» First One Hour After Birth
First One Hour After Birth
The first hour
after birth has a major influence on the survival, future
health, and wellbeing of a newly born infant. The health workers
have an important role at this time. The care they give during
this period is critical in helping to prevent complications and
ensuring intact survival.
NEEDS OF A BABY AT BIRTH
The four basic needs of ALL babies at the time of birth (and for
the first few weeks of life) are:
ii. Normal breathing
iii. Mother's milk
iv. Protection from infection
These basic needs indicate that a baby's survival is totally
dependent upon her mother and other caregivers. Therefore
it is important to provide proper care to all the neonates
immediately after birth. All newborns require essential
newborn care to minimize the risk of illness and maximize their
growth and development. This care will also prevent many newborn
emergencies. For example, the umbilical cord may be the most
common source of neonatal sepsis and also of tetanus infection,
and good cord care can dramatically reduce the risks of these
serious conditions. Exclusive breastfeeding has a significant
protective effect against infections. Early breastfeeding and
keeping the baby close to the mother reduce the risk of
hypothermia and hypoglycemia.
CARE OF THE
NORMAL NEWBORN AT THE TIME OF BIRTH
The steps to be undertaken at the time of birth for all babies
(including those who need resuscitation) are covered in the
module on `Basic resuscitation'. Here, we shall review the steps
that are essential for a normal newborn baby at birth. The steps
are summarized in the box below:
Immediate care of a normal newborn at the time of birth
1. Call out the time of birth.
2. Deliver the baby onto a warm, clean and dry towel or cloth
and keep on mother's chest (between the breasts).
3. Clamp and cut the umbilical cord.
4. Immediately dry the baby with a warm clean towel or piece of
cloth; wipe the eyes.
5. Assess the baby's breathing while drying. (if the baby is not
crying or breathing well, the next steps of resuscitation have
to be carried out).
6. Wipe both the eyes separately with sterile gauze
7. Leave the baby between the mother's breasts to start
8. Place an identity label/band on the baby.
9. Cover the
baby's head with a cap. Cover the mother and baby with a warm
mother to initiate breastfeeding (within half an hour of birth).
The individual steps
are briefly explained below:
Call out the time of birth
It is important to tell loudly the time of birth - this
helps in accurate recording of the time and more importantly,
alerts other personnel in case any help is needed.
Receive the baby on to a warm, clean and dry towel or cloth on a
warm dry surface
The baby should be delivered on to a warm clean towel and kept
on the mother's chest. If this is not possible, the baby should
be kept in a clean, warm, safe place close to the mother.
cut the umbilical cord
The umbilical cord should be clamped using a sterile, disposable
clamp or a sterile tie and cut using a sterile blade about 2-3
cm (1-inch) away from the skin.
Immediately dry the baby with a warm clean towel or piece of
cloth; wipe the eyes
The baby should be thoroughly dried to prevent from getting
cold (this would be explained in the module on 'Thermal
protection'). Blood or meconium on the baby's skin should be
wiped away; however, the white greasy substance covering
the baby's body (vernix) should not be wiped off. Because this
vernix helps to protect the baby's skin and gets reabsorbed very
Assess the baby's breathing while drying
At the time of drying itself, the baby's breathing should be
assessed. A normal newborn should be crying vigorously or
breathing regularly at a rate of 40-60 breaths per minute. If
the baby is not breathing well, then the steps of resuscitation
have to be carried out.
Wipe both the eyes with sterile gauze
Clean the eyes using sterile gauze/cotton. Use separate gauze
for each eye. Wipe from the medial side (inner canthus) to the
lateral side (outer canthus).
Leave the baby between the mother's breasts to start
Once the cord is cut, the baby should be placed between the
mother's breasts to initiate skin-to-skin care. This will help
in maintaining the normal temperature of the baby as well as in
promoting early breastfeeding.
Place an identity label on the baby
This helps in easy identification of the baby, avoiding any
confusion. The label should be
placed on the wrist or ankle.
Cover the baby's head with a cap. Cover the mother and baby
with a warm cloth
Both the mother and the baby should be covered with a warm
cloth, especially if the delivery room is cold (temperature less
than 25°C). Since head is the major contributor to the surface
area of the body, a newborn baby's head should be covered with a
cap to prevent loss of heat.
Encourage mother to initiate exclusive breastfeeding
Breastfeeding should be initiated within half an hour of
birth in all babies.
ENSURING WARMTH: 'WARM CHAIN'
A baby's skin temperature falls within seconds of being born. If
the temperature continues to fall, the baby will become ill and
may even die. This is why a baby MUST be dried immediately after
birth and delivered onto a warm towel or piece of cloth, and
loosely wrapped before being placed naked between the mother's
Keeping the baby between the mother's breasts ensures that the
baby's temperature is kept at the correct level for as long as
the skin contact continues. This first skin-to-skin contact
should last uninterrupted for at least one hour after birth or
until after the first breastfeed. The mother and baby should be
covered with a warm and dry cloth, especially if the room
temperature is lower than 25°C. The steps of prevention of heat
loss are explained in the module on 'Thermal protection'.
For maintaining the temperature, it is important to understand
the concept of 'Warm chain'. It means that the temperature
maintenance should be a continuous process starting from the
time of delivery and continued till the baby is discharged from
the hospital. The components of warm chain are summarized below:
1. At delivery
delivery room is warm (25° C), with no draughts
baby immediately; remove the wet cloth
baby with clean dry cloth
baby close to the mother (ideally skin-to-skin)
bathing/sponging for 24 hours
baby clothed and wrapped with the head covered
bathing especially in cool weather or for small babies
baby close to the mother
kangaroo care for stable LBW babies and for re-warming
stable bigger babies
mother how to avoid hypothermia, how to recognize it, and
how to re-warm a cold baby. The mother should aim to ensure
that the baby's feet are warm to touch
ESTABLISH NORMAL BREATHING
The baby's breathing should be assessed at the time of
drying. If the baby is crying vigorously or breathing adequately
(chest is rising smoothly at a rate of 40 to 60 times per
minute), then no intervention is needed. However, if the baby is
not breathing or gasping, then skilled care in the form of
positive pressure ventilation etc. might be required. These
steps are explained in the module on 'Basic resuscitation'.
During the initial skin-to-skin contact position after birth,
the baby should be kept between the mother's breasts; this would
ensure early initiation of breastfeeding.
Initially, the baby might want to rest and would be asleep. This
rest period may vary from a few minutes to 30 or 40 minutes
before the baby shows signs of wanting to breastfeed. After this
period (remember each baby is different and this period might
vary), the baby will usually open his/her mouth and start
to move the head from side to side; he may also begin to
dribble. These signs indicate that the baby is ready to
The mother should be helped in feeding the baby once the baby
shows these signs. Both the mother and the baby should be in a
comfortable position. The baby should be put next to the
mother's breasts with his mouth opposite the nipple and
areola. The baby should attach to the breast by itself
when it is ready. When the baby is attached, attachment and
positioning should be checked. The mother should be helped to
correct anything which is not quite right.
The procedure of counseling and support for breastfeeding are
explained in the module on
'Feeding of normal and low birth weight infants'.
OF INFECTIONS: 'CLEAN CHAIN'
securely placed in their mothers' womb. When they are born, they
have to be protected from the adverse environment of the
surroundings. Cleanliness at delivery reduces the risk of
infection for the mother and baby, especially neonatal sepsis
and tetanus. Cleanliness requires mothers, families, and health
professionals to avoid harmful traditional practices, and
prepare necessary materials. Hand washing is the single most
important step to be emphasized to both family members and
health care workers.
Similar to warm chain, 'Clean chain' has to be followed both at
the time of delivery and then till the time of discharge to
protect the infant from infections. The components of clean
chain are summarized below:
delivery (WHO's six cleans)
attendant's hands (washed with soap)
cutting instrument (i.e. razor, blade)
string to tie cord
to wrap the baby
to wrap the mother
caregivers should wash hands before handling the baby
cord clean and dry; do not apply anything
Use a clean
cloth as a diaper/napkin
hands after changing diaper/napkin. Keep the baby clothed
and wrapped with the head covered
IMMEDIATE CORD AND EYE
The umbilical cord can be cut and clamped/tied (according to
local custom) while the baby is on the mother's abdomen or on a
warm, clean and dry surface.
The steps of clamping, cutting the cord and its care after
cutting are summarized in the
Immediate care of the umbilical cord
baby on mother's chest or on a warm, clean and dry surface
close to the mother.
gloves; if not possible, wash gloved hands.
(using a sterile tie) tightly around cord at 2 cm and 5 cm
from the abdomen.
the ties with a sterile instrument (e.g. blade).
oozing blood. If blood oozes, place a second tie between the
and first tie.
APPLY ANY SUBSTANCE TO THE STUMP.
DO NOT bind
or bandage stump.
traditional remedies to the cord may cause infections and
Eye care is
given to protect a baby's eyes from infection. In areas where
transmitted diseases are common, eye care is needed soon after
delivery because infections such as gonorrhoea can be passed
onto the baby during the birthing process which can result
in blindness. A baby's eyes should be wiped as soon as possible
after birth. Both eyes should be gently wiped with separate
sterile swabs soaked in warm sterile water. Eye drops or
ointment should be given within one hour of delivery. This can
be done after the baby has been dried or when he is being held
by his mother. After instilling the eye drops, care should be
taken so that the drug is not washed away. A baby's eyes should
be wiped as soon as possible after birth In areas where sexually
transmitted diseases are common an anti-microbial eye medicine
should be applied within one hour of birth
Clean eyes immediately after birth with swabs soaked in
sterile water using separate swabs for each eye. Clean from
medial to lateral side Give prophylactic eye drops within 1 hour
of birth as per hospital policy
Do not apply anything else (e.g. Indian Kajal) in the eyes
MONITORING THE BABY
first hour after delivery, the baby (and the mother) should be
monitored every 15 minutes. Both of them should remain in the
delivery room for the first hour to facilitate
DO NOT leave the mother and baby alone, monitor every 15 minutes
The three most important parameters that need to be monitored
ii. Temperature or warmth and
The health personnel should monitor these three parameters every
15 minutes in the first hour after birth of the baby. The signs
to be looked for are given in the table below:
Monitoring the baby in the first hour after birth
to look for?
grunting; Look for chest in-drawing and fast
||Check to see if
baby's feet are cold to touch (by using your hands)
||Evaluate the color
of the trunk and extremities
section, instrumental delivery
Caesarean section, instrumental delivery and breech delivery,
all carry increased risks to the mother and to the baby. Before
delivery, preparation for newborn resuscitation should
be made in all these cases, since the need for resuscitation
might be more in them as compared to a normal delivery.
Delay between the time of birth and skin-to skin contact & the
first breastfeed may happen in each of these special situations.
Also, separation is common, leading to babies receiving
pre-lacteal feeds in the first hours after birth. If a long
delay between delivery and breastfeeding is expected, encourage
the mother to express colostrum. If the mother is too ill to
express herself, do it for her.
A mother who has delivered by caesarean section should NOT be
routinely separated from her baby unless either the mother or
the baby is sick and needs special care. The baby should be kept
in the same room as its mother.
Once the baby is born, monitoring every 15 minutes in the first
hour will be particularly important.
A baby born by caesarean section or instrumental delivery need
not be routinely separated from the mother; these babies need
better readiness during delivery and more careful monitoring
Skin-to-skin contact and breastfeeding in difficult deliveries
(caesarean section, instrumental and breech delivery):
who was given a general anaesthetic agent should begin
skin-to-skin contact as soon as she is able to respond to
her baby. This may be initiated within one hour of birth
who has had an epidural (spinal) anaesthetia may be able to
start skin-to-skin contact very soon after surgery
mothers will need additional assistance in positioning and
attaching the baby comfortably. Breastfeeding in lying down
position may be more comfortable in the first days
Breastfeeding can begin as soon as the mother is comfortable
and able to respond to her baby. It does not have to be
HIV and newborn care
mother is HIV positive or not, universal precautions use HIV kit
contents as per
national guidelines while delivering must always be observed and
followed when delivering a baby.
Care of the baby at delivery should be no different from the
care already described.
If the mother has decided to breastfeed, she should begin
skin-to-skin contact as soon as possible after delivery and let
her baby breastfeed when she is ready.
If the mother has decided not to breastfeed but has chosen
replacement feeding, the first few feeds should be prepared for
her. These feeds should be given by cup NOT bottle.
Avoid mixed feeding (breast and replacement). The salient
features of care in these infants are summarized in the box
Care of a baby born to HIV+ve mother
1. Universal precautions must be followed as with any other
2. Baby can have immediate skin-to-skin contact as any other
mother and baby.
3. Breastfeeding can begin when the baby is ready after
delivery. (Mother should be counseled regarding the mode of
feeding before delivery)
4. If mother chooses replacement feeding, prepare formula for
the first few feeds.
5. All other care (including cord care and eye care) remains the