Encourage mother to accompany the baby. Mother should accompany the baby for breast feeding
and for providing supportive care to the baby on the way and in the hospital. In case she cannot
accompany the baby immediately, her blood sample for blood group and cross matching should be
sent at the time of referral and she should be encouraged to reach the facility at the earliest.

• Transport team:
 Hand over all relevant documents
 Share the details of the facility where the newborn is being referred
 If a trained Emergency Medical Technician is available then discuss enroute support
3. Communication with the referral facility

Refer promptly to nearest SNCU/appropriate health facility providing comprehensive neonatal health care.
Before the newborn is referred, communicate with the concerned doctor/authority regarding the referral.
4. Pre-referral stabilization
Refer to chapter 1 and stabilize the baby before referral . Ensure to maintain the vital parameters: Temperature,
Oxygenation, Perfusion and Sugar (TOPS).
A. Temperature: Maintain temperature 36.5-37.5°C by adequate covering (Wrap the baby well in layers
with head, hands and feet covered) / Skin to skin contact or KMC during transport.
B. Airway and oxygenation: Ensure following to maintain saturation between 91-95%.
 Ensure airway patency by keeping the neck slightly extended using a shoulder roll and clearing
secretions.
 Babies who need oxygen should be transported with nasal cannula/prongs attached to an oxygen
source with flow of 0.5 to 1 L/min.
 The adequacy of oxygen in gas cylinder should be ensured, before starting.
C. Perfusion: Adequate perfusion is indicated by heart rate between 120-160/minute and a CRT <3
seconds. Manage shock and continue IV fluids.
D. Blood Sugar: The blood glucose levels should be maintained > 45mg/dL. It should be checked before
the newborn leaves the health facility and after arrival at the referral health facility. Enteral feeds/IV
fluids should be given to maintain blood glucose levels during transport.
5. Pre referral antibiotics

The antibiotics of choice to be given before transport are ampicillin and gentamicin (dosage details in
chapter 1). All newborns with emergency signs, suspected sepsis, hypoglycaemia or abdominal distension
should be given a dose of pre-referral antibiotics.
6. Referral note
The referral note should mention the following:
• Case particulars- Name, age, gender, address
• Chief complaints

• Condition on arrival at health facility- temperature, oxygenation, perfusion, sugar
• Management and treatment details provided for stabilization, including antibiotics
• Reason for referral
• Condition at referral
• Contact details of the referring health personnel
• All available reports
Referral Note format is provided in annexure.
7. Arrange for a health care provider to accompany, where feasible

Some transport vehicles (Advance Life Support) have trained personnel who can monitor and provide
necessary supportive care/resuscitation during transportation. They can be informed about the condition
of the newborn and the care that needs to be continued on the way.
If such a vehicle is not available, health care personnel should accompany, wherever feasible.
8. Arrange vehicle for transport

Arrange the hospital vehicle or a vehicle available under the JSSK.
The baby should be referred and transported safely from the health facility to a higher centre. The transport
facilities can be availed free of cost through the National Ambulance Service. The Government of India has
provided for free transport to the mother and infant (upto one year of age) under the Janani Shishu Suraksha
Karyakram (JSSK). Wherever available, prefer transportation in an ALS (Advanced Life Support) ambulance.
GPS fitted vehicles target to reach the beneficiary within a fixed response time of 30 to 45 minutes. The
facilities under this initiative, include:
• Free transfer from home to facility,
• Inter facility transfer in case of referral, and
• Drop back for mother and newborn, after 48 hours of delivery.
9. Monitoring during transport

Enroute monitoring can be done by the accompanying EMT if available and the parent/parent attendant.
Following vital parameters (TOPS) must be monitored and maintained:
• Temperature: Continue Skin to Skin contact / KMC and keep the windows of transport vehicle closed
• Oxygen saturation: Maintain position and clear airway if required using mucous extractor. If baby
becomes apnoeic during transport and if a trained health attendant/provider is present in the ambulance,
provide positive pressure ventilation using a bag and mask.

• Peripheral circulation: Monitor heart rate and CRT. Maintain the patency of the IV cannula and the
fluid rate.
• Feeding: Ensure that Enteral feeds/IV fluids are continued enroute to maintain blood glucose levels
during transport.
10. Confirm successful referral

Ensure documentation of receiving the baby and inform the referring unit.
Flow diagram for Neonatal transport
Baby needs to be transported to higher center
Resuscitation if emergency signs (as in ETAT)
Identify indication for referral

Ÿ Sick baby with emergency signs
Ÿ Need for mechanical ventilation
Ÿ Refractory shock, seizures or hypoglycemia
Ÿ Jaundice needing exchange transfusion
Ÿ Need for surgery
Preparation & Counseling & support Pre referral

Organization of transport to family stabilization
Ÿ Communication Ÿ Allow parents to see and touch Ÿ Temperature
s Explain condition, the baby
prognosis and reason for Ÿ Explain clinical condition and Ÿ Oxygenation
transfer care during transport
s Whom to contact Ÿ Information about receiving Ÿ Perfusion
s Inform referral facility hospital
Ÿ Personnel Ÿ Consider maternal tramsfer Ÿ Sugar
Ÿ Vehicle Ÿ Obtain consent
Ÿ Equipment and drugs
Enroute Care
Ÿ Continuous vigilance and
monitoring
Ÿ Maintain TOPS
Documentation
& Handover
Documentation of all the actions should be performed at each step

The transport vehicle should be equipped to shift the baby in a secure manner and stabilize the baby
en-route. The minimum requirements that should be available in a transport vehicle are shown below:
Table 2.1: Medical equipment required for transport of newborn
Essential Desirable (in ALS ambulance)

• Suction pump- manual/electric and suction catheters • Transport incubator
size 10/12 F • Trolley stretcher with back tilt and collapsible wheels
• Flow-meter • Monitor- multiparameter with neonatal
• Oxygen cylinder probes and cuffs
• Stethoscope • Infusion pump (with battery backup)
• Laryngoscope& ET Tubes (2.5,3 & 3.5) • Transport ventilator
• Extra batteries • Surgical kit
• IV fluid stand/hook
• Glucometer with strips
• Pulse oximeter with neonatal probes
• Gloves, surgical masks, hand rub
The following is a list of supplies to be carried during transport as transport kit:
Table 2.2: Medical supplies required for transport of newborn
• Self-inflating silicone bags ( 250 and 500mL) • 10% dextrose

• Ventilation mask • Normal saline
• Mucous sucker • Cotton
• 5-10 mL Syringes, needles • Antiseptic solution
• Intracath- 24 and 26 G • Sterile gloves
• Thermometer • Nasal prongs
• Feeding tube- Size5/6 F • Feeding cup
• Scissors • Small blankets
• Adhesive plaster
If a SNCU/Referral unit is very far or not available, the baby should be managed in the NBSU.
The prognosis and outcome of the baby should be explained in detail to the family.

Key Messages:
All neonates presenting with emergency signs and those who cannot be cared for at NBSU need stabilization
prior to transfer to a special neonatal care unit (SNCU).
1. Ensure:
 Assessment and stabilization of baby at time of admission and prereferral
 Communication with the family & referral facility
 Pre-referral antibiotics
 Referral note
 Arrange vehicle for transport equipped with essential supplies and equipment
 Enroute care(TOPS)
2. Presence of a trained emergency medical technician is desirable
3. Continued communication with the referral facility

Activity 2.1:
ROLE PLAY SCENARIO
A 2 days old baby, with birth weight 1.6 kg is brought to your facility with refusal to feed and subtle
convulsions. You have taken steps to stabilize the baby and now you are preparing for referral and transfer.
I. How will you communicate the situation to the parents?
II. What steps will you take to complete the referral process?

CHAPTER 3
Assessment of Newborns for
Admission in NBSU

ASSESSMENT OF NEWBORNS FOR
ADMISSION IN NBSU
Babies who are sick, but do not present with an emergency sign(s) also require initial stabilization followed
by detailed history pertaining to birth, resuscitation, presenting complaints and detailed examination.
These neonates will require investigations and appropriate treatment. Supportive management in terms of
temperature maintenance, feeding, infection prevention and specific management of common neonatal
problems can easily be done at the NBSU.
• Take a detailed history of the baby and the mother.
• Perform a complete examination of the baby
• Advise relevant laboratory investigations and interpret the results
• Record all information in the mandated format
3.1. History
Review the referral notes or records of the birth, if available. A good history along with the findings of
examination and laboratory investigations, will point towards a probable diagnosis.
Ask the mother or attendant and validate from records:
About the BABY

• What is the problem? (eg. Refusal to feed, fast breathing)
• When did the problem first start? (Time of onset, for eg - since today morning)
• How old is the baby? (Age of the baby)
• How much did the baby weigh at birth? (Birth weight, check records)
• Was the baby born at term? If not, at how many weeks’ gestation was the baby born? (Check records)
• Where was the baby born? Did anybody assist the birth? (Check records)
• Did the baby cry spontaneously at birth? (Check records)
• Did the baby require resuscitation? (Check records)
• Did the baby move and cry normally after birth?
• Has the baby’s condition changed since the problem was first noted? Is the problem getting worse? If so,
how rapidly and in what way?
• What kind of care, including specific treatment, has the baby already received? (Check records)

• Is the baby having problems while feeding, including any of the following?
 Poor or no feeding since birth or after a period of feeding normally;
 Coughing or choking during feeding;
 Vomiting after a feed.
About the MOTHER

• Review the mother’s medical, obstetric, and social history.
• Ask the mother if she has any questions or concerns (e.g. special concerns or anxiety about breastfeeding).
• If the mother is not present, find out where she is, what her condition is, and whether she will be able to
care for the baby, including breastfeeding or expressing breast milk.
Pregnancy
 What was the duration of pregnancy?

 Is there a history suggestive of a chronic disease during pregnancy, (check from records for HIV
status, hepatitis B, tuberculosis, diabetes, or syphilis)? Is there a history of any complications
during pregnancy? If so, what, and if she received any treatment? (Check records)
Labour and Birth
 Did she develop any complications, such as fever, any time from the onset of labour to three
days after birth?
 When did the membranes rupture (assess if the duration was more than 24 hours before birth)?
 Was the labour or birth difficult or complicated, including any of the following:
§ Prolonged labour
§ Caesarean section
§ Instrumental vaginal delivery (e.g. forceps or vacuum extraction)
§ Malposition of the baby (e.g. breech)
§ Blood group
§ H/O bleeding
§ Any other complications.
 Did she develop any complications after the birth?
3.2. Examine the Baby

• Examine the baby under a radiant warmer;
• Allow the mother to be present during the examination;
• Record the axillary temperature;
• If the baby has not been weighed yet, weigh the baby, and record the weight;

• While talking to the mother and before undressing the baby, observe the baby for:
 Colour
 Respiratory rate
 Posture
 Movement
 Reaction to stimuli
 Obvious abnormalities
Record axillary temperature

You have already learnt how to record the temperature. Newborn with cold stress (Axillary temperature
35.5-36.4°C) or hyperthermia (axillary temperature>37.5°C) in the absence of other signs should be
managed in NBSU as described in the subsequent section.
Record weight
All babies presenting to the facility must be weighed.
Managed at either NBSU or SNCU depending on the place of delivery and sickness. In case
1500-1800 grams
baby requires referral, ensure prereferral stabilization
More than 1800 grams Refer only if emergency signs are present (after stabilization)
>3.8 Kg Refer if baby has associated problems like hypoglycemia, feeding and/or respiratory
difficulty
Assess breathing
1. Count the breaths in one minute to decide if the newborn has fast breathing. The newborn must be
calm and quiet when you count the respiratory rate. If the newborn is crying or agitated, you will not be
able to obtain an accurate count of the newborn 's breaths. The cut-off rate to identify fast breathing is
60 breaths per minute or more. If the count is 60 breaths or more, the count should be repeated, because
the breathing rate of a newborn is often irregular. The newborn may occasionally stop breathing for a
few seconds, followed by a period of faster breathing. If the second count is also 60 breaths or more,
the newborn has fast breathing.
Fast breathing is considered serious in a newborn and needs management in a health facility. Babies
with only fast breathing can be managed in NBSU. If the baby has severe respiratory distress (as
explained in earlier section), baby should be referred to SNCU.
Assess feeding
Ask the mother how is the baby feeding at the breast. Any difficulty mentioned by the mother is important
as any feeding difficulty may be a sign of illness. A newborn who was feeding well earlier but is not feeding
well now, may have a serious illness. Breast feeding assessment should be done by observing a breastfeeding

session atleast for 4 minutes. . These newborns, who are either not able to feed or are not feeding well,
should be evaluated urgently in a health facility. Babies requiring continuous IV support or oxygen
should be managed in SNCU.
Assess for irritability/restlessness/jitteriness

A baby who cries constantly and is not consolable by the mother is irritable or restless. The differences
between jitteriness and convulsions are already covered in the previous section. If any other specific clinical
sign is noted in a baby in addition to persistent lethargy or the baby has two or more nonspecific
signs, the baby may be suffering from sepsis or asphyxia. Coma/Convulsions or unconsciousness is an
emergency sign and needs to be managed in SNCU.
Table 3.1: Conditions associated with lethargy, needing referral to SNCU

Possible Condition Symptoms and signs
• Perinatal asphyxia • Onset in first 3 days of life
• Hypoxic ischaemic encephalopathy • History of difficult delivery
• Birth trauma • Gestation: Term or preterm
• Intracranial haemorrhage
• Haemorrhagic disease of the newborn • Bleeding/oozing from any site
• Inj. Vit K not given at birth
• Onset in first 3 days of life
• Haemolytic disease of the newborn • Jaundice
• Kernicterus • Pallor
• Serious bacterial infection • Onset in first 3 days of life
• Neurological manifestations
Neonatal tetanus • Onset at age 3–14 days
• Home delivery, asepsis not maintained
• Irritability
• Difficulty in breastfeeding
• Trismus
• Muscle spasms
Meningitis • Lethargy
• Fever
• Apnoeic episodes
• Convulsions
• High-pitched cry
• Tense or bulging fontanelle
Sepsis • Fever or hypothermia
• Inability to feed
• Respiratory distress
• Shock (lethargy, fast breathing, cold skin, prolonged
capillary refill, fast weak pulse)

Assess diarrhoea
Infective diarrhoea is seldom seen in exclusively breast fed babies, however if the baby presents with
diarrhoea suspect sepsis. Assess for dehydration and also ask for blood in stool.
• If the baby has signs of dehydration (lethargy, sunken eyes, very slow skin pinch) or blood in stool,
establish an IV line and start IV fluid, while arranging for referral.
• Blood in stool in a newborn may be because of serious infection or surgical problem. Such babies
should be given 1 mg intramuscular dose of Vitamin K and referred to higher centre with pre-referral
dose of antibiotics.
Look for abdominal distension

Abdominal distension may be a sign of serious illness (sepsis, necrotizing enterocolitis or gastrointestinal
malformation or obstruction) and needs management in a higher centre.
Look for pallor/bleeding from any site

• If baby has pallor, take a blood sample, and measure haemoglobin. If the haemoglobin is less than 10
g/dl (haematocrit less than 30%), refer to higher centre for evaluation and blood transfusion/ packed
RBCs if available.
• If baby has bleeding, look for site of bleeding (e.g. umbilicus, male circumcision site, or venipuncture
site). Stop visible bleeding, if possible and give 1 mg intramuscular dose of Vitamin K and refer to
higher centre with pre-referral dose of antibiotics.
• If there are signs of shock, the baby should be referred to SNCU after initial management, as described
in the section on emergency signs.
Look for Jaundice

• Examine baby preferably in natural daylight.
• To check for jaundice, press gently on the baby's forehead or nose. If the skin looks yellow where it was
pressed, it's likely the baby has mild jaundice.
• To assess the extent of jaundice, refer to chapter 5.1.
• Many babies, particularly small babies (less than 2.5 kg at birth or born before 37 weeks gestation), may
have jaundice during the first week of life. In most cases, the level of bilirubin that causes jaundice is
not harmful and does not require treatment. However, any jaundice visible in the first 24 hours of
life and/or visible on palms and soles should be assumed to be serious. Such cases are managed in
SNCU/tertiary care facility. Management of jaundice is described in chapter 5.

Look for congenital malformations: Refer to annexure 1
Congenital malformations which are not life threatening like cleft lip, cleft palate, club feet and may not
require immediate referral. The provider must connect with Rashtriya Bal Swasthya Karyakram (RBSK)
manager after reporting the congenital defect, for facilitating any further support required by the family,
in terms of surgery etc. which is available free of cost under RBSK. Congenital defects which are life
threatening should be stabilized and referred to SNCU, for example- a baby with meningomyelocele should
be transported after covering the same with saline soaked sterile gauze during transport.
3.3. Admission to NBSU

Neonates requiring admission to NBSU fall in two categories – firstly those with emergency signs who
require immediate stabilization followed by referral and secondly those who fulfill criteria for admission
to NBSU. (See Table 3.2).
TABLE 3.2: Criteria for admission to NBSU
1. Newborns presenting to NBSU with emergency signs

2. Newborns not having emergency signs, weight above 1800 gm and any of the following signs of
sickness:
 Feeding problem
 Breathing Rate 60-70/min
 Hyperthermia (axillary temperature >37.5oC)
 Hypothermia (35.5oC -36.4oC)
 Jaundice requiring only phototherapy
 Newborns with suspected sepsis
3. Weight 1500-1800 grams, with no sign of sickness #
4. Newborns who cannot be transferred to SNCU or referral facility due to any reason
5. Newborns back-referred (from SNCU) to NBSU for completion of treatment
# Newborns weighing 1500-1800 grams can be managed at either a functional NBSU or SNCU
depending on the place of delivery and sickness

Key Messages:
• Admit newborn with emergency signs where referral is not possible after stabilization
• Babies with priority signs may be admitted to NBSU after initial stabilization.
• Detailed history of the mother and baby, thorough examination of the neonate and relevant investigations
are required to reach a diagnosis and further management.

Activity 3.1:
DRILL TO DISCUSS CRITERIA FOR ADMISSION TO NBSU
S.No Sign/s Admission for stabilization or management

i Subtle convulsions
ii Axillary temperature < 35.50C
iii 2 kg baby with respiratory rate 66/minute
iv Cold extremities with capillary refill time > 3 seconds
v 1.9 kg baby with temperature 35.90C
vi Respiratory rate > 70/minutes, with severe chest in-drawing
vii Baby weighing 1.9 kg with difficulty in feeding
viii Baby with diarrhoea with dehydration
ix Baby weighing 1.7 kg
x Jaundice on palms and soles
xi Temperature 390C
xii Baby with bluish discolouration of lips

CHAPTER 4
Supportive Care
SUPPORTIVE CARE
While babies with emergency signs and those without emergency signs, who fulfill the criteria for admission
to SNCU would be referred, there may be situations, where referral is not possible or gets delayed. Such
babies will need to be managed at the NBSU. Babies who fulfill the criteria for admission to NBSU will also
need optimum care and support until they are fit to be discharged. It is therefore important to know the
components of supportive care, how to counsel the mother and the family and involving them in the care
of their newborn baby.
1. Enumerate methods of maintaining temperature of babies admitted in NBSU
2. Provide support for and encourage exclusive breast feeding
3. Provide IV fluids where needed
4. Encourage family participatory care
5. Plan discharge of admitted babies
6. Counsel mothers regarding care at home
7. Ensure infection prevention in NBSU
4.1. Maintain Temperature

• For babies with low body temperature (< 35.5oC), use radiant warmer for maintaining temperature (the
steps have been described in the previous section).
• The best way to maintain temperature of a baby with hypothermia (35.5-36.4oC) is to place the baby in
skin-to-skin contact with the mother (or any adult).
Take following steps to prevent hypothermia:
• Maintain room temperature between 26-28oC. Also check that there is no cold source or fan directed
straight at the newborn or draught of air from open windows, ventilators and doors.
• Always keep the baby dry and well covered. Remove wet clothing, if any. Cover the head, hands and feet
with cap, mittens and socks, respectively and continue breastfeeding.
• Bathing should be postponed, till 24 hours after birth in normal weight baby and 7 days in low birth
weight baby; hospitalised neonates should instead be sponged with lukewarm water daily.
• Pay special attention to prevent hypothermia during examination or investigations and before removing
clothes.

When Skin to Skin contact is not possible:
1. Keep the room warm.
2. Clothe the baby in multiple layers, enough to keep the peripheries warm and keep monitoring
temperature using tactile method.
3. Let baby and mother lie together on a soft, thick bedding;
4. Cover the baby and the mother with additional quilt, blanket or shawl, especially in cold weather.
 Provide Kangaroo Mother Care (KMC) to all low birth weight babies. KMC can be started in the
hospital and should be continued at home.
KMC can be initiated immediately in all babies, the ongoing medical support, like intravenous
fluids and tube feeding are not contraindications to KMC.
Video 6 & 7
KMC counselling and KMC technique
Hyperthermia (axillary temperature above 37.5°C): may be either due to an environmental cause or it
may be a sign of infection (usually in a term neonate).
If baby has hyperthermia, maintain optimal room temperature, correct environmental factors (such as
removal of any heat source), ensure that the baby is not overly clothed or covered by blankets. Antipyretics
are not recommended. Continue breast feeding.
4.2. Administer Vitamin K

Give vitamin K1 (phytomenadione) 1 mg IM once, if not given earlier in babies weighing more than 1000
gms; and 0.5 mg for those weighing less than 1000 gms using a 26 gauge needle and 1 ml syringe.
4.3. Feeding
Most newborns weighing 1800 grams or more will be able to suckle at the breast. Initiate breastfeeding
soon after (within half to one hour) birth. Do not introduce prelacteal feeds (ghutti, gripe water, honey
or any other milk). They will reduce the breast milk intake by the baby and increase risk of infection.
Breastfeed day and night on demand at least eight times or more per day. Allow baby to feed at one breast
till the baby stops sucking and releases the breast, then offer him the other breast and offer this breast first
at the next feeding session.
Following two hormones are important for sustaining breast feeding:

• Prolactin hormone secretion is stimulated by suckling and at night. Frequent and specially night feeding
are thus very important . Also this hormone suppresses ovulation and hence prevents conception.

• Oxytocin hormone secretion increases by suckling, smell, sound, touch of the baby and when the mother
is relaxed and stress free. Back massage also increases the secretion of oxytocin.
Prolactin Refex Oxytocin refex Helping and hindering of oxytocin re ex
Secreted AFTER feed Sensor impulses Works BEFORE or DURING feed

to produce NEXT feed from nipple to make milk FLOW
ese help re ex ese hinder re ex
Prolactin in blood Oxytocin in blood Sensor impulses

from nipple
Baby sucking More prolactin

secreted at night Baby sucking
Suppresses ovulation
Makes uterus contract
• “Rooting” reflex is when the breast or nipple touches a baby’s lip or cheek, he opens his mouth and may
turn his head to find it, puts his tongue down and forward.
• “Sucking Reflex”: When something touches a baby’s palate, he starts to suck it, and when his mouth fills
with milk, he swallows.
A full term healthy neonate is endowed with all these reflexes, which help him feed at the breast without
the need to learn them. The adequacy of milk intake can be assessed by counting the number of wet diapers
per day (6 – 8 times / day), and weight gain (20 – 30 gms a day in 1st 3-4 months). Those who cannot
breastfeed should be given expressed breast milk with a cup/paladai. Newborn unable to feed from a cup/
paladai should be given intermittent bolus feeds through an oro-gastric tube. When the newborn starts to
suckle well and is gaining weight, reduce the cup/orogastric feeds gradually. Ensure exclusive breastfeeding
during first 6 months of life (feeding only breast milk and medications, if required).
Table 4.1: Feeding initiation and protocol for stable babies
Birth weight (g)

1200-1800 (g) >1800 (g)
Day of life
Initial Orogastric Breastfeeding. If unsatisfactory, give cup /paladai feeds
After 1-3 days Paladai feeding Breastfeeding
1-3 weeks and beyond Breastfeeding Breastfeeding
Breastfeeding is ideal for all newborns and should be supported. Breast milk is the ideal feed for all
infants, including LBW infants. Anything other than breast milk is less than optimal.
Feed the newborn, mother’s own expressed breast milk.

In exceptional situations, when mother’s own milk (MOM) is not available, donor human milk can be
given, only where safe milk-banking facilities are available. Formula feeds should only be given, if neither
of the above is possible and switch over to breastmilk as soon as possible. Babies should be fed every two
hours and the amount to be fed should be calculated according to the weight and day of life (Table 4.2).
Video 8,9 & 10

Breastfeeding technique, expression of breast milk & feeding by paladai
4.4. Fluid Therapy

Fluid management is important in managing some of the small and sick newborns who cannot be given
enteral feeds. These cases are best managed in SNCU. In certain situations, where referral is not possible,
service providers will be required to provide intravenous fluids. Refer to table 4.2 for daily fluid requirement
for newborns.
Table 4.2: Daily Fluid requirement of newborns (ml/per kg body weight)
Day of life Fluids in ml/kg/day

Birth Weight ≥1.5 Kg Birth Weight <1.5 Kg
1 60 80
2 75 95
3 90 110
4 105 125
5 120 140
6 135 150
7 150 150
Type of fluid:
• During the first 2 days of life, give 10% dextrose as IV infusion. After the first 2 days of life, use IV
dextrose with low sodium, such as commercially available Isolyte P.
Administration of IV fluids:
• Use syringe infusion pump or paediatric microdrip infusion set to administer IV fluids in newborns.
• Calculate the drip rate: first calculate the total fluid requirement per day in ml and divide by 24. This will
give the estimate of fluids in ml per hour which can be set on the syringe infusion pump or drops/min
in a microdrip set. In microdrip set, 1 ml=60 micro drops. The number of drops per minute is equal to
ml of fluid per hour. So if a baby needs 5 ml/hour, then set the drop rate at 5 drops per minute).
• Record the drip rate and volume infused every hour in the case sheet.
• Weigh the infant daily. Watch for weight loss/gain and urine output and increase/reduce IV fluids accordingly.

• Check IV catheter site for signs of leakage, swelling or redness, in which case IV access at a new site
should be established.
• Introduce breastfeeding or milk feeding by orogastric tube, as soon as it is safe to do so.
Transition from IV fluids to feeding:

Newborn may be transitioned from IV fluids to enteral feeds or may be shifted from one mode of feeding
like orogastric to cup/paladai feeding or to breastfeed.
• Transition from IV fluid therapy to enteral feeds must be attempted as soon as the newborn stabilizes
and is fit to receive oral feeds.
• Whenever baby is shifted from IV fluids to enteral feeds, the initial volume should be 12- 24 mL/kg/day.
• Increase the amount of enteral feeds to 20-30ml/kg/day, signifying that smaller increments are to be
done in smaller babies.
• The volume of enteral feeds introduced should be subtracted from total fluid requirement per day (table
4.2). Give rest as IV fluids. The total daily fluid requirements is to be met from feeds and fluids.
• IV fluids can be omitted when the baby is able to consume feeds equal to two-thirds of total fluid requirement.
• When the baby is not on breastfeeding, put baby on the empty breast (after milk expression), before
every feed to help promote lactation and enable the baby to learn how to suck (non-nutritive sucking).
• Whenever feeding transition is done, introduce new mode for only some of the feeds to begin with
(example 1 per shift). Subsequently, add newer mode in remaining feeds, if baby shows consistent
weight gain for consecutive days.
Example of fluid calculation:

A stable baby weighing 1.6 Kg. on day 1 will require 60mL/kg/day of feed or fluids. Therefore, total
requirement = 60 ml x 1.6 Kg = 96 ml. If this can be given as enteral feeds then the total volume needs to
be divided into 12 aliquots = 96/12= 8ml. The final order will be = 8mL expressed breast milk by orogastric
tube every two hours. However, if this needs to be given as IV fluid, then the total volume needs to be
divided by 24 = 96/24 = 4 mL per hour, as IV fluid.
Excessive weight loss (greater than 3-5% in 24 hours): Check for inadequate feeding, and manage
underlying conditions, if any (cold stress, excessive insensible water loss or systemic illness).
Video 11
OG tube insertion & feeding
4.5. Watch for and treat apnoea

Small babies are prone to episodes of apnoea, which are more frequent in very small babies (less than 1.5
kg at birth or born before 32 weeks gestation) but they become less frequent as the newborn grows.

If active, or crying, the newborn is obviously breathing. Look for slow breathing with prolonged intermittent
pauses (lasting >20 seconds) with or without central cyanosis or bradycardia. If present, it means newborn
has apnoea.
• Monitor all small babies for occurence of apnoea.
• If the newborn stops breathing, stimulate the newborn to breathe by rubbing the newborn’s back.
• If the newborn does not begin to breathe by tactile stimulation, resuscitate the newborn using a bag and
mask after positioning and suctioning, if required.
• In addition, maintain temperature, oxygen saturation and glucose levels.
• If the apnoeic episodes become more frequent, refer to SNCU for further management.
4.6. Family Participatory Newborn Care

Family participatory newborn care is a partnership between parents and service providers, wherein they
work together, while the baby is in the newborn care unit and share responsibility for caring for the baby.
Involving mother or parent-attendants has shown to be associated with numerous benefits including
decreased length of stay, enhanced parent–infant attachment and bonding and improved well-being of
pre-term infants, better allocation of resources, and greater patient and family satisfaction. Interventions
for which there is positive evidence, include-skin-to-skin care (KMC) and support for breastfeeding as well
as better understanding of baby’s developmental needs.
Family participatory care (FPC) in newborn care units entails supervised delivery of care to haemo-
dynamically stable, sick & preterm newborns by the parents/attendants, in addition to the standard care
provided by the healthcare providers in the nursery.
Thus FPC has two distinct interventions:

1. Building capacity of caregiver
2. Supervising and supporting the caregiver
The process of skill building, under supervision, enables parents to participate not only in delivery of
care during hospitalization, but also allows for continuum of care at home.
Detailed operational guidelines on FPC have been issued by the Government of India and should be
referred to for making newborn care family participatory.
4.7. Rooming in of Babies Weighing 1800-2500 Grams

• Babies weighing 1800-2500 grams, being cared for by the mother in the postnatal ward, require
temperature maintenance and adequate breast feeding.

Temperature maintenance:
• The best way to maintain temperature is by placing the baby in skin-to-skin contact (KMC) with the
mother (or any adult). KMC can also be used to keep a baby warm during transport and at home.
Breastfeeding:
• Optimum nutrition for the baby is its own mother’s milk. Mother should be advised and supported to
exclusively breastfeed her baby. The healthcare worker needs to assess the adequacy of breastfeeding.
In case of any concern regarding adequacy of breastfeeding, the newborn should preferably be weighed
on the same weighing scale that was used to weigh the infant at birth. Excessive weight loss (normal
8-10% of birth weight by 3-4 days of age) would indicate inadequate breastfeeding. In such a situation,
check for frequency of feeding, night feeds, positioning, attachment and look for any breast or nipple
problems.
 If breastfeeding less than 8 times in 24 hours, advise to increase frequency of breast feeding.
 If not well attached or not suckling effectively, teach correct positioning and attachment.
 If unable to breastfeed, help mother express her milk and feed this expressed breast milk with katori
spoon/paladai.
 If breast or nipple problem, help the mother to treat breast or nipple problems.
4.8. Stabilization of neonate back referred after discharge from SNCU

Babies may be transferred back to NBSU after treatment from SNCU/District hospital for antibiotic
completion and assisted feeding. The following should be done in such babies:
• Assess and stabilize.
• Record the current weight of the baby
• Record the diagnosis and treatment received at SNCU
• Plan completion of antibiotics, if required, as mentioned on referral/discharge note from SNCU
• Encourage breastfeeding and support assisted feeding, if necessary
• Communicate with the referring doctor, for any clarification, on treatment to be continued.
• Communicate with the family about progress and treatment plan of the baby
• Inform ASHA/ANM of their respective area, regarding home visits and continuation of medications,
if any and assisted feeding
4.9. Discharge From NBSU

Infant should be discharged once the following criteria are fulfilled:

Criteria for discharge from NBSU
• Baby is maintaining normal body temperature (in room temperature/when cared for by the mother)
• Baby not requiring IV fluids/medications
• Baby is accepting breastfeeds/assisted feeds well and gaining weight for 3 consecutive days
• IV antibiotic therapy has been completed
• Baby admitted for neonatal jaundice and has completed phototherapy treatment
• Mother has been counselled for danger signs*( Refer Box on Page-77), assisted feeding (as required) ,
KMC (as required) and follow up plan.
Preparation for Discharge

• Prepare discharge summary. Birth weight, discharge weight, length and head circumference should be
mentioned in the discharge summary. Standard format has been provided in annexure.
• Inform ASHAs/ANM about the discharge and home based follow up
• Baby should have received the following vaccines- BCG, zero dose OPV (can be given till 14th day
of life) and birth dose of hepatitis B (within 24 hours of birth). There is no lower weight limit for
vaccinating a newborn.
• Advice screening for preterm babies to be done at a higher centre for:
1. Retinopathy of Prematurity (ROP) for all babies < 2000 gms at 4 weeks;
2. BERA (Brainstem evoked response audiometry) at 40 weeks corrected age
• While communicating the discharge instructions to mother:
 Use words that she understands
 Use teaching aids that are familiar to her
 Give feedback when she practices what she has learnt. Praise what was done well and make
corrections, if necessary
 Allow more practice, if needed
 Encourage the parent/mother to ask questions and answer all the questions.
• Advise mother to continue the following at home: Breastfeed infant exclusively, keep infant
warm, keep cord clean and dry.
• Explain importance and correct method of handwashing & danger signs.
Nutritional supplements for LBW babies

1. Supplements are required for low birth weight babies and should be started, once the baby is accepting full
oral feeds.
2. Vitamin D: All LBW infants, who are exclusively breastfed should receive 400 IU daily of vitamin D. The
supplementation should continue until one year of age. Most available vitamin D drops contain 400 IU/ml.

3. Multivitamin drops with zinc: All VLBW infants, should receive 1 ml/day from 2 weeks of age, till 40
weeks corrected age.
4. Calcium and phosphorous: All very low birth weight babies (birth weight< 1500 gms) should receive
elemental calcium and phosphorous at 120-160 mg/Kg/day and 60-80 mg/Kg/day, respectively. This
should be continued till 40 weeks corrected age. For optimal supplementation, the preparations having
a calcium and phosphorous in 2:1 ratio should be used.
5. Iron: Elemental iron supplementation at 2 mg/kg/day at 2-4 weeks in <2500 grams infants is effective
in preventing anaemia of prematurity and should be continued till one year of age.
Table 4.3: Nutritional supplements for LBW babies (1.5 to 2.5 Kg)
Indicated in Till when to

Supplement When to start Dose
which babies administer
When baby starts
Vitamin D All babies 400 IU/day Till one year of age
accepting full feeds
From 2-4
Iron LBW babies <2.5 kg 2 mg/kg/day Till one year of age
weeks of age
Danger signs in the newborn/young infant

Danger signs should be explained to the mother before discharge and she should be advised to bring the
baby to the facility, if any of the following danger sign is observed:
Danger signs to be explained to mother:

• Refusal to feed
• Fast or difficult breathing,
• Cold or Hot to touch,
• Jaundice involving palms and soles /pallor/cyanosis,
• Abnormal movements,
In addition the following also need urgent care at the facility:
• Abdominal distension
• Bleeding from any site
• Diarrhoea with blood in stool

• All discharged babies should be followed up within a week or earlier depending on the medical
condition. Date and time at follow up should be informed to the parents. The same must be recorded in
the discharge summary. All discharges should be linked with local ASHA and DEIC (Wherever needed)
4.10. Infection Prevention and Control

Sepsis is a major cause of neonatal morbidity and mortality. Thus, infection control is an integral part of
neonatal care. Infection control practices consist of the following:
1. Disinfection of equipment
2. Disinfection of surroundings
3. Hand washing practices
4. Additional practices
Table 4.4: Disinfection of equipment
S.no Equipment Disinfection/Sterilisation process Frequency

Daily & Every time after shifting a
1. Radiant warmer Clean canopy and mattress with detergent solution
baby
2. Cot Clean with 3% phenol/5% Lysol/2% glutaraldehyde Daily
Suction tube should be changed daily
3. Suction apparatus Suction jar should be cleaned with detergent
Suction jar should be cleaned daily
4. Oxygen hood Clean with detergent Daily and after every use
Disinfect-Clean with detergent and wash
Disinfect daily and after every use.
5. Bag and mask Sterilize- Immerse in 2% gluteraldehyde for 4-6
Sterilize weekly.
hours followed by rinsing with water
Clean with soap and water and boil in water for
6. Feeding utensils After every feed
15-20 minutes
7. Thermometer Wipe with alcohol swab After every use
1. Disinfection of newborn care unit:

A. Disinfection of surroundings:
• Dry dusting should be avoided.
• Wet mopping should be done at least 3 times a day.
• Walls should be cleaned once a day
• Surface cleaning of the unit may be done using detergent/ 2 percent glutaraldehyde.
• Concentration of the available glutraldehyde may vary from place to place and therefore each
unit should also look at the manufacturer’s instructions to prepare the appropriate solution.
B. Housekeeping routines:
a. Segregation of waste- This should be done as per bio-medical waste management guidelines.
Sharps should be discarded separately in puncture proof containers.
b. Disposal of waste- Waste containers should be colour coded and covered with lids and lined by
plastic bags. Bins should be emptied regularly and spillage should be avoided.

c. C
leaning of spillage- use 10 gram of bleach in 1L of water. The area should be covered with
this solution for 20 minutes. It should be mopped with a disposable cloth which should be
discarded after use.
2. Hand washing:
This is the single most effective step to reduce infection. It should be done before and after contact with
any patient or body fluid or after leaving patient surroundings. The essential steps of hand washing are as
shown below:
Hands should be allowed to dry on their own without use of any mop/cloth/paper.

3. Additional practices-
In addition, adopt policies which promote:
a. Early enteral feeding
b. Exclusive breastmilk feeding
c. Rooming in with mother
d. Maintenance of maternal hygiene
The health care facility should also avoid cross-infection at all times by practicing strict hand hygiene.
Video 12 & 13
Hand hygiene and Infection control protocols
Key Messages:
• Supportive care is as important as specific care.
• Ensure baby is normothermic always (temperature between 36.5- 37.5oC), airway is patent and
oxygen saturation is between 91-95%
• Promote and encourage enteral feeds (breast feeds or assisted breast milk feeds) IV fluids to be
started only when enteral feeds can not be given, (add enteral feeds as soon as the condition permits)
• Monitoring the newborn is important to assess and initiate course correction. Promote rooming in,
infection prevention measures and encourage family participation
• Discharge criteria should be fulfilled prior to discharge

Exercise 4.1:
CASE STUDIES
1. Ranno delivered a 2.0 Kg baby 48 hours ago. There are no emergency signs. The baby is feeding well
at the breast and maintaining temperature. How will you manage this baby?
2. Baby of Shanti, weighing 2 kg, was admitted with fast breathing on day 1 of life. He was started on IV
fluids.
a) Calculate total IV fluids to be given.
b) Baby stabilized on Day3 . Plan the fluid and feeding schedule
c) When will you plan for discharge
3. Baby of Malti, weight 1900 grams is being discharged from NBSU at day 6 of life after receiving
phototherapy. What feeding advice will you give to the mother? What supplements will you advise,
in what quantity and for how much duration?

Exercise 4.2:
INDICATE THE MODE OF FEEDING AND VOLUME OF FEEDS TO BE STARTED IN THE FOLLOWING
BABIES (FILL IN BLANKS IN LAST TWO COLUMNS)
S.No. Day of life Weight Feed mode Volume

1. Day 1 1500g
2. Day 1 1900g

CHAPTER 5
Management of Jaundice and
Sepsis in Newborn

MANAGEMENT OF JAUNDICE AND
SEPSIS IN NEWBORN
The service providers at NBSU will commonly treat cases of Jaundice (yellow discoloration of skin and
sclera) and Sepsis.
About 60% of term and 80% of preterm neonates are clinically jaundiced and these newborn can be
appropriately managed at NBSU, if required.
Sepsis is the most common cause of neonatal deaths. If diagnosed early and treated with good supportive
care and antibiotics, it is possible to save most cases of neonatal sepsis. Newborns with sepsis who do
not have any emergency or danger signs can also be managed at the NBSU. These neonates need close
monitoring and protocol-based management as described in this chapter.
1. Enumerate the characteristics of physiological jaundice.
2. Enumerate the characteristics of pathological jaundice and alert signs.
3. Assess the severity of jaundice based on the clinical estimation.
4. Institute phototherapy based on recommended guidelines.
5. Identify neonate with sepsis.
6. Interpret the ‘sepsis screen’.
7. Treat neonatal sepsis.
8. Know when to refer
5.1. Management of Jaundice

More than 60% of normal newborns and 80% of preterm newborns develop jaundice due to immaturity
of liver, short life span of red blood cells and increased enterohepatic circulation of bilirubin. However, in
some babies bilirubin levels may be high and if not managed early, can result in neurological manifestations.
Jaundice may be normal (physiological)

Any baby who has Physiological jaundice will have following features:
• Icterus appears after 24-36 hours, peaks around 4-5th day (term), 7th day (LBW) and resolves by 10-14th day
• Serum bilirubin generally does not rise above 15 mg/dl in term and 12 mg/dl in preterm babies
• Skin and eyes yellow, but none of the signs of abnormal jaundice (given below).

A baby who has physiological jaundice can be sent home on exclusive breastfeeding. The baby should be
re-assessed for any fresh symptoms or progression of jaundice, after 48 hours of discharge.
Jaundice may be abnormal (pathological)

• Starting on the first day of life
• Lasting > 14 days in term and > 21 days in preterm infants
• Severe jaundice: palms and soles of the infant are yellow
Assessment of jaundice
When a neonate is clinically jaundiced, the total serum bilirubin (TSB) is usually >5-7mg/dl.
Jaundice in newborn progresses in cephalocaudal (head to toe) direction and thus the extent of yellowness
of the skin is useful to assess the level of bilirubin. Kramer’s criteria is used to clinically assess jaundice.
However, serum bilirubin levels must be done to guide management.
12
15
18-20
Figure 5.1
Figure 5.1: Clinical
: Clinical visualvisual perception of
perception of jaundice:
jaundice:Kramer 1969 1969
Kramer
Management of newborns with jaundice:

1. Determine baby’s weight and gestational age {from mother’s last menstrual period (LMP)} -
What to investigate in case of jaundice:
2. Examine the baby for level of jaundice according to Kramer's chart.
1. Send blood samples for estimation of
3. Look for associated risk factors for jaundice like: sepsis, asphyxia or haemolysis due to blood group
o Total serum bilirubin
incompatability.
2. Look for associated risk factors for jaundice like: Sepsis, asphyxia or haemolysis due to
blood group incompatibility (mother O+ and baby A+/B+/ AB+ or mother Rh negative an
baby Rh positive).
4. Send blood samples for estimation of
 Total serum bilirubin (TSB)
 Mother and baby’s blood group (Collect cord blood when mother's blood group is known to be O or
Rh negative)
Management of jaundice is directed towards reducing the level of bilirubin and preventing central nervous
system toxicity and has two main components:
1. Prevention of hyperbilirubinemia: by early and frequent feeding
2. Reduction of bilirubin: This is achieved by phototherapy, and/or exchange transfusion.
The decision to treat depends on the severity and the cause of jaundice.
Phototherapy: a treatment for jaundice, where the skin of the neonate is exposed to a specialized light
source, which helps to reduce the bilirubin levels.
Phototherapy should be initiated (after sending blood sample for TSB), if:
• Jaundice appears on day 1
• Jaundice is severe i.e. involving palms and soles
• S. Bilirubin level is in phototherapy range as per American Academy of Paediatrics (AAP) charts (Refer
Figure 5.2).
Continue phototherapy until the serum bilirubin level is 2-3 mg lower than the phototherapy range.
Important information:
1. Prophylactic phototherapy is not recommended
2. Sunlight exposure or exposure to artificial light at home like a bulb has no effect on bilirubin levels
Treatment of jaundice based on serum bilirubin level

Jaundice is treated as per the following AAP charts in neonates ≥35 weeks as shown in Fig 5.2. This chart
correlates the level of Serum bilirubin with the age of the newborn and the risk associated including
gestational age. The level of the bilirubin is to be matched with the age and the action is to be taken
according to the three different graphs, based on the risk associated and gestational age.

Figure 5.2:
Fig 5.3: chart for exchange Chart for phototherapy
transfusion as per AAP Guidelines
as per AAP Guidelines 2004 2004
Fig 5.3: chart for exchange transfusion as per AAP Guidelines 2004
Exchange transfusion is not described in this training package. The AAP chart for exchange transfusion is
Exchange transfusion is not described in this training package. The AAP chart for exchange
included, in case
Exchange isexchange
transfusion
transfusion intransfusion
is not
included described
case inisthis
exchange required,
training so
transfusion is that
package. the
Theinfant
required soAAP can
thatchart be exchange
for transferred
the infant can be quickly and safely
transfusion
transferredis included
quickly in
and case exchange
safely to transfusion
another facility is required
where
to another facility where exchange transfusion can be performed. so
exchange that the infant
transfusion can
can beperformed.
be
transferred quickly and safely to another facility where exchange transfusion can be performed.
Figure 5.3: Chart for exchange transfusion as per AAP Guidelines 2004
56 56

Table 5.1: Guidelines to start phototherapy for <35 weeks and birth weight <2500 g
Serum Bilirubin Levels (mg/dl) Serum Bilirubin levels

Birth weight (gms) (Phototheraphy) (mg/dl) to refer for
Healthy Sick exchange transfusion
<1000 05-07 04-06 10-12
1001-1500 07-10 06-08 12-15
1501-2000 10-12 08-10 15-18 mg/dl
2001-2500 12-15 10-12 18-20 mg/dl
Source: Martin & Fanaroff, Neonatal -Perinatal medicine, 8th edition, p1450
Care of babies under phototherapy: (Refer to section on phototherapy in skill station annexure)
Alert Signs
1. Serum bilirubin increasing despite phototherapy
2. Neurological signs (high pitched cry, hypertonia, opisthotounus, seizure, etc.,) develop
3. Jaundice requiring exchange transfusion
4. Jaundice persisting after three weeks and/or associated with clay coloured stools
Key Messages:
• Assess jaundice, admit and treat with phototherapy if required.
• Stabilize neonates with severe jaundice and refer.
• Refer if any danger sign appears during the course of treatment.

Exercise 5.1:
CASE STUDIES
1. Ram, a 5 days old baby, born full term with birth weight of 2.8 kg, is brought to health facility with
jaundice on the face and chest which developed over last 24 hours. Baby is feeding well. There are no
risk factors.
a. How will you manage this baby?
b. What advise should be given to the mother?
2. Baby Prerna was born at 34 weeks and has been brought to FRU with yellow palms and soles. The
baby is four days old.
a. How will you manage this baby?
b. What additional information and investigations are required?

5.2. Management of sepsis in newborn
Neonatal sepsis is a clinical syndrome characterized by signs and symptoms of infection in the first month of
life. It encompasses various systemic infections of the newborn such as septicemia, meningitis, pneumonia
and urinary tract infections (UTls). Depending on the age of onset, two patterns of the diseases have been
recognized: early onset sepsis (EOS) and late onset sepsis (LOS). Table 5.2 enlists the features suggestive
of both.
Table 5.2: Early versus late onset sepsis
Early onset sepsis (EOS) Late onset sepsis (LOS)

Time of onset of signs & Appears within 72 hours of birth Appears after 72 hours of age
symptoms
Source of pathogens Maternal genital tract/the delivery area External environment of community or
hospital (nosocomial)
Risk Factors • Very low birth weight (<1500g) • Very low birth weight, prematurity
• Prematurity • Lack of breastfeeding
• Prolonged rupture of membranes • Delayed enteral feeding
(>24 hours) • Frequent handling
• Foul smelling liquor • Disruption of skin integrity with
• Multiple (>3) per vaginum needle pricks and use of intravenous
examinations in 24 hours fluids
• Intra-partum maternal fever (>37.8°C) • Poor hygiene
• Poor maintenance of asepsis in
neonatal units including improper
hand washing techniques
• Superficial infections (pyoderma,
umbilical sepsis)
• Previous or prolonged hospitalization
Predominant manifestation Respiratory distress due to congenital Commonly presents as septicemia,
(intrauterine) pneumonia pneumonia or meningitis
Clinical picture of sepsis Highly variable, signs and symptoms may be minimal, subtle, or nonspecific
When to suspect sepsis Any newborn with risk factors, any newborn brought with emergency signs, if there is
history of - feeding difficulty, fast breathing, hypo or hyperthermia, poor weight gain and
lethargy

Table 5.3: Common clinical features of neonatal sepsis
General Symptoms Refusal to suckle, not arousable, comatose, poor cry, poor weight gain, abdominal distension,
vomiting, poor perfusion, shock, bleeding
Suggestive of Cyanosis, tachypnea, chest retractions, grunt, apnoea/gasping
pneumonia
Suggestive of Fever, seizures, blank look, high pitched cry, excessive crying/irritability, neck retraction,
meningitis bulging fontanelle
Diarrhoea Diarrhoea is suspected if there is passage of watery stools or an increase in usual stool
frequency
Sclerema Sclerema neonatorum manifests as diffuse hardening of the subcutaneous tissue resulting in a
tight smooth skin that feels bound to the underlying structures
Renal failure Renal failure can be suspected clinically by presence of oedema/excessive weight gain and
oliguria/anuria
Diagnosis of sepsis
Isolation of microorganisms from blood, CSF, urine or pus is diagnostic of sepsis. In clinically
suspected cases of sepsis, blood culture should be sent prior to starting antibiotics. As culture facility
may not be available at most NBSUs, indirect method such as sepsis screen may be used to diagnose
sepsis.
Sepsis screen: This is a combination of laboratory parameters which help in predicting sepsis in
newborns, with clinical features suggestive of sepsis. It should be done in all babies with probable
sepsis and in babies born to mothers with risk factors for sepsis. A positive “sepsis screen” takes into
account two or more positive tests as given below:
Sepsis screen
Perform sepsis screen if

• Sepsis is suspected clinically, or
• There are two or more risk factors in an asymptomatic baby
Positive sepsis screen:
• TLC <5000/cu.mm
• Neutropenia (Absolute Neutrophil Count < 1800/cu.mm)
• Immature neutrophil (band cells) to total neutrophil (I/T) ratio > 0.2
• Micro ESR (ESR> 15mm 1st hour)
• C-Reactive Protein–positive

Management
Supportive care and antibiotics are two equally important components of the management of sepsis.
A. Supportive care to neonate diagnosed with sepsis:
• All newborns who present with danger signs should be managed first using TABC approach (described
earlier in Chapter1) and referred.
• In case referral is refused/not possible and sepsis is strongly suspected, supportive care should be
provided, in addition to specific antibiotic therapy.
Maintain TABC
1. Maintain normothermia
2. Position and clear airway if required
3. Ensure optimum oxygenation (maintain SpO2 91-95%)
4. Shock to be treated with NS bolus of 10ml/kg over 30 mins
5. Maintain normoglycemia
6. If hemodynamically compromised, avoid enteral feed and give maintenance IV fluids. Start orogastric
feeds, as soon as hemodynamically stable.
7. Consider referral for exchange transfusion, if there is sclerema.
Administration of antibiotics:
• Give Injection ampicillin and gentamicin, as first line of treatment.
• Give cloxacillin (if available) instead of ampicillin, if there are extensive skin pustules or abscesses, as
these might be signs of Staphylococcus infection.
• Antibiotics should be given slowly, after dissolving in 5-10 ml fluid using a microdrip set or infusion
pump.
• Never mix two antibiotics in same syringe.
• If baby has been referred/shifted from SNCU, total duration of antibiotics should be as per treatment
plan from SNCU. In babies admitted and managed at NBSU alone, antibiotics should be given for 7-10
days.
Any baby who is being treated with antibiotics but fails to improve by 48-72 hours of admission
should be referred to SNCU/referral unit.

Table 5.4: Antibiotic schedule and dosage in neonatal sepsis
Antibiotic Dosage Frequency* Route Duration

(a) 0-14 (b) >14 days of
days of life life
Ampicillin or 50mg/kg/dose 12 hourly 8 hourly IV 7-10 days
Cloxacillin
and
Gentamicin 5mg/kg/dose 24 hourly 24 hourly IV 7-10 days
*This frequency of antibiotics is valid in babies weighing < 2kg. In baby weighing ≥ 2kg, the frequency remains as (a) from
0-7 days of life and (b) from > 7 days of life.
Meningitis
Suspect meningitis if signs of serious bacterial infection are present, particularly if the infant is:
• Drowsy, lethargic or unconscious
• Convulsing
• Has a bulging fontanelle
• Irritable
• Has a high-pitched cry.
Treat with antimicrobials as given below in the table.
Table 5.5: Antibiotic for meningitis
Antibiotic for meningitis Each dose Frequency Route Duration

0-7 days age > 7 days age
Birth wt < 2 kg
lnj Cefotaxime* 50 mg/kg/dose 12 hrly 8 hrly IV 3 weeks
lnj Amikacin** 15 mg/kg/dose 24 hrly 24 hrly IV 3 weeks
Birth wt > 2 kg
lnj Cefotaxime* 50 mg/kg/dose 8 hrly 6 hrly IV 3 weeks
lnj Amikacin** 15 mg/kg/dose 24 hrly 24 hrly IV 3 weeks
Treatment of local bacterial infection

• If the umbilicus is red or draining pus; or if skin pustules are present, give oral antibiotic at home.
• Give oral amoxicillin twice daily for 5 days in cases with local bacterial infection in the doses described
in table 1.6 on page No. 42.
• Teach the mother to treat local infections at home.

To treat skin pustules or umbilical infections, apply gentian violet paint twice daily.
The mother should:

• Wash hands
• Gently wash off pus and crusts with soap and water
• Dry the area
• Paint with gentian violet 0.5%
• Wash hands.
Care of the baby where referral is not possible or refused

Any neonate with emergency signs or sepsis, who is being treated with antibiotics but fails to improve
by 48-72 hours of admission, needs to be referred to SNCU.
Under special circumstances where referral is not possible or is refused, newborns can be provided
supportive care as explained earlier (Maintain Temperature, Airway, Breathing, Fluid, Feeding) and
administered antibiotics. However, efforts to refer should continue.
Key Messages:
• Suspect sepsis when two or more risk factors are present
• Supportive care(maintaining TABC) and antibiotics are equally important
• Refer if any emergency sign develops during the course of treatment
• Prevent infection by simple measures like breast feeding, keeping the baby warm, hand-washing and
keeping baby’s environment clean
• Local infections of skin and umbilicus can be adequately treated by oral antibiotics

Exercise 5.2:
Baby Tara, 10 day old baby has come with refusal of feeds, fever and excessive crying. On examination,
temperature is 39oC, heart rate is 170/minute, respiratory rate 66/minute, capillary refill time is 2
seconds. There is pus discharge from umbilicus. Her weight is 2.5 kg and blood sugar is 50mg/dl.
a. Are there any emergency signs ?
b. How will you proceed?

CHAPTER 6
Postnatal Care of Newborn in

Health Facility
POSTNATAL CARE OF NEWBORN IN
HEALTH FACILITY
The immediate postnatal period – first 48 hours after birth- when the mother and baby are in the hospital–
is critical to their health and survival. Postnatal care during the first two days of birth, in facilities provides
an opportunity for preventive care practices and routine assessments to identify and manage common
conditions in the baby.
All babies delivered at the health facility should be monitored and provided routine care, support for
feeding difficulties, appropriate treatment for danger signs* and prompt referral if required. [* danger signs
are same as described in Chapter 4 & and Mother & Child Protection Card (MCP)]
After completion of this chapter the participant will be able to:
• Provide care to a baby in the labour room
• Examine a baby for life threatening congenital malformations and ensure referral
• Recognise minor physical peculiarities or developmental variations
• Provide care in postnatal ward
• Provide advise at discharge including recognition of danger signs
Care in the labour room

All the following actions to be performed after one hour of skin to skin care and initiation of breast feeding.
• Documentation such as time of birth, time of initiation of breast feeding, weight, gender and any other
relevant information of all newborns.
• Ensure facility/state specific identification marking for baby
• Cord should be kept clean, dry & free of any application (antiseptic etc.)
• Weigh all the infants after breast feeding initiation, preferably on a digital scale
• Injection Vitamin K 1 should be administered intramuscularly [0.5 mg for babies weighing less than
1000 g and 1.0 mg for those weighing above 1000 gms at birth] on the antero-lateral aspect of the thigh
using a 26 gauge needle and one ml syringe.
Do not perform stomach wash in newborns at birth
The baby should be thoroughly examined at birth from head to toe to clinically screen for any life threatening
congenital anomalies, malformations and birth injuries# and findings should be recorded in the case sheet.
Remember that routine passage of catheter in the stomach, nostrils and the rectum is not recommended
but do give special attention to identify and document the anal opening. Some of the birth defects to be
reported as per RBSK Operational Guidelines are: (Refer to pictures in annexure 1)

1. Neural Tube Defect
2. Down’s Syndrome
3. Cleft Lip & Palate
4. Congenital Talipes Equino Varus (club foot)
5. Developmental Dysplasia of Hip
6. Congenital Cataract
7. Congenital Deafness
8. Congenital Heart Disease
(# cephalohematoma, brachial plexus injury, facial paralysis, fracture & dislocation of hip)
The health provider must show the newborn to the mother and other family members, with particular
attention to the identity tag on the newborn and must communicate to them the time, birth weight, gender
and condition of the newborn.
Physiological Conditions
Mothers observe their babies very carefully and are often worried by minor physical peculiarities or
developmental variations, which may be of no consequence and do not warrant any therapy.
Condition Description Action: Reassure Mother

Mastitis Neonatorum Engorgement of breasts in term babies of Local massage, fomentation and
both sexes on the third or fourth day and expression of milk should not be done
may last for days or even weeks due to as it may lead to infection.
persistence of maternal hormones.
Vaginal bleeding Seen in female babies about three to five days Additional vitamin K is unnecessary.
after birth because of withdrawal of maternal
hormones. The bleeding is mild and lasts for
two to four days.
Mucoid vaginal Most female babies have thin, grayish, Should not be mistaken for purulent
secretions mucoid, vaginal secretions discharge.
Tongue Tie A fibrous frenulum with a notch at the tip of Does not interfere with sucking or later
the tongue. speech development.
Non-retractable Normally non-retractable in all male Mother should be advised against
prepuce newborn babies, should not be diagnosed forcibly retracting the foreskin.
as phimosis. The urethral opening is often
pinpoint and is visualized with difficulty.
Hymenal tags Seen at the margin of hymen in two-third of
female babies
Umbilical hernia Manifest after the age of two weeks or later. Most of these disappear spontaneously
by one or two years of age.

Developmental Variations
Peeling skin Dry skin with peeling and exaggerated transverse sole creases are seen in all post term and
some term babies
Milia Yellow – white spots on the nose or face due to retention of sebum, are present in
practically all babies and disappear spontaneously
Toxic erythema/ An erythematous rash of unknown cause with a central pallor appearing on the second
Erythema or third day in term neonates, which begins on the face and spreads down to the trunk
Neonatorum and extremities in about 24 hours. This should be differentiated from pustules which
need treatment. It disappears spontaneously after two to three days without any specific
treatment.
Storkbites (Salmon These are discrete, pinkish- gray, sparse, capillary hemangiomata commonly seen at the
patches or naevus nape of neck, upper eyelids,forehead and root of the nose which invariably disappears
simplex): after a few months.
Mongolian blue In babies of Asiatic origin irregular blue areas of skin pigmentation are often present over
spots the sacral area and buttocks, though extremities and rest of the trunk may also be affected.
These spots disappear by the age of six months.
Subconjunctival Semilunar arcs of sub-conjuctival hemorrhage are a common finding in normal babies.
hemorrhage The blood gets reabsorbed after a few days without leaving any pigmentation.
Epstein Pearls These are white spots, usually one on either side of the median raphe of the hard palate.
Similar lesions may be seen on the prepuce. They are of no significance.
Sucking callosities The presence of these button like, cornified plaques over the centre of upper lip has no
significance.
Daily care in the postnatal ward

Doctors and nurses at NBSU should take rounds in the postnatal wards daily. They should observe the
newborn for the following:
1. Cry, activity, reflexes
• During the first few days of life, babies sleep throughout the day and they are awake, noisy and
troublesome during the night.
• Babies cry when they are hungry or in discomfort. Discomfort may be due to the unpleasant sensation
of a full bladder before passing urine, painful evacuation of hard stools or soiling by urine and stools.
An experienced mother or nurse can usually distinguish between the cry used as a signal for food and
the cry of discomfort. Persistent crying needs examination and detailed evaluation for inflammatory
conditions and other causes.
2. Weight
Weight should be monitored daily. Most healthy term babies lose weight during the first 2 to 3 days of life
and regain birth weight by the end of first week; averaging 20-30 gram per day; whereas a preterm takes
10-14 days of age to regain birth weight.

3. Adequacy of breast feeding
An adequately fed baby passes urine at least 6-8 times in a day. Regular and optimal feeding will avoid any
excessive weight loss. Any weight loss >5% in a 24-hour period is abnormal.
4. Maintenance of temperature
Ensure that the baby is kept warm. Advice the mother to:
• Keep the baby clean and dry at all times. Maintain room temperature in all weathers.
• During winter: pre-warm the linen and clothes of the baby before dressing. Cover the baby adequately
using cap, socks and mittens.
• During summer: dress the baby in loose cotton clothes and keep indoors, as far as possible.Exposure of
the baby to direct sunlight during the hot summer months can lead to serious hyperthermia.
5. Jaundice
All the infants must be examined in daylight for the development and severity of jaundice, twice a day for
first few days of life. Visual assessment in daylight is the preferred method.
6. Passage of urine/meconium
Any baby who has not passed meconium for 24 hrs after birth or urine within 48 hours needs to be
evaluated. Many babies pass urine (even stools) after each feed during the first 3 months of life.
• Transitional stools: (Day 3 to 4 of life) are often semi-loose and greenish-yellow with increased frequency
and settle within 24 to 48 hours, need no treatment. Reassure mother if baby continues to feed well.
• Stools: Breast fed babies pass frequent golden yellow, sticky, semi loose stools. This is due to exaggerated
gastrocolic reflex, which may persist for a couple of weeks. These infants, however generally continue to
gain weight satisfactorily.
7. Vomiting
Many normal babies regurgitate or spit out some amount of milk soon after feeds. This is often due to
faulty technique of feeding and aerophagy. Counsel all mothers regarding feeding and burping. Investigate
further, if the vomiting is persistent, projectile, or bile stained or is associated with abdominal distension
or tenderness.
8. Danger signs
• Poor feeding
• Undue lethargy
• Sudden rise or fall in body temperature
• Respiratory difficulty, apnoeic attacks or cyanosis
• Seizures
• Appearance of jaundice within 24 hours of age or yellow staining of palms or soles

Newborn may also require further investigation or referral for the following:
• Excessive crying
• Drooling of saliva or choking during feeding
• Persistent vomiting
• Bleeding from any site
Advice at discharge
1. Maintenance of body temperature – as explained earlier
2. Breast feed every two to three hours on a semi-demand schedule both during day and night. During
each feed, one breast should be completely emptied before the baby is put to the other breast. Exclusive
breastfeeding should be advised and the mother should be counselled that there is no need for additional
water or other fluids except under medical supervision.
3. Skin care/bathing Always take special precautions during bathing to prevent draught and chilling.
Daily baths may be avoided during the winter months and the baby can be sponged in a warm room to
avoid exposure and to keep the baby clean.
4. Care of the umbilical stump: Do not apply any medication on the cord, leave it open without any
dressing. The cord usually falls after 4 to 10 days.
5. Care of the eyes: Some neonates may develop persistent epiphora (watering) due to blockage of
nasolacrimal duct by epithelial debris. The mother should be advised to massage the nasolacrimal duct
area (by massaging the either side of the nose adjacent to the medial canthus) 5 to 8 times daily, each
time before she feeds the baby. Routine application of antiseptic ointment/drops for prevention of
ophthalmia neonatorum is not recommended
Immunization: It is recommended to give BCG vaccine, zero dose of oral polio vaccine and Hepatitis B
vaccine as per schedule and document it in the MCP Card. The mother should be informed about the date
of the next visit and the same should be shown in the MCP card.
Checklist before discharge from postnatal ward

Ideally all normal newborns should be discharged after 48 hours, along with the mother once the following
criteria are fulfilled:
• Newborn is free from any illness, including significant jaundice
• The newborn has been immunized
• Adequacy of breastfeeding has been assessed in all newborns, indicated by:
 Passage of urine at least 6 to 8 times over 24 hours
 Onset of transitional stools
 Baby sleeping well for 2-3 hours after feeding
 Normal weight loss pattern

• Mother is free from any significant illness and confident to take care of her infant.
• Mother has been oriented with the use of MCP card, including danger signs and home visits by ASHA.
• Next follow up visit has been explained and scheduled.
• Mother may continue with a variety of beneficial traditional practices such as oil massage or inconsequential
practice such as putting black mark on forehead.
• However, she should be discouraged to follow harmful traditional practices: like applying kajal/surma
in eyes as it may transmit infections, cause injury or even cause lead poisoning.
Follow up
Preferably, each baby should be followed up in the clinic for assessment of growth and development, early
diagnosis and management of illnesses and health education of parents. Routine use of MCP card should
be done to promote monitoring and awareness of parents. Immunization visits can be used for assessment
of newborn by service provider.
Key Messages:
• All neonates need monitoring and support for temperature maintenance,feeding and danger signs
• Recognition of life threatening congenital malformations and danger signs along with timely referral
is life saving
• Mother should be given appropriate advise regarding care of her neonate at discharge

SKILL STATIONS

SKILL STATIONS
Day 1: Neonatal Resuscitation

Time: 2-5 pm
Stations: Four
Station 1: Assessment and management of emergency signs
Station 2: Initial steps
Station 3: Bag and mask ventilation and chest compressions
Station 4: Umbilical vein cannulation and medications
Station 1
Assessment and management of emergency signs
Supplies and equipment
• Wall chart of assessment and management of emergency signs
• Radiant warmer
• Appropriate Mannequin (that allows for bag & mask ventilation)
• Shoulder roll
• Sheets
• Suction apparatus (e.g. DeLee mucus trap), suction catheters, 10, 12F size with suction machine
• Self inflating Bag and mask
• Oxygen tubing and source
• Stethoscope
• Wall clock
• Pulse oximeter
• Glucometer and strips
• IV Cannula 24/26, Pedia drip set
• Sterile cotton swabs, Spirit, Povidone Iodine, 10% Dextrose, Normal Saline
• Drugs: Phenobarbitone, Calcium Gluconate 10%

Assessment and management of emergency signs
• Discuss assessment and management of emergency signs on the wall chart by giving case scenarios
• Baby received in Triage area with cold peripheries and abdomen.
Classify and manage.
• Baby received in triage area with cold peripheries and abdomen, gasping respiration.
• Baby received in triage area with cold peripheries, weak and fast pulse and CFT of 4 seconds.
• Baby received in triage area with abnormal movements of the face and limbs.

before 37 weeks gestation] and size 1 for a normal size baby)
• Suction apparatus (e.g. DeLee mucus trap), suction catheter with suction machine
Station 2
OCEDURE Initial steps:
vance preparation:
Equipment and supplies
• Check•daily/in
Radiant warmer
every shift that necessary equipment and supplies are in place.
• Two sheets
• Ensure• that the roll
Shoulder resuscitation equipment is functioning properly. Block the mask
by making a tight seal with the palm of your hand, and squeeze the bag:
• Mannequin
• Suction apparatus (e.g. DeLee mucus trap)
- • IfSuction
you feel pressure
catheters, against
10, 12F size with your
suctionhand, the bag is generating adequate
machine
• pressure;
Pulse oximeter
• Stethoscope
- If the bag reinflates when you release your grip, the bag is functioning
• Oxygen source,
• properly.
Oxygen tubing
• Wall clock
• Equipment (bag and mask) should be cleaned as per the recommended asepsis
procedure.
Provide warmth by placing the baby under a radiant warmer
Position the head to open the airway; clear the airway if required
OPENINGDry
THEandAIRWAY
Stimulate the baby to breathe
Reposition the head to maintain an open airway
• Move the baby to a firm, warm surface under a radiant warmer. Keep the baby
wrapped or covered,
Provide warmth except for the face and upper chest.
• Position the the
• Place baby
baby on a firm, warm surface under a radiant warmer
- Place the baby on her/his back;

Open the airway
- Position thethebaby’s
• Position baby head in a slightly extended position to open the airway (the
neck should
• Place notonbeher/his
the baby as extended
back as for adults). A rolled-up piece of cloth under
the• baby’s
Position the baby’s head in a slightly extended position to open the airway (the neck should not be as
shoulders may be used to extend the head.
extended as for adults). A rolled-up piece of cloth under the baby’s shoulders may be used to extend the
Correct position of the head for ventilation

head.
Correct position of the head for ventilation

31
Clear the airway
• If mucus or vomitus is present, clear the airway by suctioning first the mouth and then the nostrils.
A suction machine or Delee trap can be used. Catheter size to be used is 10F. For meconium and thick
secretions use 12F catheter.
Do not suction deep in the throat as this may decrease the baby’s heart rate
• Dry the baby and remove any wet linen.

• Stimulate to breathe if still not breathing, by rubbing the baby’s back twice.
Evaluate: You should evaluate the newborn’s respiration and heart rate:
• If the baby is breathing and has a heart rate of >100/min, manage other emergency signs.
• If the baby is not breathing (is gasping or has apnoea) or has a heart rate below 100 beats per minute
(bpm), you should immediately proceed for bag and mask ventilation.
NOTE: The initial steps are same, whether baby is being received in delivery or emergency room

Station 3
Bag and mask ventilation and Chest compressions
Equipment and Supplies:
• Mannequin
• Shoulder roll
• Suction apparatus (e.g. DeLee mucus trap)
• Suction catheters, 10, 12F size with suction machine
• Self inflating bag 250/500ml
• Face Masks 0 and 1 size
• Pulse oximeter
• Reservoir
• Shoulder roll
• Oxygen tubing
• Oxygen source
• Stethoscope
• Wall clock
Indications: Apnoea/gasping "OR" Heart rate < 100/min after initial steps
Ventilating with a bag and Mask

• Recheck the baby’s position and ensure that the neck is slightly extended.
• Position the mask and check the seal:
 Place the mask on the baby’s face so that it covers the baby’s chin, mouth, and nose;
 Check for chest rise after ventilating five times.

Positioning the mask and checking the seal
• If there is chest rise, ventilate the baby at a rate of 40-60 breaths/min. Maintain the correct rate
(approximately 40-60 breaths per minute) and pressure during ventilation:
 If the baby’s chest is not rising after five ventilatory breaths, take the following corrective steps
■ Reapply the mask on the baby’s face to make a good seal
■ Reposition the neck
 Provide 5 breaths and continue looking for chest rise, if there is still no chest rise take the following
next two corrective steps
■ Suction, if secretions are present
■ Squeeze, the bag harder to increase ventilation pressure
• After 30 seconds of effective Positive Pressure Ventilation (PPV), evaluate the newborn again to ensure
that ventilation is adequate, before moving to the next step. With appropriate ventilation, in almost all
cases, the heart rate would rise to above 100 beats per minute (bpm). You can slowly withdraw PPV if
there is spontaneous breathing and heart rate is above 100/min.
 Babies who receive PPV for <1 minute during resuscitation after birth and are breathing well should
be provided observational care with the mother in skin to skin contact and breast feeding is initiated.
 Babies who receive PPV for >1 minute during resuscitation after birth should be shifted to the NBSU
or transferred to SNCU. Continue PPV during shifting, if required.
• If during evaluation you find that the heart rate is below 60 bpm, you should proceed to provide chest
compressions while continuing bag and mask ventilation.
Chest compressions
Indications: Heart rate <60/min after 30 seconds of effective ventilation.
• In order to support circulation start chest compressions, while continuing PPV. At this stage provide
100% oxygen. It is strongly recommended to attach a pulse oximeter and perform endotracheal
intubation (if skilled), if not done earlier. This is for more effective coordination of chest compressions
and PPV.
Compressions and ventilation should be coordinated. For every 3 compressions, 1 breath is delivered.
Thus, the ratio is 90 chest compressions coordinated with 30 breaths per min.

ensured and chest movement is present, ventilate the baby using
en is not immediately available, begin ventilating using room air.
orrect rateTechnique
(approximately 40-60 breaths
of chest compressions: The per minute)
technique and
for providing chest compressions is the "Thumb
g ventilation:
Technique”:
’s chest is •rising, ventilation

Place thumbs pressure
just below is probably
the line connecting adequate;
the nipples on the sternum (see below).
• The sternum should be depressed to a depth of approximately one third of the antero-posterior diameter
’s chest is not rising:
of the chest.
• While
k and correct, releasing the the
if necessary, pressure, the thumbs
position should
of the remain in contact with the chest to avoid relocating the
baby;
compression area and delay in providing the next compression.
ion the mask on the
face to improve the
tween the mask and
by’s face;
e the bag harder to
e ventilation pressure.
sions
er 30 seconds of
heart rate less than 60
mpressions along with
d ventilation should be
3 compressions, 1
us the ratio is 90 chest
ted with 30 breaths
w the line connecting the nipples on the sternum (see below).

e anterior–posterior diameter of the chest.
index or ring finger are used to compress the sternum. The spine is
hand or by placing the baby on a hard surface.
e depressed to a depth of approximately one third of the antero-

he chest.
se, the fingers should remain in contact with the chest to avoid
Station 4
Umbilical vein catheterisation and medication
Equipment and Supplies
• Sterile gloves
• Sterile umbilical catheter or ordinary feeding tube, triway cannula
• Syringes- 1ml, 10ml and 20ml
• Swabs or cotton-wool balls soaked in antiseptic solution
• Sterile blade
• Sterile forceps
• Suture
• Adhesive strapping, or thin paper tape (to secure catheter)
• Fresh umbilical cord for demonstrating umbilical vein catheterization
Indications: For IV access during newborn resuscitation at birth

Procedure
• Gather necessary equipment and supplies.
• Wash hands and wear sterile gloves.
• Prepare the umbilicus and surrounding skin by cleaning in an outward circular motion starting at the
umbilicus with a swab or cotton-wool ball soaked in alcohol, allow to dry. Repeat the procedure with
Povidone iodine swab and finally with alcohol swab once more, using a new swab or cotton-wool ball
each time and allowing to dry each time.
• Fill the umbilical catheter with normal saline using a closed syringe (i.e. with the plunger completely
inside the barrel of the syringe) attached to the end of the catheter.
Ensure that there is no air in the catheter and that a closed syringe is attached to the end of the
catheter; a sudden deep breath by the baby just after the catheter has been inserted may result in an
air embolus if air is inside the catheter.
Place sterile drapes over the baby’s body so that only the umbilical area is exposed.
• P
lace a cord tie or suture around the base of the umbilicus to control bleeding, and using a sterile blade,
cut the cord to a length of 1 to 2 cm
• Identify the two umbilical arteries, which are thicker-walled and usually contracted, and the
single umbilical vein, which usually has a wider opening and is found above the arteries (at 12 o’ clock
position)

found above the arteries (closer to the baby’s head;
FIGURE Inserting an umbilical vein catheter
Inserting an umbilical vein catheter
old Hold
• •H theincatheter
the catheter in one
one hand (applying hand
gentle (applying
traction gentle
to the cord with traction
forceps in the otherto theif cord w
hand,
the and
necessary) otherinserthand, if necessary)
the catheter and
into the umbilical vein,insert the
guiding the catheter
catheter towards into the
the head umbilica
of the
baby and to the baby’s right side.
• As thethe catheter
catheter towards
is advanced, periodicallythe
applyhead of thewith
gentle suction baby anduntil
the syringe to the
bloodbaby’s
flows back.right sid
Once blood flows back freely through the catheter (usually after the catheter is inserted 5 to 7 cm), do
As the
•not advance the catheter is advanced, periodically apply gentle suction with th
catheter any further.
blood flows back. Once blood flows back freely through the cathete
• If resistance is encountered while advancing the catheter, especially in the first 2 to 3 cm, do not
continue. Remove the catheter and try again.
the catheter is inserted 5 to 7 cm), do not advance the catheter any
Never force the umbilical catheter, if resistance is encountered.
•
• T
If resistance is encountered while advancing the catheter, especia
ie the cord tie or suture around the stump of the umbilicus to hold the catheter in place and prevent
to around
bleeding 3 cm,thedo notorcontinue.
catheter Remove
from one of the arteries. the catheter and try again.
• Secure the catheter with suture material or adhesive tape to prevent it from being dislodged.
Never force the umbilical catheter if resistance is encountered.

• Tie the cord tie or suture around the stump of the umbilicus to hold
place and prevent bleeding around the catheter or from one of the
• Remove the syringe and connect the infusion set to the catheter,
there are no air bubblesNewborn
in the set. Unit Training Participants’ Module | 115
Stabilization
• Secure the catheter with suture material or adhesive tape to pre

Medication:
Drugs used in newborn resuscitation
Epinephrine Normal Saline

When HR < 60 bpm, despite ongoing chest No-response to resuscitation or presence of
compressions with ventilation shock or history of sudden onset blood loss
Dose Route IV, ET IV, IO
Dose 0.1-0.3 cc/kg, 1:10,000 (IV) 10 cc/kg
Administration Quickly Over 5-10 min
How to prepare epinephrine?

Epinephrine is available as 1ml ampoule of 1:1000 concentration; however for neonate take one ml of
1:1000 solution and add 9 ml of normal saline. This makes 10 ml of 1:10,000 concentration.
How to administer epinephrine?

Epinephrine should be given intravenously. If administration is delayed due to placement of intravenous
access, the endotracheal route may be used to administer the drug. But the endotracheal route results in
lower and unpredictable blood levels that may not be effective. Some clinicians may choose to give a dose
of endotracheal epinephrine while the venous access is being established.
What is the dose of epinephrine during neonatal resuscitation?

The recommended intravenous dose in newborns is 0.1 to 0.3 mL/kg of a 1:10,000 solution (equal to 0.01
to 0.03 mg/kg). You will need to estimate the baby’s weight after birth.
When the drug is given intravenously through a catheter, you should follow the drug with a
3 ml flush of normal saline to be sure that the drug has reached the blood.
How should you give epinephrine during neonatal resuscitation?

Administer epinephrine rapidly - as quickly as possible
What is the expected response after giving epinephrine?
Check the baby’s heart rate 60 seconds after administering epinephrine. As you continue positive-pressure
ventilation and chest compressions, the heart rate should increase to more than 60 bpm within 60 seconds
after you give epinephrine. If this does not happen, you can repeat the dose every 3 to 5 minutes. In
addition, ensure that:
• There is good air exchange as evidenced by adequate chest movement and presence of bilateral breath sounds.
• Chest compressions are given to a depth of one third the diameter of the chest and are well coordinated
with ventilations.

Strongly consider placement of an endotracheal tube (if skilled), if one has not already been inserted. Once
in place, ensure that the tube has remained in the trachea during cardiopulmonary resuscitation activities.
If the baby is pale and there is evidence of blood loss, and there is a poor response to resuscitation, you
should consider the possibility of volume loss.
What should you do if the baby is in shock, there is evidence of blood loss, and the baby is responding
poorly to resuscitation?
Babies in shock appear pale, have delayed capillary refill and have weak pulses. They may have a persistently
low heart rate, and circulatory status often does not improve in response to effective ventilation, chest
compressions, and epinephrine
If the baby appears to be in shock and is not responding to resuscitation, administration of a volume
expander may be indicated.
What can you give to expand blood volume? How much and how to give it?
The recommended solution for treating hypovolemia is an isotonic crystalloid solution. Acceptable
solutions include
• 0.9% NaCl (“Normal saline”)
• O Rh-negative packed red blood cells should be considered as part of the volume replacement when
severe fetal anemia is documented or expected. If timely diagnosis permits, the donor unit can be
cross- matched with the mother who would be the source of any problematic antibody. Otherwise,
emergency- release of O-Rh negative packed cells may be necessary. (Only if facilities and expertise is
available)
What is the dose of volume expander?

The initial dose is 10 ml/kg. However, if the baby shows minimal improvement after the first dose, you
may need to give another dose of 10 ml/kg. In unusual cases of large blood loss, additional dose might be
considered
How to give volume expander?

A volume expander must be given into the vascular system. The umbilical vein is usually the most accessible
vein in a newborn, although other routes (e.g., intraosseous) can be used. If hypovolemia is suspected, fill
a syringe with normal saline or other volume expander while others on the team continue resuscitation.
How rapidly to give volume expander?

Acute hypovolemia, resulting in a need for resuscitation should be corrected fairly quickly, although some
clinicians are concerned that rapid administration in a newborn may result in intracranial hemorrhage,
particularly in preterm infants. No clinical trials have been conducted to define an optimum rate, but a
steady infusion rate over 5 to 10 minutes is reasonable.

Day 2: Skill stations
Time: 2-5 pm
Stations: Four
Four groups by rotation:
Station 1: Equipment: Radiant warmer, Phototherapy
Station 2: Oxygen delivery and Pulse Oximeter
Station 3: Bedside skills:
a. Hand washing
b. Peripheral venous access & blood sample collection
c. Procedure of Intramuscular injection
Station 4: Use of glucometer and infusion pump
Station 1: Equipment
Radiant Warmer
Upon completion of this section the participant should be able to
1. Describe the parts of a radiant warmer
2. Demonstrate the working of the warmer
3. List the dangers associated with its usage
4. Identify trouble shoot and correct
5. Manage minor maintenance
Parts
1. Bassinet (for placing the neonate)
2. Radiant heat source (Quartz/ceramic or similar heating rod)
3. Skin probe (for measuring baby’s skin temperature)
4. Air probe
5. Control panel (Displays and control knobs)
i. Mode selector (selects manual or servo mode)
ii. Heater output control key/knob (to increase or decrease the heater output manually)
iii. Heater output display (indicates heater output)
iv. Temperature selection key/knob (select the desired skin temperature)
v. Temperature display (displays temperature of baby ’s skin, the set temperature and air temperature)
vi. Alarm display for power failure, system failure, skin probe failure, skin temp. high/low & heater
failure.

Working
i. Connect to mains and switch on
ii. Select the manual mode and keep heater output to maximum for 15-20 minutes for pre-warming the
bassinet and linen
iii. Select servo mode and set the desired skin temperature to 36.50C. Heater output adjusts automatically
to keep baby at set temperature
iv. Place baby in the bassinet. Cover head with cap, feet with socks and hands with mittens
v. Connect skin probe to baby’s abdomen with a skin friendly tape
vi. If baby is hypothermic one may use the manual mode
vii. In manual mode, record baby’s axillary temperature every 30 minutes till hypothermia is corrected
Do not leave the baby unattended when operating in manual mode. Switch to servo mode once temperature
is 360C
Cleaning & Disinfection

Bassinet
i. Soap/detergent - daily
ii. Clean using disinfectant like 2% glutaraldehyde when the bassinet is unoccupied or weekly (move the
baby while using disinfectant)
Probe
i. Clean using Isopropyl alcohol swab before and after each use.
Dos & Donts

1. Place skin probe in the right upper abdomen in the supine position and in the flanks if baby is prone.
2. Use skin friendly adhesive tape to secure the probe in place. Do not place probe on bony structures.
3. Ensure that the skin is dry or else prepare using alcohol/spirit swab to ensure good adhesion to the
skin.
4. Check repeatedly to ensure that the sensor probe is in position.
5. Check temperature manually at least once per shift.
6. Always respond to alarms promptly and take corrective measures.
7. Do not apply probe to bruised skin.
8. Do not reuse disposable probes.

Trouble Shooting
Problem Action
1. No power on turning instrument on - Check power supply, plug, fuse
- If above okay, call engineer
2. Power on, heater not on - Call engineer
3 No skin temperature display - Faulty skin sensor (replace/call engineer)
4. Display temperature and baby temperature variation > 1°C - Needs calibration, call engineer
Side effects and dangers

1. Hyperthermia (especially in the manual mode if temperature is not monitored or in the servo mode
when the probe gets displaced). To prevent hyperthermia, ensure probe is properly attached and the
temperature of baby is monitored when the warmer is used in manual mode.
2. Hypothermia (due to equipment failure). To prevent hypothermia the equipment should be maintained
in good condition and alarms should be attended immediately.
3. Increased insensible water loss (IWL) (occurs due to exposed skin surface)
Phototherapy Unit
Objective
Upon completion of this section the participant should be able to:
i. Describe the types and parts of a phototherapy unit
ii. Demonstrate the working of a phototherapy unit
iii. Manage a baby under a phototherapy unit
Types of phototherapy units

All phototherapy units have a designated light source to provide irradiance ranging from 6 – 40 uw/cm2/
nm in the wavelength of 420 -460 nm. The various types available are Conventional, CFL & LED units.
Parts
Source of light
1. Fluorescent lights (Conventional phototherapy)
• 6-8 white fluorescent light OR
• A combination of 2 special blue and 4-6 white fluorescent lights with a plexiglass shield.
 White tubes (Philips TL 20 W/52)
 Blue tubes (F 20 T 12/ BB)
• Tube life is 1000 hours/ 6 months, whichever is earlier
• Irradiance provided
 6-8 uw/cm2/nm (White light)
 8-12 uw/cm2/nm (Blue + White light)

2. Compact Fluorescent lights (CFL)
• Compact high intensity bulbs (4 blue and 2 white) enclosed in the unit with reflecting grills
• Irradiance provided: 12-18 uw/cm2/nm
• Lamp life is 2000 – 3000 hours
3. Light emitting diode (LED)
• Multiple high intensity gallium nitrate LED encased in a unit
• Irradiance provided: 20-40 uw/cm2/nm
• Bulb life is 20000 - 30000 hours.
Other parts
• Radiator fan (as applicable)
• Hour meter (as applicable)
Working
i. Connect to mains.
ii. Switch on the unit & check that all tubes/lamps are working.
Cleaning
i. Soap/Detergent once daily
ii. Clean with disinfectant once a week
iii. Keep the lamps, the covering shield and the grill clean
Dos & Donts

1. Cover eyes with an eye patch
2. Place baby naked only with the nappy to cover genitalia
3. Place baby as close as possible to light source avoiding hyperthermia
4. Check temperature every 4 hourly to monitor for hypo/hyperthermia
5. Check weight daily
6. Increase in allowance for fluid/feed if there is any evidence of dehydration
7. Change position frequently (after each feed)
8. Measure serum bilirubin every 12 hours or earlier if required.
9. Do not put anything on top of the phototherapy unit (this may block the air vents)
10. Low birth weight babies can have their socks, caps and mittens on while under phototherapy for
preventing hypothermia.
11. Ideally a Fluxmeter should be used to check for and ensure optimal irradiance.

Trouble Shooting
Problem Action
1. No power on turning instrument on - Check power supply, plug, fuse
2. Fan not working - Call engineer
3. Timer not working - Call engineer
4. Conventional phototherapy units
- Tubes not coming on - Tubes faulty/choke needs change
- Blackening / flickering of tubes - Tubes need change
Ineffective Phototherapy
i. Baby covered or frequently removed from phototherapy
ii. Low irradiance (tubes old, flickering, black ends, bulbs covered with dust or reflectors dirty)
iii. Distance between phototherapy lights and baby is more than recommended
iv. Hemolytic conditions can cause bilirubin to rise in spite of phototherapy
Side Effects and Dangers

i. Transient maculopapular rash on the trunk
ii. Hyperthermia/Hypothermia
iii. Increased insensible water loss and dehydration
iv. Loose stools
v. Bronzing of the skin in the presence of direct hyperbilirubinemia
Maintenance
1. Change lights if:
i. Irradiance as measured with flux meter < 15 uw/cm2/nm
ii. Lamp life > 1000 hours of use for fluorescent tubes, for LED > 20000-30000 and for CFL 2000 –3000
hours / as per manufacturer’s instruction manual
iii. If Flux meter and hour meter are not available, then change fluorescent tubes every 6 months
iv. Tube ends are black or flickering or not working

Station 2 Oxygen Delivery Systems
Following oxygen delivery devices are used in neonates
• Nasal prongs/canula : Nasal prongs/canula provide FiO2 between 25 to 45% with flow rates of
0.5-2 L/min. Among the various types of nasal prongs available, short bi-nasal prongs are most
commonly recommended. They come in various sizes and the appropriate neonatal size prongs should
be used. These are the most preferred mode of providing oxygen.
• Oxygen hood: The flow rates in the oxygen hood should be maintained between 2-3 L/Kg/min.
These are capable of providing FiO2 between 30 to 90%. They have occludable portholes on the
sides. With one port hole opened it provides a FiO2 close to 40-50%, while with both opened it
provides 30-40%. With both port holes closed, 80-90% FiO2 can be achieved.
Precautions
1. Prewarm and humidify oxygen especially when the flow rates are >2 L/min
2. Oxygen saturation should not cross 95% as hyperoxia leads to widespread free radical injury.
3. Set appropriate alarm limits on pulse oximeter.Use pulse oximeter to titrate the FiO2 when Oxygen
therapy is initiated and thereafter, whenever a change in the flow rate is made or a change in the
respiratory status of the neonates has occurred.
Oxygen Concentrators
An oxygen concentrator is a device providing oxygen therapy to a patient at minimally to substantially
higher concentrations than available in ambient air. Oxygen concentrators are less expensive than liquid
oxygen and are the most cost-effective source of oxygen and a more convenient alternative to tanks of
compressed oxygen.
Room air contains 21% oxygen combined with nitrogen and a mixture of other gases. A miniaturized
compressor inside the machine pressurizes this air through a system of chemical filters. This chemical filter
is made up of silicate granules called Zeolite. The Zeolite will sieve the nitrogen out of the air, concentrating
the oxygen. Through this process, the system is capable of producing medical grade oxygen up to 96%
consistently. Most of the portable oxygen concentrator systems available today provide high concentration
of oxygen and also maximize the purity of the oxygen.
Safety
The concentrator’s instruction manual indicates as to what maintenance is necessary; here are some general
guidlines to follow:
• The concentrator needs good, clean air to operate properly. Hence, operate the concentrator in a well-
ventilated area.
• Wash the filters periodically (at least once in a week).

• Replace the filters periodically (at least once in a year).
• Ensure examination of the concentrator at least once in a year by the company engineer.
There are also some very important safety issues to be kept in mind. Oxygen is most dangerous in the
presence of fire. Keep flammable materials safely away, and do not allow any heat sources to be near a
working oxygen concentrator. In both clinical and emergency-care situations, oxygen concentrators have
the advantage of not being as dangerous as oxygen cylinders, which can, if ruptured or leaking, greatly
increase the combustion rate of a fire.
Oxygen concentrators are considered sufficiently foolproof to be used in neonatal units. They can be used
for more than one patient by using flow splitters. Oxygen concentrators need a power source to function.
Parts
1. Machine with compressor
2. Flow meter with/without splitter
3. Humidification bottle
Working
1. Plug on to the power supply.
2. Switch on the concentrator using the ON/OFF button.
3. Once the concentrator is on, a yellow light will come up.
4. Next, adjust the flow to 3-4 liters. This light will be on till the desired concentration of oxygen is achieved,
which in most concentrators is nearly 90-93%, after which it goes off.
5. Every manufacturer has its own way of showing the achieved desired concentration. In some concentrators
this yellow light will become green after achieving the desired concentration.
Maintenance
1. Coarse filter –Ensure it is dust free, wash daily
2. Zeolite granules –Change every 20,000 hrs
3. Bacterial filter –Change every one year

Trouble shooting
Problem Possible cause Corrective action

Machine too noisy Coarse filter blocked by dust Wash filter daily
Machine or room gets heated Machine is near the wall Keep away from wall or outside the room for
free circulation of air
Yellow light is not going off Desired oxygen concentration not May be due to high humidity or the flow rate
reached is more, which exceeds the capacity of zeolite
material. Decrease the flow rate.
Compressor heats up Malfunctioning of compressor Look at the fan, it may be jammed, and hence
may need repair.
Pulse Oximeter
Objective
i. Describe the parts of Pulse Oximeter
ii. Demonstrate the working of the pulse oximeter
iii. Interpret the Pulse Oximeter readings
iv. Describe daily maintenance, cleaning and troubleshooting
Parts
i. Display panel
a. Numeric display
b. Graphic display
ii. Control buttons
a. Power / standby button
b. SpO2 alarm setting button
c. HR alarm setting button
d. Set button (alarm, volume, trend)
e. Alarm silence button
iii An electric cable
iv. An extension cable for attachment of the patient sensor
v. A patient sensor which is to be connected to the extension cable
Working
i. Connect to the mains.
ii. Switch on the machine
iii. Set the alarm limits for heart rate 100 – 160 bpm
iv. Set saturation alarm limits—90/96%

ii. Connect the patient sensor to the patient by wrapping it around the baby’s hand or foot.
iii. Pulse oximeter starts detecting signal from the patient and displays heart rate and saturation in a few
seconds. The values displayed may not be reliable in the presence of shock, cold peripheries, excessive
movement, electrical interference and exposure of probe to bright ambient light. Values are reliable
when the plethysmographic waveform or bar signal is good and when the display is constant and not
blinking or repeatedly changing.
Cleaning and Disinfection

i. Clean display panel with moist soft cloth
ii. Clean body with soft cloth dampened with soap water followed by moist soft cloth
iii. Clean reusable sensors with spirit after each patient use
Do’s & Dont’s

i. Inspect sensor site every 2 to 4 hours for any erythema or discoloration
ii. Change sensor site every 4 – 6 hourly
iii. Do not apply sensor too tightly
iv. Do not apply probe to edematous or bruised sites
Trouble shooting
Alarm Possible cause Corrective action

Ambient light Excessive light on sensor Relocate, cover with opaque paper/
cloth
Check sensor Motion, low perfusion, wrong Reposition, relocate
position
Interference detected Erratic signal with electromagnetic Remove interference
waves in vicinity like Tv, mobile ph.
Low battery Low internal battery Connect to AC power
Sensor failure Broken cable, faulty photodiode, Replace sensor
sensor damage
System failure Internal component failed Unit needs service/change
Side Effects & Dangers

i. Failure of operation.
ii. Explosion hazard in presence of any flammable anesthetic mixture.
iii. Local reddening, blistering, skin discoloration, burn etc. because of the sensor placement.

Maintenance
i. Cleaning the Oximeter as necessary.
ii. Recharging the battery as necessary.
iii. Replacing the fuses in power module as necessary.
iv. Comprehensive/Annual maintenance contract
Pulse Oximeter

Station 3: Bedside skills
a. Hand washing
b. Peripheral venous access & blood sample collection
c. Procedure of intramuscular injection
Hand Washing
Objective:
Upon completion of this session each participant should be able to demonstrate steps of hand washing
Rationale:
Prevention of infection in newborns is easily achievable by simple measures like hand-washing and keeping
baby’s environment clean. Prevention is much more rewarding as therapy for neonatal sepsis is not always
successful.
Equipment & Other Requirements:

1. Soap
2. Running water
3. Hand washing chart
Procedure
i. Remove watch, bangles and rings
ii. Fold sleeves above the elbows
iii. Wet hands till elbows
iv. Apply soap
v. First rub hands with both palms facing each other
vi Then rub palm of right hand over the left dorsum and left palm over the right dorsum
vii. Rub palm to palm with fingers interlocked to clean the web spaces
viii.Then interlock both the palms with rotational movements for cleaning the knuckles
ix. Rub both the thumbs with the palm of the opposite side
x. Fingers over the opposite palm on both sides
xi. Keep elbows dependent during the entire procedure so that water drips from palm to elbow
xii. Air dry or dry with disposable sterile paper/ napkins

IV injection/ IV Access:
Rationale:
To adminiter parental fluids & medications.
IV Access:
The training for gaining an intravenous access shall be done on a model which is provided. Each participant
shall carry out this skill on this given model.
Procedure
1. Select the vein (dorsum of hand/foot)
2. Wash hands and dry
3. Wear gloves
4. Prepare skin by cleaning with spirit, povidone iodine and spirit, let dry between applications
5. Hold the limb proximally to make the vein prominent
6. Pierce skin distal to the intended site of puncture
7. Insert needle into the vein (feeling of give way)
8. Ensure free flow; thread the needle further up
9. Secure the intracath by adhesive tape
10. Secure splint if needed
11. Flush the cannula with normal saline 0.5ml
12. Inject fluid/medications
13. Check distal limb for adequacy of circulation
For collection of blood sample follow the same procedure till point 8, let the blood flow into the vial for
collection and then secure the intracath and flush the cannula.
Intramuscular (IM) Injections
Rationale:
Intramuscular injections are used in the newborn period to administer vit K, some vaccines and pre-
referral dose of antibiotics
• The site for IM injection is Quadriceps muscle group of the upper, outer thigh (anterolateral part at the
junction of the upper and middle thirds of this muscle). This site is preferred because of the small risk
of giving the injection intravenously, hitting the femur with the needle, or injuring the sciatic nerve.
• Minimize pain associated with injection by:
 Ensuring pain management with breast feeds/assisted feeds with EBM or 25% dextrose/swaddling
 Using a sharp needle of the smallest diameter that will allow fluid to flow freely (e.g. 22- to 24-gauge)
 Using a minimal volume for injection (e.g. 2 ml or less at any single injection site)
 Avoiding rapid injection of drug/vaccine
 Using alternative injection sites for subsequent injections

Supplies
• Sterile 1-inch needle of the smallest size that will allow fluid to flow freely (e.g. 22- to 24-gauge)
• Sterile syringe of the smallest size available that has adequate markings for proper dose (e.g. 1- to 3-ml)
• Alcohol swabs
• Dry cotton-wool ball
Procedure
• Gather necessary supplies.
• Wash hands.
• Select the site for injection.
• Draw the drug for injection into the syringe.
• Ensure that the drug and dose are correct.
• Clean site with alcohol swab.
• Grasp the anterolateral part of the Quadriceps muscle at the junction of the upper and middle thirds
between the thumb and forefinger, if possible.
• Insert the needle at a 90-degree angle through the skin with a single quick motion.
• Withdraw the plunger of the syringe slightly to ensure that the tip of the needle is not in a vein (i.e. no
blood should enter the needle)
• If the needle is in a vein:
 Withdraw the needle
• Select without
the site injecting the drug
for injection.
 Apply• gentle
Draw pressure to the site
the material for with a dryinto
injection cotton-wool ball to prevent bruising
the syringe.
 Place a new, sterile needle on the syringe
• Ensure that the drug and dose are correct.
 Choose a new site for injection
 Repeat Grasp
• the the centre
procedure of theabove
described target muscle between the thumb and forefinger, if
possible.
• If the needle is in the muscle,:
Insert
 If the •needle is inthe
theneedle
muscle,atinject
a 90-degree anglewith
the material through
steadythe skin with
pressure a single
for three quick
to five seconds. Upon
completionmotion.
of the injection, withdraw the needle and apply gentle pressure with a dry cottonwool
ball.
Intramuscular injection into quadriceps muscle group

FIGURE: Intramuscular injection into quadriceps muscle group
• Withdraw the plunger of the syringe slightly to ensure that the tip of the needle is
not in a vein (i.e. no blood should enter the needle):
• Potential complications of IM injections:
 Inadvertent intra-arterial or intravenous injection.
 Infection from contaminated injection material.
 Local tissue damage due to injection of irritants.
• Avoid these complications by:
 Selecting the safest agents for injection.
 Choosing the proper injection site.
 Establishing anatomic landmarks.
 Cleansing the skin thoroughly.
 Alternating sites for subsequent injections.
 Aspirating before injecting the drug/vaccine.
 Avoiding tracking the drug into superficial tissues.
 Using a needle of adequate length to reach the intended injection site

Station 4. Use of glucometer and Infusion Pump
Use of glucometer
Hypoglycaemia is to be suspected and managed in all sick or low birth weight newborn.
For this blood glucose levels can be estimated at the bedside using a glucometer.
Using a glucometer to test Blood Sugar

Equipment & Supplies
EQUIPMENT AND SUPPLIES
1. Glucometer Glucometer
Glucometer test strips
2. Glucometer test strips
Sterile needle (26G) or lancet
3. Sterile needle (26G) or lancet
Alcohol for skin preparation
4. Cotton
Alcohol for skin preparation
5. Cotton swabs
PROCEDURE
Hypoglycaemia is to be suspected and managed in all sick or low birth weight newborn.
Procedure For this blood glucose levels can be estimated at the bedside using a glucometer.
• Check the expiry•date before

Check theusing
expirythe strips
date before using the strips
• Insert a new strip• into
Insert
the aglucometer.
new strip into Thethe glucometer.
meter will turnTheon meter will turn on automatically
automatically
• For taking the blood sample, heel is the most commonly used site. Warm the heel by
• For taking the bloodholding
sample,the heel is the most commonly used site. Warm the heel by holding the heel in
heel in your palm, while gently squeezing it for a few minutes.
your palm, while•gently squeezing
Prepare the siteit with
for a spirit
few minutes
and always allow spirit to dry. Do
• Prepare the site with spirit and always allow spiritcleaning
not use povidone/betadine for to dry. Do not use povidone/
• Make a needle stick puncture on the postero- lateral aspect of
betadine for cleaning
heel. Avoid the middle portion of heel and avoid making deep
• Make a needle stick puncture on the postero lateral/medial aspect of heel.
punctures (osteomyelitis of the heel bone, calcaneus). In heel-
• Avoid the middle portion
pricks,ofthe
heel andshould
depth avoid making deep punctures
not go beyond 2.4 mm. For(osteomyelitis
premature
of the heel bone-calcaneus)
neonates, a 0.85 mm lancet is available. The distance for a 3 kg.
• Allow blood to collect andfrom
baby formouter
a droplet. Apply to
skin surface thebone
blood
is: droplet to the test strip
when the blood droplet symbol appears in the glucometer window
- medial and lateral heel – 3.32 mm;
• The glucometer will count down and display the result of blood glucose level.
- posterior heel – 2.33 mm (this site should be avoided, to
Read the result from thereduce
glucometer
the riskdisplay panel
of hitting and record it
bone);
Area to Prick
• Apply slight pressure with sterile gauze/dry cotton over puncture site
- toe – 2.19 mm.
• Discard the used strips and lancet/needles as per biomedical waste management
• Allow blood to collect and form a droplet .Apply the blood droplet to the test strip when
(BMW) guidelines the blood droplet symbol appears in the glucometer window.
•The glucometer will count down and display the result of blood glucose level. Read the
result fromover
Note: You can also directly prick the glucometer
the vein to display
obtain panel
bloodand record
sample it. this is less painful compared
and
to the heel prick. • Discard the used strips and lancet/needles as per the BMW guidelines.
Note: You can also directly prick over the vein to obtain blood sample and is less painful compared
to the heel prick.

Infusion Pump
Objective
• Describe parts of a Syringe pump
• Demonstrate the working of a syringe pump.
• Set proper rate for fluid administration
• Maintain the apparatus
Parts
• Syringe barrel clamp
• Pusher & push guard/ flange guard
• Handle assembly bolt
• SWING lock clamp
• ON/Off
• Screen
• Silence alarm
• Bolus OR Prime
• Value selection
• Pre alarm & alarm warning
• Stop – Infusion stop
• Menu
Working
• Connect to Mains. Observe indicator light comes on.
• Press the ‘ON’ key to turn the pump on. All signals on display panel will glow.
• Select the type of syringe and the appropriate size of syringe10ml or 20ml or 50ml, (some pumps
may do it automatically)
• Press OK to confirm syringe.
• Install syringe loaded with desired amount of fluid with intravenous tubing attached and primed
with the required fluid.
• Select the flow rate in ml/hour.
• Connect the tubing to the patient.
• Start the infusion. Check arrow indicator movement to ensure that the fluid is being delivered.
• Press OK to confirm syringe.
• Install syringe loaded with desired amount of fluid with intravenous tubing attached and primed
with the required fluid.
• Select the flow rate in ml/hour.
• Connect the tubing to the patient.

• Start the infusion. Check arrow indicator movement to ensure that the fluid is being delivered.
• Check IV site regularly to avoid inadvertent extravasations.
• To give a BOLUS, press the bolus key and continue pressing till the desired amount has been infused.
• Press STOP to stop the infusion.
• Prime the line with desired fluid every time you change the type of fluid
Cleaning & Disinfection

• Use a cloth soaked in soap water for cleaning.
• Use spirit swab for control panel and probe
Do’s & Dont’s

• Cross check the flow rate (e.g 5 ml/hr instead of 0.5ml/hr)
• Label the syringe with the drug name
• Respond to alarms and take corrective action immediately
Trouble Shooting
Problem Action
No power on turning instrument on - Check power supply, plug, fuse
Alarms - Check syringe position and clamps
Occlusion alarm with no block in line (easy fluid - Call engineer
infusion when manually pushed)
Side Effects & Dangers

• Inadvertent IV extravasation / if IV cannula is displaced.
Maintenance
• Comprehensive/ Annual maintenance contract.

Day 3:
Time: 11 am -2 pm
Stations: Four
Participants are divided into four groups:
1. Postnatal ward: to practice the skills to assess newborns (history & examination) & general care
2. SNCU: to assess and discuss the management protocols of sick & small newborns
3. Temperature Recording & Thermal Control, KMC
4. Breast Feeding / expression of breast milk & Assisted Feeding
Station 1 Visit to Postnatal ward

• Participants visit the postnatal ward to practice the skills to assess newborns (history & examination) &
general care.
• Facilitator will demonstrate history taking and examination of a newborn.
• The group will be divided in two and each group will be given a case for history taking and examination.
• They will record the history and examination findings on the sheet provided for 'Assessment of Newborn
during daily Postnatal Rounds'.
• The case will be discussed by the facilitator.
Station 2 Visit to SNCU

• Participants visit the SNCU and are assigned cases (sick & small newborns) to assess and discuss the
management protocols.
• The group will be divided in two and each group will be assigned a case for history taking, examination
and management.
• They will record the history and examination findings on the NEONATAL CASE RECORD SHEET
(Developed by National Health Mission) provided in Annexure 2 of the module.
• The case will be discussed by the facilitator.
Station 3
1. Temperature Recording & Thermal Control and KMC

Objective
Upon completion of this session each participant
• Should be able to record axillary temperature in a newborn
• Should be able to clinically assess hypothermia, cold stress and normal temperature
• Should be well versed with ways to achieve thermal control during domiciliary care, institutional care
& transport
• Should be able to counsel and help mother initiate skin to skin care

Rationale
Temperature recording is a simple bedside tool to assess the baby’s temperature and ascertain the degree
of hypothermia
Equipment & Other Requirements
i. Digital thermometer
ii. A manikin
iii. Cotton Swabs
iv. Cotton sheet
v. Mother or other caregiver to demonstrate kangaroo care
Skills
1. Drying
2. Wrapping & covering the baby
3. Recording temperature
4. Tactile assessment of temperature (Cold stress assessment)
5. Kangaroo mother care
Procedure
1. Drying
Dry baby from head to toe, back, front, axillae & groin and discard wet linen.
2. Wrapping
Wrap the baby using a baby sheet. Spread the square sheet and fold one corner on itself- place baby’s
head on the in folded corner so as to cover the head till the hairline on forehead. Cover over the right
shoulder & tuck on left side. Fold from the foot end & tuck beneath the chin & finally cover over the
left shoulder and tuck on the right side
3. Record temperature
i. Place the baby supine or on the side
ii. Ensure dry arm pit. Switch on the digital thermometer
iii. Abduct arm at shoulder. Place the bulb of the digital thermometer in the apex of the axilla
iv. Hold arm in adduction at shoulder & flexion at the elbow till you hear a beep
v. Remove thermometer & read temperature
4. Tactile assessment of temperature
i. Wash hands
ii. Allow them to dry
iii. Rub together & warm them
iv. Touch the baby’s soles & palms with the dorsum of your hands
v. Now touch the baby’s chest using the dorsum of your hands
vi. If both are warm- baby is normothermic, if periphery is cold but chest is warm- cold stress, if both
are cold – baby is hypothermic.

Kangaroo Mother Care (KMC)
Equipment and supplies
1. Mother with her low birth weight baby
2. KMC Chair
3. Gown (Disposable or Cotton gown)
4. Baby socks, cloth/disposable diaper and head cap
5. A doll/mannequin
6. Cloth for wrapping the baby
Procedure
Kangaroo mother care (KMC) is care of a small baby, who is continuously carried in skin-to- skin contact
by the mother and exclusively breastfed. It is the best way to keep a small baby warm and it also helps
establish breastfeeding.
Beginning KMC
• Counsel the mother and the family. Ensure that the mother has support from her family to stay at the
hospital. Discuss with the family, if possible, how they can support the mother so she can provide KMC.
• Explain to the mother that KMC may be the best way for her to care for her baby once the baby’s
condition permits. Enumerate the advantages of KMC.
• Clothes for the mother: light, loose clothing that is comfortable in the ambient temperature, provided
the clothing can accommodate the baby.
• Clothes for the baby: shirt open at the front, a napkin, a cap, and socks
 Place the baby in an upright position directly against the mother’s skin in between her breasts
 Ensure that the baby’s hips and elbows are flexed into a frog-like position and the baby’s head and
chest are on the mother’s chest, with the head in a slightly extended position
 Use a soft piece of fabric (about 1 square metre), folded diagonally in two and secured with a knot
 Make sure it is tied firmly enough to prevent the baby from sliding out if the mother stands, but not
so tightly that it obstructs the baby’s breathing or movement
 After positioning the baby, allow the mother to rest with the baby, and encourage her to move
around when she is ready
 KMC should be provided for as long as possible and never less than one hour at a time

Monitoring the baby’s condition:
1. If the baby is in continuous KMC, measure the baby’s temperature twice daily.
2. Teach the mother to observe the baby’s colour & breathing pattern. If the baby stops breathing, teach
the mother to stimulate the baby to breathe by rubbing the baby’s back for 10 seconds and inform the
nurse/ doctor.
3. Teach the mother to recognize danger signs (e.g. apnoea, decreased movement, lethargy, or poor
feeding).
4. Respond to any concerns the mother may have. If the baby is feeding poorly, determine if the mother’s
technique is correct or if the baby is still too immature, or the baby is sick.

Station 4:
Breast Feeding and Expression of breast milk
Objective
Upon completion of this session each participant should be able to
i. Assess breastfeeding and help mother initiate breastfeeding.
ii. Teach mother the skill of manual expression of breast milk.
iii. Allay all fears & anxiety of a lactating mother regarding adequacy & superiority of breast milk.
Rationale
Breast milk is the ideal milk for all neonates and every attempt must be made to ensure establishment
of breastfeeding in babies who can feed at the breast. For small and sick neonates expressed breast milk
should be provided by alternative feeding methods. Advantages of breast milk are many fold and mothers
of babies in NBSU/ SNCU must be encouraged, counselled and supported to ensure this mode of feeding.
Equipment & Other Requirements

1. Lactating mother
2. Katori/cup/paladai
3. 5 fr & 6 fr feeding tubes
4. 10 ml & 5 ml syringes
5. Adhesive tape
6. Manikin
Skills
1. Assessment of breastfeeding – Attachment, position and effective sucking and swallowing
2. Manual Expression of breast milk
3. Assisted feeding
Procedure
1. Assessment of breastfeeding
• Ask mother to feed her baby if she has not fed in the previous one hour
• Check for signs of good attachment and positioning
• Observe for effective sucking and swallowing
• Demonstrate the same to the participants

2. Manual expression of Breast Milk
• After washing hands ask mother to sit comfortably, lean forward and support the breast over a bowl
using both hands
• Initially massage the breast in all quadrants
• Position the thumb and the forefinger at the margin of areola on both sides & press the breast tissue
into the ribcage
• Maintaining the backward pressure and start bringing the thumb & the forefinger of the hand towards
each other. Do not slide finger and thumb over the breast towards the nipple
• Repeat the same several times till no further milk can be expressed out
3. Assisted feeding
Objectives:
• Provide gavage feeds to the baby
• Provide paladai feeding to the baby
Skills
Gavage feeding
• Take 5 fr or 6 fr catheter depending on the gestation and weight of the baby
• Measure length from angle of mouth to tragus to midpoint between umbilicus and xiphisternum
• Insert the tube from mouth till the desired length has been introduced
• Check position using a syringe & a stethoscope to auscultate the gush of air
• Tape the tube to the side of mouth & close outer end after removing the syringe
• To instil feed-Take a 10 ml syringe barrel without the plunger and insert nozzle into the open end of
the feeding tube. Pour milk in to the syringe and wait for it to go down slowly by gravity. After a feed,
close the open end
• Check abdominal girth at next feeding session & proceed to feed if no increase in girth. If the girth
increases by 2 cm, do a pre-feed gastric aspirate and analyse the amount and content to decide about
continuing/discontinuing feeds
• Always confirm the position of the tube prior to giving a feed

Paladai feeding
• Take baby in the lap hold the baby semi upright with head well supported.
• Stimulate the angle of mouth and rest the spoon/paladai at the angle of the mouth
• Pour milk slowly into open mouth & watch for swallowing. Gently stroke behind the ear or on the sole
if the baby goes to sleep.
• Continue feeding in this manner till the desired amount has been fed.
• Burp the baby
• Place in lateral position with head supported a little higher than the rest of the body.

ANNEXURE

[Grab your reader’s attention with a great quote
from the document or use this space to
emphasize aAnnexure 1: Examination
key point. To place this text box of a newborn from head to toe for
anywhere on the page, just drag it.]
common birth defects
Annexure 2
Head and
Face
Fontanelle,
Facial
appearance for
dysmorphic
features
Source (RBSK)

Examination of a newborn from head to toe for
Annexure 3 common birth defects

Annexure 2: NBSU Stationery and Formats
1. Newborn Stabilization Unit (Nbsu) Admission Register
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NEWBORN STABILIZATION UNIT (NBSU)

Community Health Center / Civil Hospital ............................., District..........................
Developed by National Health Mission
Admission Register
Sister Incharge...........................................................
Start Date....................... End Date......................

New Born Stabilization Unit, CHC / CH_________________, District_______________
Month……………..Year…...…….
To be Filled at the Time of Admission by Sister on Duty To be Filled at the Time of Discharge by Sister on Duty
Admission Name and
Contact No. Date of Time of
Date Hospital NBSU Baby of : Wt. on Name of Place of Type of Indication for Provisional Sign. Of Final Out DISCHARGE / DISCHARGE / Doctor
(DD/MM/YY) Age Complete Address ( Relative / Maturity
Father's Name Sex Caste Contact No. Delivery LAMA / LAMA /
Admission IPD NO. Reg. No. (Mother's Name) Admission. ASHA / AWW Admission Admission Diagnosis Person Entering Diagnosis Come REFERRAL / REFERRAL / Incharge
Parent ) with Name DEATH DEATH
Time Details
District/Year/ Male/ In In Kgs GEN/OBC/SC/ST MENTION FULL ADDRESS WITH Ambulance/ 1. INBORN PRETERM PICK UP PICK UP PICK UP DISCHARGE /
Monthly S.No./ Female/ Days and BLOCK NAME / SHC / VILLAGE Home / 2. OUTBORN (<37 Wks)/ FROM FROM FROM LAMA / DD/MM/YY
Yearly S.No. Ambigu Write in ( MENTION WARD NO. FOR URBAN AREA ) (Pvt. Hospital / (Hospital Referred) FULLTERM CASE SHEET CASE SHEET CASE SHEET REFERRAL /
-ous Hours if Govt. Hospital) 3. OUTBORN (37- <42 Wks)/ DEATH
birth Name (Community POSTTERM
<48 Hrs. Referred)
(=>42 Wks)

2. NEWBORN STABILIZATION UNIT (NBSU) NEONATAL CASE RECORD SHEET
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Community Health Center / Civil Hospital ............................., District..........................
NEONATAL CASE RECORD SHEET
(Developed by National Health MIssion)
NBSU Reg. No............................................
RCH No.
Doctor In charge.........................................
Baby of (Mother’s Name) Sex: Male / Female / Ambiguous
Father’s Name Category: General / OBC / SC / ST
Complete Address with

Village Name / Ward No.
Contact No. & Relation 1. 2.
Date and Time of Birth ...../...../20......... ..... : ..... Birth Weight (grams) :
Date and Time of Admission ...../...../20......... ..... : ..... Age on Admission : Wt. on Admission (grams) :
Date and Time of Discharge ...../...../20......... Age on Discharge : Wt. on Discharge (grams) :
Type of Admission Inborn / Out born (Health Facility Referred) / Out born (Community Referred)
Place of Delivery Home / Ambulance/ Pvt. Hospital / Govt. Hospital (Name) :
Referred From Mode of Transport : Self Arranged / Govt. Provided
Indication for Admission ( Encircle the most relevant single indication, If multiple indication also mention all relevant numbers in the end as per priority, mention even if admitting for stabilization)
1. Prematurity <34 weeks 10. Neonatal Convulsions 18. Meconium Aspiration

2. Low Birth Weight <1800 gm. 11. Baby of Diabetic mother 19. Bleeding
3. Perinatal Asphyxia 12. Oliguria 20. Diarrhoea
4. Neonatal Jaundice 13. Abdominal Distension 21. Major Congenital Malformation
5. Resp. Distress (Rate>60 or Grunt / Retractions) 14. Hypothermia <35.4 ºC 22. Unconsciousness
6. Large Baby ( >4 Kg. at 40 weeks) 15. Hyperthermia >37.5 ºC 23. Any Other (….....….....……..............……..)
7. Refusal to Feed 16. Hypoglycemia <45 mg% 24. Multiple Indication -
8. Central Cyanosis 17. Shock : Cold Periphery with Mention All Relevant Numbers:
9. Apnea / Gasping CFT >3 sec & Weak Fast Pulse a ............. b ............. c ............. d .............
Provisional Diagnosis:
*Presumptive Diagnosis ( Encircle the most relevant single diagnosis, If multiple causes also mention all relevant numbers in the end as per sequence)
Other LBW (1000 gm – 2499 gm) : P 07.1 Neonatal Jaundice : P 59 Any Other Diagnosis (…...............…..
Prematurity (28-<37 Weeks) : P 07.3 Neonatal Diarrhoea : A 09 ...........................................................)
Small for Gestational Age (IUGR) : P 05.1 Hypothermia of Newborn : P 80 Multiple Diagnosis-
RDS of Newborn (HMD) : P 22.0 Environmental Hyperthermia of Newborn : P 81.0 Mention All Relevant Codes :
Transient Tachypnoea of Newborn : P 22.1 Congenital Malformation : a .......... b ........... c ............ d ............
Acquired Pneumonia : J 15 (a) Cong. Hydrocephalus : Q 03
Birth Asphyxia : P 21.0 (b) Meningomyelocele : Q 05
HIE of Newborn : P 91.6 (c) Imperforate anus : Q 42.3
Neonatal Sepsis : P 36.9 (d) Cleft Palate : Q 35
Meningitis : G 00 (e) Cleft Lip : Q 36
Convulsions of Newborn : P 90 (f) Cleft Palate with Cleft Lip : Q 37
(Hypoxic, Hypoglycaemic, Hypocalcaemic, (g) Congenital Deformities of Hip : Q 65
CNS Infections, Birth Trauma, Metabolic, (h) Congenital Deformities of Feet : Q 66
Other, Unknown Cause) (i) Other Malformation (.........................)
* ( Based on WHO, ICD - 10 Version: 2010 )

This Sheet has to be filled on Admission by Doctor on Duty

MOTHER’S INFORMATION : Past History, ANC Period and During Labour
Mother’s Age …….. Yrs. Mother’s Wt ……...........…..Kgs. Age at Marriage……….Yrs.
Birth Spacing: < 1 Yr / 1-2 Yr / >2-3 Yr / > 3 Yr / Not Applicable
Gravida :……........... Para :………....... Live Birth :……........... Abortion: ……………...........
LMP : ...../....../............ EDD : ...../....../............ Gestation Weeks : ………...............
Antenatal Visit’s : None / 1 / 2 / 3 / 4 T.T. Doses : None / 1 / 2
Hb : ……………................... Blood Group : …........
PIH : No [ ] Yes [ Hypertension / Pre Eclampsia / Eclampsia ]
Drug : No [ ] Yes [ ] (................................................................)
APH : Yes [ ] No [ ] GDM : Yes [ ] No [ ]
VDRL : Not Done / + Ve / -Ve HbsAg : Not Done / + Ve / -Ve
HIV Testing : Done / Not Done
Antenatal Steroids : Yes [ ] No [ ] If Yes, Dexamethasone [ ]
No. of doses : [1] [2] [3] [4] Foul Smelling Discharge : Yes [ ] No [ ]
Leaking P.V. > 24 Hours. : Yes [ ] No [ ] PIH : Hypertension / Pre Eclampsia / Eclampsia
Course of Labour : Uneventful / Prolonged 1st stage / Prolonged 2nd stage / Obstructed
E/O Feotal Distress : Yes [ ] No [ ] Type of Delivery : LSCS / AVD / NVD
Indication for Caesarean, : [Cephalo Pelvic Disproportion] [Malpresentation] [Placenta Previa] [Obstructed Labor] [Foetal Distress]
if Applicable
[Prolonged Labour] [Cord Prolapse] [Failed Induction (Dystocia)] [Previous LSCS] [Other ....................]
Delivery Attended by : [Doctor] [Nurse] [ANM] [Dai] [Relative] [Any Other]………….……………………...
Other Significant Information :
If Information is Not Available, Leave the Field Blank, Do Not ü “No [ ]”

BABY’S INFORMATION: At Birth
Cried Immed. after Birth : Yes [ ] No [ ] Wt. at Birth: ……..…….. Kgs.
Gestational age : ................….. in completed weeks - Wk)

Maturity : Preterm (<37 Wk) / Full term / Post term (>42
Resuscitation Required : NO [ ] Yes [ ] Tactile Stimulation /Only Oxygen / Bag & Mask [Duration....................min.]/
Intubation / Chest Compression / Adrenaline
Vitamin K Given : Yes [ ] No [ ] Breast Fed within 1 Hour : Yes [ ] No [ ]
BABY’S INFORMATION : On Admission
PRESENTING COMPLAINTS:
GENERAL EXAMINATION
General Condition : [Alert] [Lethargic] [Comatose] Temperature ………..ºC Heart Rate………./min
Apnea : Yes [ ] No [ ] RR …………./min.
Grunting : Yes [ ] No [ ] Chest Indrawing : Yes [ ] No [ ]
Head Circumference : …………….……c.m.
Color : Pink / Pale / Central Cyanosis / Peripheral Cyanosis
CRT >3 secs : Yes [ ] No [ ] Skin pinch > 2 secs : Yes [ ] No [ ]
Cry : Absent / Feeble / Normal / High Pitch
Tone : Limp / Active / Increase Tone Convulsions : Present on Admission / Past History / No
Jaundice : Yes [ ] No [ ] If Yes, extent [Face] [Chest] [Abdomen] [Legs] [Palms / Soles]
Bleeding : Yes [ ] No [ ] If Yes ,specify site [Skin] [Mouth] [Rectal] [Umbilicus]
Bulging Anterior Fontanel : Yes [ ] No [ ] Taking Breast Feeds : Yes [ ] No [ ]
Sucking : [Good] [Poor] [No Sucking] Attachment : [Well attached] [Poorly attached] [Not attached]
Umbilicus : [Red] [Discharge] [Normal] Skin Pustules : [No] [Yes <10] [Yes >=10] [Abscess]
Congenital Malformation : No [ ] Yes [ ] Hydrocephalus / M.M.C. / Imperforate Anus / Cleft Palate / Cleft Lip /
Cleft Palate with Cleft Lip /Cong. Deformity of Hip / Cong. Deformity of Feet /
Other..................................
Blood Sugar : ……………………………. Oxygen Saturation :………...............................
Other Significant Information :
If Information is Not Available, Leave the Field Blank, Do Not ü “No [ ]”

SYSTEMIC EXAMINATION
CVS : ...........................................................................................................................................................
RESPIRATORY : ...........................................................................................................................................................
PER ABDOMEN : ...........................................................................................................................................................
CNS : ...........................................................................................................................................................
OTHER SIGNIFICANT FINDING : ...........................................................................................................................................................
TREATMENT ADVISED : On Admission
INVESTIGATIONS ADVISED : On Admission
Doctor’s Name and Signature
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Foot Print of Newborn

(Left Foot)
FINAL OUTCOME
Successfully Discharged / Left Against Medical Advice / Referred / Expired
In Case of Death : Mention Cause of Death ( The Most Relevant Cause of Death)
1. Respiratory Distress Syndrome 6. Meningitis 11. Cause not established

2. Meconium Aspiration Syndrome 7. Major Congenital Malformation 12. Any Other : ..........................
3. HIE / Moderate-Severe Birth Asphyxia 8. E.L.B.W. (Wt. less than 1000g) ...................................................
4. Sepsis 9. Prematurity ( <28 weeks of Gestation) ...................................................
5. Pneumonia 10. Neonatal Tetanus
This Sheet has to be filled on Admission by Doctor on Duty
2020 VERSION - UNICEF - GOI

3. TREATMENT CONTINUATION SHEET
TREATMENT CONTINUATION SHEET

NBSU Reg. No................................................................. Date of Admission.........................................
Baby of (Mother’s name).................................................. Sex................................................................
Birth Weight...................................................................... Doctor Incharge.............................................
Oxygen and Other

Supportive Care
I / V Drugs
I / V Fluids
Oral Drugs
Feeding
Investigations
Conducted
(Results with Date)
Planning for
Next Day
This Sheet has to be filled by Doctor Incharge of Patient PTO

4. MONITORING SHEET
MONITORING SHEET
NBSU Reg. No............................................................................... Date of Admission.........................
Baby of (Mother’s name)................................................................ Sex……….....................................
Weight............................................................................................ Date...............................................
Time
Activity
( Dull / Active )
Temperature
Colour
HR
RR
CRT
B.P.
O2 Flow
Rate
FIO2
Oxygen
Saturation
Blood
Glucose
Urine
Stool
Abdominal
Girth
R.T.
Aspirate
IV Patency
( Yes / No )
Blood
Collection
Other
This Sheet has to be filled by Nurse on Duty

5. NURSES ORDER SHEET
NURSES ORDER SHEET

Treatment Time Time Time Time Time Time Time Time Time Time Time Time Total
Administered ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. ............. (ml)
Oral Feeds
Feeding Tube ( ml )
Spoon & Cup ( ml )
Breast Feed ( adlib )
Oral Drugs
1. .......................................
2. .......................................
IV Drugs
(Also Record Fluid Volume)
1. .......................................
2. .......................................
3. .......................................
IV Fluids
1. ....................................... .......ml / hr .......ml / hr .......ml / hr .......ml / hr .......ml / hr .......ml / hr .......ml / hr .......ml / hr .......ml / hr .......ml / hr .......ml / hr .......ml / hr
( Enter Rate & fluid given
between each time slot ) ( ........ml ) ( ........ml ) ( ........ml ) ( ........ml ) ( ........ml ) ( ........ml ) ( ........ml ) ( ........ml ) ( ........ml ) ( ........ml ) ( ........ml ) ( ........ml )
2. ....................................... ......ml / hr ......ml / hr ......ml / hr ......ml / hr ......ml / hr ......ml / hr ......ml / hr ......ml / hr ......ml / hr ......ml / hr ......ml / hr ......ml / hr
IV Infusions
1. ....................................... .......ml / hr .......ml / hr .......ml / hr .......ml / hr .......ml / hr .......ml / hr .......ml / hr .......ml / hr .......ml / hr .......ml / hr .......ml / hr .......ml / hr
2. ....................................... ......ml / hr ......ml / hr ......ml / hr ......ml / hr ......ml / hr ......ml / hr ......ml / hr ......ml / hr ......ml / hr ......ml / hr ......ml / hr ......ml / hr
IV Bolus
................................. ml
Blood / Packed Cell /

FFP / Platelet ( ..........ml )
Rate................. ml / hr
Any Other Treatment
........................................................
........................................................
Total Input in 24 Hours ( ml ) .............

6. Referral Form
REFERRAL SUMMARY
Name of NBSU.....................................................
NBSU Reg. No. Sex : M / F / A Age : Weight (grams) :
Baby of (Mother’s Name) Father’s Name :
Date & Time of Referral ....../....../20...... ...... : ...... Place of Referral :
Indication for Referral Ventilation / Surgical Intervention / Diagnostic Work up / Metabolic Work up / Dialysis / Other
*Final Diagnosis ( Encircle the most relevant single diagnosis, If multiple causes also mention all relevant numbers in the end as per priority)
*( Based on WHO, ICD - 10 Version: 2010 )
TREATMENT GIVEN
......................................................................................................
1. Oxygen : Yes / No ( If yes duration..............................................)
2. Phototherapy : Yes / No ( If yes duration..............................................)
......................................................................................................
3. Antibiotics : Yes / No ( If yes fill the details below)
Treatment Given No. of Days ......................................................................................................
a) .................................................................................. .......................
b) .................................................................................. ....................... ......................................................................................................
c) .................................................................................. .......................
d) .................................................................................. ....................... ......................................................................................................
PRESENTING COMPLAINTS & COURSE DURING TREATMENT
RELEVANT INVESTIGATIONS
CONDITION AT TIME OF REFERRAL
TREATMENT ADVISED ON WAY

.....................................................................................................................................
1. Keep Baby Warm.
2. Take Care of Airway and Breathing. .....................................................................................................................................
3. Monitor Color / Heart Rate / Blood Glucose.

.....................................................................................................................................

This Sheet has to be filled on Referral by Doctor on Duty

7. Discharge Form
DISCHARGE NOTES : FOR NBSU RECORD

NBSU Reg. No. Sex : M/F/A
Baby of (Mother’s Name) Father’s Name :
Date & Time of Discharge ....../....../20.... .... : .... Age on Discharge : Wt. on Discharge (grams) :
Final Outcome Successfully Discharged / Left Against Medical Advice / Expired

*Final Diagnosis ( Encircle the most relevant single diagnosis, If multiple causes also mention all relevant numbers in the end as per priority)
* ( Based on WHO, ICD - 10 Version: 2010 )
TREATMENT GIVEN
3. KMC : Yes / No ( If yes duration..............................................)
Treatment Given No. of Days

a) .................................................................................. .......................
b) .................................................................................. .......................
c) .................................................................................. .......................
d) .................................................................................. .......................
COURSE DURING TREATMENT
CONDITION ON DISCHARGE (Mention Vitals, Provisional Diagnosis, General Condition, Persisting Health Problems)
IMMUNIZATION STATUS TREATMENT ADVISED ON DISCHARGE

RI Card .........................................................................................................................................................
BCG
.........................................................................................................................................................
OPV (0 Dose)
Hepatitis B (Birth Dose) .........................................................................................................................................................

This Sheet has to be filled on Discharge by Doctor on Duty

8. NEWBORN STABILIZATION UNIT (NBSU) DISCHARGE CARD
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Community Health Center / Civil Hospital ............................., District .......................
DISCHARGE CARD
(Developed by National Health Mission)
NBSU Reg. No............................................
RCH No.
Doctor In charge.........................................
Baby of (Mother’s Name) Sex:
Father’s Name Category:
Complete Address with Date of Birth:

Village Name / Ward No.
Contact No. & Relation 1. 2.
Date and Time of Admission Age on Admission : Wt. on Admission (grams) :
Date and Time of Discharge Age on Discharge : Wt. on Discharge (grams) :
Place of Delivery Type of Admission :
Indication for Admission
Final Diagnosis
Final Outcome
PRESENTING COMPLAINTS :
MOTHER’S INFORMATION : Past History and ANC Period

(Put Same as in Case Record Sheet)
Mother’s Age : __________Yrs. Mother’s Wt. :__________Kgs. Age at Marriage :_______Yrs
Birth Spacing : __________ L.M.P. :__________ E.D.D.:__________ Antenatal Visit’s :__________
T.T. Doses :__________ Gestation Weeks :__________ Gravida :__________ Para :__________
Live Birth :__________ Abortion :__________ Hb :__________ Blood Group :__________
PIH :__________ Drug:__________
APH :__________ GDM __________ VDRL :__________
HbsAg :__________ HIV Testing :__________
Any Other Significant History :
This Card has to be filled on Discharge by Doctor on Duty

MOTHER’S INFORMATION : During Labour
Antenatal Steroids :________________ Number of Doses :_________________ Foul Smelling Discharge :______________
Leaking P.V. > 24 Hours :____________ PIH :___________________________ Course of Labour :____________________
E/O Feotal Distress :_______________ Type of Delivery :___________________ Indication of Caesarean, If Applicable
Course of Labor :__________________ Delivery Attended by :_______________ [ _________________________________ ]
BABY’S INFORMATION : At Birth

Cried Immed. after Birth :__________ Wt. at Birth :__________Kgs. Gestational Age_______(in completed weeks)
Maturity :__________
Resuscitation Required :__________ Vitamin K Given :__________ Breast Fed within 1 Hour :________
BABY’S INFORMATION : On Admission

GENERAL EXAMINATION
General Condition :___________ Temperature :_______ºC Heart Rate :________/min Apnea:_________ RR :________/min
Grunting :__________ Chest Indrawing :__________ Head Circumference :_______c.m.
Color :__________ Cry :__________ CRT > 3 secs : __________
Skin pinch > 2 secs :________ Tone :__________ Convulsions :__________
Jaundice :________________ Bleeding :__________ Bulging Anterior Fontanel :_____ Taking Breast Feed :__________
Sucking :__________________ Attachment :__________ Umbilicus :________________ Skin Pustules :_________
Congenital Malformation :_________________________ Blood Sugar :______________ Oxygen Saturation :_________
SYSTEMIC EXAMINATION
CVS : ...........................................................................................................................................................
RESPIRATORY : ...........................................................................................................................................................
PER ABDOMEN : ...........................................................................................................................................................
CNS : ...........................................................................................................................................................
OTHER SIGNIFICANT FINDING : ...........................................................................................................................................................

TREATMENT GIVEN
3. KMC : Yes / No ( If yes duration..............................................)
Treatment Given No. of Days

a) .................................................................................. .......................
b) .................................................................................. .......................
c) .................................................................................. .......................
d) .................................................................................. .......................
COURSE DURING TREATMENT
RELEVANT INVESTIGATIONS
CONDITION ON DISCHARGE (Mention Vitals, Provisional Diagnosis, General Condition, Persisting Health Problems)
IMMUNIZATION STATUS RI Card BCG OPV (0 Dose) Hepatitis B (Birth Dose)
TREATMENT ADVISED ON DISCHARGE

1. Exclusive Breast Feeding till 6 months of Age. .....................................................................................................................................
2. Burp well after feed.

.....................................................................................................................................
3. Maintain Temperature.
4. Immunization as per Schedule. .....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

Any other information
160 | Newborn Stabilization Unit Training Participants’ Module 2014 VERSION - UNICEF - GOI
Annexure 3: Mentoring Checklists
1. Emergency triage of new born

2. Management of a newborn with emergency signs
3. Use of radiant warmer
4. Newborn resuscitation
5. Oxygen therapy in new born
6. Umbilical vein catheterization
7. Measuring oxygen saturation using pulse oximeter
8. Use of glucometer
9. Measuring temperature of a newborn
10. Management of severe hypothermia
11. Use of phototherapy unit
12. Management of neonatal seizures
13. Orientation on breastfeeding
14. Management of Sepsis in new born
15. Kangaroo Mother Care (KMC)
16. Technique of expression of breast milk and spoon/paladai feeding
17. Feeding with oro-gastric tube
18. How to clean self-inflating bag
19. Hand washing
20. Personal protective equipment (PPE)
21. Segregation of bio-medical waste and their disposal
Mentoring Checklists are available online on NHM portal under Child Health guidelines:
https://nhm.gov.in/index1.php?lang=1&level=3&sublinkid=1184&lid=368


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CHILD HEALTH DIVISION

Ministry of Health and Family Welfare

(Dr. Harsh Vardhan)

(Ashwini Kumar Choubey)

Office : 250, ‘A’ Wing, Residence :

RAJESH BHUSHAN, IAS

Room No. 156, A-Wing, Nirman Bhawan, New Delhi-110 011

Additional Secretary & Mission Director (NHM)

xqjukuh] Hkk-Á-ls- Hkkjr ljdkj

Tele : 011-23063693, Telefax : 011-23063687 E-mail : vandana.g@ias.nic.in

(Dr. Manohar Agnani)

Talking about AIDS is taking care of each other

(Dr. Sumita Ghosh)

Healthy Village, Healthy National

Talking about AIDS is taking care of each other

Ministry of Health and Family Welfare Child Health Division

Technical Experts Dr Misbah Samad

Dr Ajay Khera Dr Ashfaq Bhat

SKILL STATIONS / 105

1.1. Arrival & Rapid Assessment

Newborn Stabilization Unit Training Participants’ Module | 21

Sick newborns are triaged into following categories:

Categories after Triage Action required

22 | Newborn Stabilization Unit Training Participants’ Module

Emergency Signs Priority Signs Non-urgent Signs

This order is also followed while stabilizing any sick newborn.

Newborn Stabilization Unit Training Participants’ Module | 23

24 | Newborn Stabilization Unit Training Participants’ Module

Sign/Condition Emergency Treatment Needed: Yes or No

Newborn Stabilization Unit Training Participants’ Module | 25

Temperature below 35.5°C is an emergency sign

26 | Newborn Stabilization Unit Training Participants’ Module

Check for severe respiratory distress

LOOK for severe chest indrawing

Newborn Stabilization Unit Training Participants’ Module | 27

LOOK and LISTEN for grunting

Check for Central Cyanosis

Is the CRT ≥ 3 seconds?

Is the pulse weak and fast?

28 | Newborn Stabilization Unit Training Participants’ Module

How to differentiate convulsions and jitteriness?

• Like convulsions, jitteriness is characterized by repetitive movements; however, in a jittery

Newborn Stabilization Unit Training Participants’ Module | 29

Check for consciousness level

✓ If newborn has an emergency sign, perform bedside diagnostics

A. Check oxygen saturation

Check for oxygen saturation

30 | Newborn Stabilization Unit Training Participants’ Module

Newborn Stabilization Unit Training Participants’ Module | 31

Assessment Emergency signs

• Check for severe respiratory distress • Severe respiratory distress

• Check for central cyanosis • Central cyanosis

• Assess circulation • Shock

• Check for abnormal movements • Convulsions/Unconsciousness

• Check for consciousness level

• Perform bedside diagnostics

32 | Newborn Stabilization Unit Training Participants’ Module

Low Body Temperature (Temp. <35.5°C)

Not breathing at all "OR" gasping respiration

How to administer Positive Pressure Ventilation (PPV) using self-inflating bag

22 | Newborn Stabilization Unit Training Participants’ Module

24 | Newborn Stabilization Unit Training Participants’ Module

26 | Newborn Stabilization Unit Training Participants’ Module

28 | Newborn Stabilization Unit Training Participants’ Module

30 | Newborn Stabilization Unit Training Participants’ Module

32 | Newborn Stabilization Unit Training Participants’ Module

34 | Newborn Stabilization Unit Training Participants’ Module

36 | Newborn Stabilization Unit Training Participants’ Module

38 | Newborn Stabilization Unit Training Participants’ Module

40 | Newborn Stabilization Unit Training Participants’ Module

42 | Newborn Stabilization Unit Training Participants’ Module

44 | Newborn Stabilization Unit Training Participants’ Module

50 | Newborn Stabilization Unit Training Participants’ Module

52 | Newborn Stabilization Unit Training Participants’ Module

54 | Newborn Stabilization Unit Training Participants’ Module

56 | Newborn Stabilization Unit Training Participants’ Module