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F Cost of setting up newborn care corner

1. Ventilate o Chest not moving Call for help Monitor with mother Imporves Bre Breathing 30 min HR gt 100 min Prepare for birth Continue ventilation Gas 5 Suction device 40 min Check HR Cloths X Ventilation bag mask HR 60 min m ethos Ste 5 lt 60 min s Scissors Timer Ties clock watch Administer Chest HR 60 min compressions HR 60 min Ch eck HR Breathings 30 min HR gt 100 min Continue CPR special care preferable Administer Drups at SCANU Helping Babies Breathe THE GOLDEN MINUTE If liquor is meconium stained suction mouth first and then both nostrils before drying Steps to improve ventilation if chest is not moving Check the mouth the back of the throat and the nose for secretions and clear as necessary Open the baby s mouth slightly before reapplying the mask Reapply the mask to the face to form a better seal Reposition the head with the neck slightly extended Squeeze the bag harder to give a larger breath 3CPR One CPR cycle comprises of 3 chest compressions plus 1 ventilation To give chest compression hold the baby with the fingers around the torso thumbs in front in the midline just below the nipple line over the lower third of the sternum Depress the sternum to a depth of approximately one third of the antero posterior diameter of the chest about 2 3rd to 1 Count one and tw
2. UO M N pe 5 Z pue UOIS uon SIS slupe uolssiwipe sau YON siq sisouBoJd ouBeig dus 104 uoseay no jeydsoyH 24 15 UOHEZIIGEIS NNVOS 941 X9 S 10 ewo Resources and Guidelines 1 Toolkit for setting up Special Care Newborn Units Stabilization Units and Newborn Care Corners by Oo gt National Neonatology Forum amp UNICEF India Bangladesh National Neonatal Health Strategy and Guidelines 2009 Pocketbook of Hospital care for children guidelines for the management of common illnesses with limited resources World Health organization 2005 STPs by WHOCC All India Institute of Medical Sciences New Delhi Pakistan Initiative for Mothers and Newborn PAIMAN USAID JSI Philippines Protocol Tricia L Gomella M Doughlas Cunningham Fabien G Eyal Neonatology Management Procedures On Call Problems Diseases and Drugs 6 Ed Mc Graw Hill 2009 Jhon P Cloherty Eric C Eichenwald Ann R Stark Manual of Neonatal Care 6 Ed Lippincot Williams amp Wilkins 2008 Textbook of Neonatal Resuscitation 5 Ed Editor John Kattwin
3. Part 3 Newborn Care Corner A Setting up of Newborn Care Corners in the labour room and obstetric OT Labour room and obstetric OT in every facility at every level are required to have appropriate facility for providing essential care to newborns and for resuscitating those who might require it Thus Newborn Care Corner refers to the space within the labour room or obstetric OT with essential equipment and logistics for providing immediate care to all newborns B Services at the corner Newborn care corner provides an acceptable environment for all infants at birth Services provided in the Newborn care corner include e Routine immediate care at birth e Resuscitation e Provision of warmth e Early initiation of breastfeeding e Weighing the neonate e Quick baby check C Configuration of the corner e Clear floor area should be provided for in the room for newborn care corner It should be within the labour room 20 30 sq ft in size where a radiant warmer is kept e Resuscitation kit should be placed in the radiant warmer Availability of oxygen source is desirable but not essential e The area should be away from draughts of air and should have appropriate power connection for plugging in the radiant warmer D Equipment and renewables required for the corner 12 Oxygen cylinder 8 F 01 Open care system radiant fixed height with trolley drawers E 1 0 bottles 02 B
4. MANAGEMENT OF JAUNDICE Jaundice Physiological Pathological e Jaundice appears on 3rd day of e Jaundice starts on the first day of life life e Jaundice lasting longer than 14 days in e Bilirubin level rises slowly term and 21 days in preterm e Level rarely goes above 15 mg dl e Arise in serum bilirubin levels over 0 5 e Baby remains otherwise healthy mg dl hour or 10 mg di day e Jaundice clears spontaneously e Jaundice with any sign of sepsis sickness within 7 10 days of life e Jaundice extend upto palms and soles e Jaundice with pale stool e Breast feeding e Breast feeding e Thermal Care e Thermal care 2 3 e Phototherapy e Do investigation blood grouping of the baby and parents serum bilirubin total indirect and direct CBC with PBF Phototherapy e Exchange transfusion e Treat underlying cause s e Refer to a higher center Visual Inspection of neonates with jaundice Baby should be examined under good day light Jaundice visible up to 1 Face approximate bilirubin level 5mg dl 2 Umbilicus approximate bilirubin level 10 15mg dl 3 Palms and soles approximate bilirubin level 20 mg dl Phototherapy Exchange transfusion Healthy babies Babies with risk factor s Healthy babies Babies with risk factors Any visible jaundice 15 mg dL 260 10 mg dL 220 15 mg dL 260 10 mg dL 170 20 mg dL 425 15 mg dL 260 18 mg dL 310 15 mg dL 250 25 mg dL 425
5. For Newborn Care Services At Primary and Secondary Level Hospitals STANDARD PROCEDURE SOP For Newborn Care Services At Primary and Secondary Level Hospitals y World Health CB int em unicef Country Office for Bangladesh Background Bangladesh has made significant progress in child survival during the last decade Under five mortality has declined remarkably in recent years and Bangladesh is on track to achieve Millennium Development Goal MDG 4 for a two thirds reduction in child mortality by 2015 Despite this encouraging trend high rate and slow declines in neonatal mortality is one of the major concern for child survival and challenge for sustaining progress towards achieving MDG 4 An estimated 100 000 neonates die each year in Bangladesh which accounts for almost 70 of infant and 57 of under five deaths BDHS 2007 More than two thirds of the neonates who die do so within 7 days of birth and half of the them die within 24 hours of birth Infections including sepsis birth asphyxia and complications of prematurity and low birth weight are the main causes of neonatal mortality and morbidity in Bangladesh Lack of awareness regarding essential newborn care practices at home inability for early identification of danger signs of newborns and prompt referral to appropriate facility or service provider often led to fatal outcome of the neonate The Government of Bangladesh GoB is committed to achieve
6. Fluid bolus IV fluids Antibiotics Cardiac Term baby Normal at birth Age Day 3 4 Look for delayed femoral pulse murmur May need PGI Arrange referral Meconium stained term baby Age Day 1 3 At admission Fluid bolus Oxygen Arrange referral HR mt CFT sec Urine output Sensorium Temperature Core extremities ALGORITHM FOR MANAGEMENT OF NEONATAL APNEA Neonate with Apnea Emergency treatment Maintain temperature ABC Investigations BS PCV ABG Sepsis screen Na K Ca USG of head Evaluate to exclude secondary causes of apnea Apnea of prematurity Secondary cause Aminophylline Start specific 5 to 6mg kg PO or I V infused Treatment slowly over 20 minutes as loading dose Maintenance dose 2 2 5mg kg dose 12 hourly Apnea responds No response Continue till 34 weeks CPAP Stop drug if no No response Trial of apnea for 7 days Doxapram Refer for IMV sNIPPV Responds Continue for 48 hours ABC airway breathing circulation BS blood sugar PCV packed cell vol ABG arterial blood gas CPAP continuous positive airway pressure IMV intermittent mandatory ventilation sNIPPV synchronized intermittent positive pressure ventilation MANAGEMENT OF NEONATE WITH SEIZURE Neonate with seizures Secure airway and optimize breathing circulation and temperature Start 02 if seizur
7. Deliver the baby onto mother s abdomen In case of c section keep the baby next to the mother on a clean warm surface Dry the baby thoroughly If amniotic fluid is meconium stained clear mouth and then both nostrils with a mucous sucker before drying the baby Remove wet clothe and Cover the baby s head with a cap cloth Cover both mother and the baby with a warm cloth Assess color cry breathing while drying If color cry breathing is normal proceed to next steps Keep the baby skin to skin with the mother Tie clamp and cut the umbilical cord after 1 3 minutes of delivery with a sterile instrument Give a quick look to see if there is any malformations birth injury Place an identity label on the baby Help mother to initiate breastfeeding as soon as possible no later than 1 hour Weigh the baby after the first breastfeed keep baby note Preparation for Delivery Identify a helper and explain role Make an emergency plan Be prepared to act quickly to manage problems such as asphyxia Prepare the environment privacy light warmth Prepare a place for resuscitation Wash hands Prepare and check equipment Equipment and supplies Gloves Cap Two or more warm clothes Threaed cord clamp Scissors Suction device Bag amp mask Stethoscope Clock timer Weighing scale Light source 3Start Resuscitation at once if the baby is not crying breathing or if gasping ERGENC
8. 20 mg dL 340 Tips for delivering safe and effective phototherapy Protect the eyes with eye bandages Keep the baby naked with a small nappy to cover the external genitalia Place the baby as close to the lights as the manufacturers instructions allow Use white cloth or aluminum foil to reflect light back onto the baby making sure not to impede the airflow that cools the bulbs Do not place anything over the top of the phototherapy unit This may block air vents or light and items may fall on the baby Encourage frequent breastfeeding Unless there is evidence of dehydration supplementing breastfeeding with IV fluid is unnecessary Change position supine to prone after each feed to expose the maximum surface area of baby to phototherapy Keep diaper area dry and clean Phototherapy does not have to be continuous and can be interrupted for feeding clinical procedures and to allow maternal bonding Monitor temperature every 4 hours and weight every 24 hours Giving frequent feeding will prevent excessive weight loss and temperature from rising Measure serum bilirubin frequently about every 12 hours Visual assessment of jaundice during phototherapy is unreliable Change tube lights every 6 months or usage time gt 1200 hrs whichever is earlier or if tube ends blacken or if tubes flicker Criteria for referral to a higher center Jaundice appearing within 24 hours Rapidly rising serum bilirubin level gt 0 5mg hour
9. Ref OXY W UN Durable sensor for short term or long term non invasive SpO2 monitoring of all patients The tape and foam wrap are single patient use 1 x All fit adhesive sensor 0 9m extra adhesive tape included bx 10 Ref OXY AF 10 Single patient use adhesive sensor for short term or long term non invasive SpO2 monitoring 1 x Sensitive skin sensor with UN connector 0 9m bx 3 Ref OXY SE 3 Multiple patient use sensor for short term or long term non invasive SpO2 monitoring of all patients including premature infants The tape and foam wrap are single patient use 1 x Spare rechargeable battery pack Ref 6050 0006 579 Clear instructions for use diagrams for assembly in 3 languages English French and Spanish list of accessories parts Phototherapy unit w access Technical Specifications Mobile freestanding height adjustable overhead phototherapy unit be used in combination with a newborn and infant bed Sturdy and stable construction on 4 antistatic ball bearing swivel castors 2 with breaks Single head surface size approx 470x285x90mm Head height adjustable approx 1150x1600mm Blue light 4 compact fluorescence tubes CFL each approx 20 W White light 2 compact fluorescence tubes CFL each approx 15 W Tubes are protected by metal grid rradiance standard up to 35 uW cm2 Amelux with 6 blue light CFLs 43 uW cm2 Wavelength 400 to 550nm
10. do not touch anything e g hair pen or any fomite till you carry out the required job e Keep elbows always dependent i e lower than your hands e Close the tap with elbow e Dry hands using single use sterile napkin or autoclaved newspaper pieces e Discard napkin to the bin kept for the purpose If newspaper pieces discard in the black bucket e Do not keep long or polished nails Remember Rinsing hands with alcohol is NOT A SUBSTITUTE for proper hand washing Poster on hand washing should be displayed at all hand washing stations 3 Skin preparation for venepuncture and other procedures Skin preparation is an import part of asepsis routines It should be performed meticulously to avoid entry of pathogens during insertion of IV cannula pricks or procedure Always wear sterile gloves after two minutes of thorough hand washing The procedure of skin preparation is given in the box below Skin preparation for venepuncture Steps 1 Wash and dry hands Wear sterile gloves Prepare skin site confine to smallest possible area of skin Swab with alcohol first allow it to dry Swab iodine on site and allow it to dry Swab again and alcohol to wipe off iodine allow it to dry oO o Skin is now ready for puncture of prick 4 Other recommendations e Never use stock IV fluids Do not use a single dextrose saline bottle for gt 24 hours e Label the bottle with date and time of opening e After seal is removed fi
11. lt 25mg dl 1 4mmol l or if baby If blood glucose 1 4 to 2 6mmol l 4 is symptomatic asymptomatic Give a bolus of 10 glucose 2ml kg IV slowly Initiate breast feeding over 5 10 minutes Initiate breastfeeding 1 If IV line cannot be established quickly give 2 Measure blood UGG SORORIS ml kg of 10 glucose by tube If blood glucose If blood glucose Start infusion of 10 glucose at the daily lt 1 4 mmol 1 4 2 6 mmo l maintenance volume according to the baby s age Continue feeding Measure blood Measure blood glucose after 30 60 minutes and glucose in 2 3 hours then every 3 hours If blood glucose 1 4 2 6 Y If blood glucose gt 1 4 2 6 mmol l If the blood glucose is less than 1 4mmol dl repeat the bolus of glucose as above and continue the infusion If baby is receiving IV fluid for any reason continue blood glucose If the blood glucose 1 4 2 6 mmol l then continue measurements every 12 hrs for as infusion till blood glucose is 2 6 mmol l or more long as the baby requires IV fluid on two consecutive measurements 2 3 hrly If baby is no longer receiving IV fluid As a baby s feed improves slowly decrease IV measure blood glucose every 12 glucose hrs for 24 hrs Indications of IV glucose in Hypoglycaemia Inability to tolerate oral feeds Symptomatic Hypoglycemia Oral feeding can not maintain normal glucose level Glucose level lt 25mg dl 1 4 mmol L
12. All necessary materials to complete the preventive maintenance e Repetition of user and technical training for current and new hospital staff e All parts to be replaced those which are most likely to break down within the next 6 months On call corrective intervention The objective is to intervene immediately and repair limiting the downtime to the minimum Hence it includes and covers e On site visit of service engineer technician s with necessary spare parts within a specified period of notification of the malfunction e All necessary materials and spare parts to complete the repair e Availability of spare parts for the technical lifetime of the device approximately five years e Incase the device can not be repaired on site and the device is to be evacuated a similar replacement model should be provided for the period of the repair Itis recommended thatthe procurement should include installation commissioning training and maintenance contract for a reasonable period not less than 2 years as well Detailed instructions on use of open care radiant warmer phototherapy units resuscitation bags foot operated suction machine electrically operated suction machine and weighing scale are provided in Annexure 2 F Human Resources Staffing for SCANU The SCANU should have the required number of appropriately trained and qualified doctors nurses and supporting staffs There should be a designated consultant pediatrician respon
13. X E 27 Disinfectant chlorhexidine 2096 savlon betadine X E 28 Glucostix X E E Human Resource Staffing One dedicated nursing staff needs to be available round the clock for newborn care in the stablisation unit One Medical Officer skilled in newborn care or pediatrician is required for clinical care and or oversight Training Doctors and nurses posted in the stabilization unit must undergo skill based training for 5 days on Emergency Triage Assessment and Treatment ETAT and Sick Newborn Care at the designated training institute s Hands on training at medical college hospital or an equivalent facility with SCANU NICU for at least four weeks F Referral services Each unit accepting sick newborns and required to make neonatal referrals should have or have access to an appropriately staffed and equipped transport service Cost of setting up a Stabilization Unit The costs mentioned below are indicative and could vary widely Renovations and civil works TK 2 50 000 50 000 Highly variable depending on the state of the health facility Equipment and furniture TK 10 00 000 20 00 000 Capacity building Training TK 1 50 000 Average does not include the salaries of staff TK 20 25 000 Recurring or running cost per year Does notinclude the salaries of staff Consumables TK 25 000 50 000 Maintenance cost TK 30 000 Average TK 69 000
14. consideration in infection control Very deep sinks create big splashes as the water usually strikes form a distance The splashed water must be considered to be contaminated whether the sink is made of stainless steel or porcelain Very wide front to back sinks cause the hand washer to lean into the sink again contaminating clothing Countertops around sinks should also be avoided as staff and parents tend to put items on them These counters must also always be considered to be contaminated Space for pictorial hand washing instructions should be provided above all sinks e Walls adjacent to hand washing sinks should be constructed of non porous non absorbent material to prevent growth of moulds e Space should be provided for soap and towel dispensers and for appropriate trash receptacles A 4 2 3 Examination area This should include comfortable seating and allow complete visual and acoustic privacy A 4 2 4 Mother s area Comfortable seating and privacy should be provided to allow mother to breastfeed comfortably This area should have communication aides booklets in bangla so that families can learn newborn care practices A 4 3 General Support space Distinct facilities should be provided for clean and soiled utilities medical equipment storage and unit management services A 4 3 1 Clean utility holding area s Clean utility holding area should be there for storage of frequently used supplies Routinely used supplies such as
15. diapers linen cover gown charts etc may be stored in this space Space should also be provided for storage of syringes needles intravenous infusion sets and sterile trays A 4 3 2 Soiled utility holding room This is essential for storing used and contaminated material before its removal form the care area e Unless used only as a utility room this room should contain a counter and a hands free hand washing station separate from any utility sinks e Ideally the ventilation system in the soiled utility room should be engineered to have negative air pressure with all air being exhausted to the outside a simple exhaust fan can also improve ventilation in the area e The location of the soiled utility room should be as such which will enables removal of soiled materials without passing through the baby care area A 4 3 3 Charting staff work areas Along with the provision of charting space on each bedside an additional separate area or desk for takes such as compiling records completing requisitions etc should be provided Dedicated space can also be allocated for electronic medical record keeping Aclerical area in a 12 bedded SCANU should be located near the entrance to the supervise traffic into the unit e Newborns charts computer terminals and hospital forms may be located in this space e Design of the unit must anticipate use of electronic medical record devices such as computers so that their introductions does not sig
16. facility Equipment and furniture 40 00 000 60 00 000 50 00 000 Trainings 3 00 000 4 00 000 3 50 000 Sub total 58 50 000 89 00 000 73 50 000 Recurring or running cost per year does not include the salaries of staff Consumables Tk 50 000 Maintenance cost Tk 50 000 Sub total Tk 1 00 000 Stabilization Unit A Setting up of stabilization units in the Upazila Health Complex first referral facility for newborn care Every first referral unit must have clearly established arrangements for the prompt safe and effective resuscitation of babies and for the care of sick newborns Most sick newborns can be stabilised at this level B Services at a stabilisation unit A stabilisation Unit provides the following services e Provision of thermal care e Resuscitation e Monitoring of vital signs e Initial care and stabilisation of sick newborns e Care of low birth weight newborns not requiring intensive care e Breast feeding and feeding support e Referral services C Configuration of a stabilisation unit e The stabilization unit should be located in close proximity of the labour ward or OT If space is not available adjacent to labour ward OT part of the female ward may be allocated for stabilization unit e Space of approximately 200 300 sq ft 40 50 sq ft per bed is needed where four radiant warmers can be kept e Provision of hand washing and infection control s
17. heater output regulated by knob on front panel The output is displayed as or bars or bulbs e Use maximum 100 output for repaid warming of bassinet in labor room 10 minutes before delivery Reduce output to 25 75 after 10 minutes depending on ambient temperature If left on with heater output gt 80 alarm in activated within 15 or 20 minutes later there after the heater output goes to 40 if alarm is silenced the heater will kept on for another 15 to 20 minutes as per manufactures recommendation e For low birth weight or sick neonate adjust heater output depending on baby temperature e Never use full 100 heater output unsupervised e Record baby temperature every 2 4 hourly e Use this mode only for pre warming during resuscitation and initial stabilization For disinfection e For daily cleaning of front panel use damp cloth soaked in mild detergent soap water e Don t use spirit or other chemical e Bassinet cot should be disinfected daily using soap detergent solution or disinfection solution Alarms on the servo radiant warmer No alarms in manual mode Power alarm This alarms if the mains power Find alternative means for heating if power fail cannot be fixed KMC Check the fuse System This alarms if there is an error in Change WARMER needs repair the electrical electronic circuit Skin probe failure This alarm sounds if the Try to re connect the sensor correctly If this alarm temperature probe sen
18. of neonatal death review done Impact indicators 12 Case fatality rate 13 Cause specific facility mortality rate 14 Number and percentage of low birth weight in the facility 9 sonoiqnuy OW eJe2 8 OU JO pejyejnuins ueuw uo Z 39 66 10 Do 9 6 uey 19494 9 6 96 20 D0S SE uey 5591 8 seuo eJe eg p puooes uo Jeujo N 09 lt Z s H 1524 2 ue 5 1 pe ee SUOIS NAUOD 2 AIB 9102 195 ATT 3 IN pue JOJSUBI MON 5 jon 483 jew uuiq uone sua uJoqweu UNO Jo eu jo s y YON syew y eBuuosiq y Snes suBis jo ypg uuia e4 owen 15 991 4 ejduies JeuiO 8 dnojeqn Z N A sonoiqnuy 9 S JOUJJEM ul 9129 Je SsoJp
19. temperature 4 hourly and weight every 24 hours Estimate serum bilirubin frequently q 12 hourly Clinical or visual assessment of jaundice under lights becomes fallacious Change tube lights every 6 months or usage time gt 1000 hrs whichever is earlier or if tube ends blacken or if tubes flicker Monitor irradiance of the phototherapy machine once every week Use a flux meter to monitor irradiance Change light source if irradiance fall below 6 8 uw cm nm Don t place anything on the phototherapy unit this blocks air vents Caution Do not use phototherapy unit under a warmer Ensure eye patches do not obstruct nostrils For babies below 2kg preferably use phototherapy over incubator After switching on the unit check if all tubes bulbs are on Trouble shooting If unit is not switching on check the following Mains Socket change to another socket Fuse Loose contact in the plug or a damaged mains cord If any tube is flickering do the following and check Change starter of the lamp Change lamp After doing the above procedure s if the unit is still having problem call qualified technician to repair the unit Cleaning disinfection Use moist or dry cloth to clean unplugged unit Ensure the reflectors remain dust free Resuscitator self inflating bag with mask A Part Valve assembly Patient outlet Air inlet Oxygen inlet Safety valve Body of the bag B Test function Block patient outlet or
20. the Millennium Development Goal 4 by reducing under five mortality to 50 per 1000 live births and infant mortality to 31 per 1000 live births by 2015 These reductions can not be achieved without a significant reduction in neonatal mortality The commitment by the GoB to the reduction of neonatal and child mortality is also reflected in the next Health Sector Programme HPNSDP 2011 16 as a priority objective with a goal to reduce the neonatal mortality to 22 1000 live birth by 2015 The Government of Bangladesh along with its partners has therefore identified the improvement of neonatal health status as one of the key priority areas for policies programming and interventions The Ministry of Health and Family Welfare MOH amp FW has developed and approved the National Neonatal Health Strategy and guidelines in 2009 which now provides the strategic directions for neonatal health policies and programming in Bangladesh A National Action Plan for Neonatal Health has also been developed to implement the National Neonatal Health Strategy through scaling up of both home community and facility based newborn care within the preview of health sector programme The new Health Sector Programme HPNSDP 2011 16 has incorporated ambitious plan to scale up home community based essential newborn care services in 325 upazilas through community IMCI with pro vision of a post natal care visit within 2 days of delivery by a trained provider Facility based newborn
21. within the district hospital The unit should be in a distinct area within the healthcare facility with controlled access and environment e The unit should be in close proximity to the labor room e f obstetric and neonatal service units are on different floors quick access like a ramp or an elevator should be available e Transport of newborns within the hospital should be possible without using public corridors It should provide effective movement for staff family and equipment A 2 2 Size projected bed demand of the Unit As a general guide for all deliveries occurring within the health facility three beds for every 1 000 annual deliveries may be dedicated to the newborn care unit This demand is for intramural deliveries those occurring within the hospital Additionally for newborns delivered outside the hospital extramural and being brought to the hospital for special care an extra allowance of 50 per cent of the estimated beds should be considered For example if a hospital conducts 3 000 deliveries per year the number of beds required would be e For intramural 3 1000x 3000 9 beds e For extramural 50 9 4 5 4 5 beds e Total beds required 13 14 No patient whether intramural or extramural should be refused admission into the unit if any bed is available It is universally felt that units providing special care should have a minimum of eight beds and a maximum of 16 beds A unit with fewer beds become availab
22. ANING AND DURATION OF ANTICONVULSANT THERAPY Newborn on anticonvulsant therapy Taper all antiepileptic drugs except phenobaritone once seizure is controlled Perform neurological examination prior to discharge after 7 days of seizure free period Normal Abnormal Stop phenobarbitone Continue phenobarbitone for prior to discharge 1 month Repeat neurological examination at 1 month Abnormal examination Normal Examination Evaluate EEG Taper drugs over 2 Normal EEG Abnormal EEG continue weeks Taper drugs drugs Seek advice from a pediatric neurologist Maintenance therapy If convulsions recur within two days of initial control give phenobrbital 5 mg kg body weight once daily until the baby has not had a convulsion for seven days If convulsions recur after two days repeat treatment with phenobarbital as described for initial management of convulsions and follow with phenobarbital maintenance therapy as above TRANSPORT OF A SICK BABY Determine if there is a genuine indication to transport the baby to higher health facility Birth weight lt 1200 gm gestation lt 30 wk Severe respiratory distress Shock not responding to fluid boluses and vasopressors Severe jaundice needing exchange transfusion Major congenital malformations e g meningomyelocele Refractory seizures Abdominal distension with bilious vomiting Making the baby S T A B L E before transport Secure IV line and gi
23. Integrated electronic timer 1 to 59 min with automatic shut off at time elapse Total run hour timer for replacement of the lamps after 2 000 hours Therapy timer with zero reset button to count the therapy hours separate from the total run hour timer Power requirement 220 V 50 Hz Power consumption approx 108 W Supplied with 2 x Spare blue light tubes 20W Ref 99 02 682 1 x Spare white light tube 15W Ref 99 02 683 1 x Set of fuses Ref T2 5A set of 5 pieces Standard included German English available also French and Italian Thermometer max min Filled with mercury alternative thermometer to measure ambient temperature Double scale min and max and current temperature With reset button Range 30 C to 60 C Graduation 1 C Sturdy plastic construction Annexure 3 Instructions for equipment and use Radiant warmer High Ensure that the temperature of the room is 22 C Place the warmer away from air currents Clean the mattress and platform and cover the mattress with clean linen sheet When it is known beforehand that a baby is to arrive in the newborn unit turn of the warmer at least 20 minutes prior to pre warm the linen and mattress so that the baby does not lie on a cold surface initially Read temperature on display Adjust heater output to If baby temperature is below 36 C Medium If baby temperature is between 36 36 5 C and to Low If baby temperature is be
24. Quick identification and protection hygiene identify danger prompt referral signs FWC Newborn Care corner in labour rooms Prompt referral Upazila Health comlplex Newborn care corner in labour rooms Newborn Stabilisation Unit First referral Unit and in operation theatre OT District Hospital Newborn care corner in labour room and Special Care Newborn OT Unit Part 1 Special Care Newborn Unit A Setting up of a special Care Newborn Unit SCANU at District Hospital The following principles are applicable for setting up an SCANU in a District hospital or in an equivalent facility While many of these specifications are minimums the intent is to optimize resources and facilitate quality health care for the newborns A 1 Services at the unit The configuration of the SCANU at the district level should be such that it supports delivery of the necessary quality services and has the potential to expand in order to accommodate increased demand The SCANU at the district hospital is expected to provide the following services e Care at birth including resuscitation of asphyxiated newborns e Managing sick newborns except those requiring mechanical ventilation and major surgical intervention e Post natal care e Follow up of high risk newborn e Referral services In addition the unit should also provide training to medical doctors and paramedics on newborn care A 2 Location and size of the unit A 2 1 Location
25. Stethoscope measuring taps thermometer swabs BP cuffs probes of Radiant warmer Incubator pulse oximeter Clean with sprite Daily Laryngoscope Clean with spirit swab thorough daily and after each use If used for an infection baby wash with soap and water Put the blade in 2 gluteradehyde warp in autoclaved cover and mark date on the cover Oxygen hood Wash soap amp water Daily dry with clean linen Face mask Clean with soap and water immerse gluteradehyde for 20 min rinse in distilled running water dry and warp with autoclaved Daily and after each use resuscitation bag and reservoirs oxygen tubing bottle and tubing of suction machine Clean with soap and water after dismantling Immerse in gluteraldehyde for 4 6 hours Rinse in distilled water Dry Weekly for resuscitation bag and reservoir Daily for others Use savlon for suction bottles Change daily wrap in autoclaved lined and put a date Weighing machine Wipe with 296 Bacillocid Daily morning shift and when required Radiant warmer and incubator Clean with soap water daily if Daily occupied If unoccupied clean with 296 Bacillocid Color coded disposal drums bags The following are the different colour drums with different colour polythene for different types of waste to be disposed of in a different way a Black drums bags Left over food fruit feeds ve
26. Treat according to PLAN Dehydration Lethargy If two signs e Sunken eyes positive e Very slow skin pinch Severe For all newborns displaying emergency signs e Manage airway e Make sure neonate is warm e Provide the treatment as above e Draw blood for emergency investigations Glucose calcium sepsis screen e Check and correct hypoglycemia e Treat cause STEPS OF MANAGEMENT OF THE NEONATES WITH PRIORITY SIGNS TRIAGE Check for emergency signs If absent Check for priority signs or conditions If present T e HISTORY AND EXAMINATION e LABORATORY AND OTHER INVESTIGATIONS if required List and consider DIFFERENTIAL DIAGNOSES Select MAIN DIAGNOSIS and secondary diagnoses Plan and begin INPATIENT TREATMENT including supportive care y MONITOR for e Complication e Response to treatment Not improving or new problem complication Improving REVISE TREATMENT Continue treatment TREAT COMPLICATIONS COUNSEL and Refer if indicated PLAN FOR DISCHARGE DISCHARGE HOME Arrange continuing care or FOLOW UP at hospital or at home ALGORITHM FOR NEONATAL RESUSCITATION Prepare for birth Birth A If meconium clear airway Dry thoroughly Crying Crying Not crying a 3 S Clear airway Stimulate 9 nS Breathing Keep warm E Check breathing Breathing well Not breathing Cut cord Cut cord Breathing 4
27. Y TRIAGE ASSESSMEMT AND TREATMENT ETAT Look for following emergency signs e Severe hypothermia temp lt 32 C cold to touch abdomen e Apnea or gasping respiration e Severe respiratory distress respiratory rate 2 60 min severe chest indrawing grunting e Central cyanosis e Shock capillary refill time CRT longer than 3 seconds and weak and fast pulse e Coma or convulsing now Present Absent Look for following priority signs Initiate emergency Priority cases 2 Treatment until LBW babies 1800gms Stable e Cold stress moderate hypothermia e Respiratory distress rate 260 min no retractions grunting e Irritable lethargy e Refusal to feed e Abdominal distension e Significant jaundice yellow palms and soles e Severe pallor e Bleeding manifestations e Major congenital malformations Present Manage as per Priority sign Algorithm Triage is the process of rapidly screening sick newborn soon after their arrival in hospital in order to identify those with emergency signs who require immediate emergency treatment those with priority signs who should be given priority while waiting in the queue so that they can be assessed and treated without delay non urgent cases who have neither emergency nor priority signs By triaging patients are sorted into priority groups according to their need s and the resources available Absent Non urgent cas
28. adequacy of suction pressure Don s e Do not do vigorous and deep suction e Troubleshooting e Check for leakage in the bottle tubing e Incase fluid jar cannot be emptied immediately when full to prevent overflow of fluid into the bellows open the alternate suction inlet No suction pressure will be created even if bellow is compressed Maintenance e Check for adequacy of suction pressure e Change tubing if leaky or broken Suction matching Electric Parts e Motor e Vacuum gauge with precision regulator e Suction bottles e Suction catheter e Suction tubing Working e Connect to mains e Switch on the unit and occlude distal end to check the pressure Ensure it dose not exceed 100cm of water e Take disposable suction catheter e Connect to suction tubing e Perform suction gently e Switch off the suction machine Cleaning amp Disinfection e Wash suction bottle with soap amp water e Change bottle solution every day Do s e Suction gently e Maintain asepsis during the suctioning procedure e Use only disposable suction catheters e Check adequacy of suction pressure Don ts e Do not do vigorous and deep suction Maintenance e Check for adequacy of suction pressure e Change tubing if leaky or broken Weighing machine Electronic Parts e Pan or baby tray e Weight scale display e Machine proper Working e Putona firm even surface Wipe clean the weighing pan e Plug on and wait till
29. ag and Mask neonate 250 500ml E 1 03 Scale baby electronic 10kg lt 5g gt E 1 04 Pump suction foot operated D 1 05 Room Thermometer E 1 06 Light examination mobile 220 120 V D 1 07 IV Cannula 24 G 26 E 08 Extractor mucus 20ml ster disp Dee Lee E 09 Towels for drying and wrapping the baby E 10 Sterile equipment for cutting and tying the cord E 11 Tube feeding CHO7 L40cm ster disp E D E 13 Sterlie Gloves E Human Resources Staffing One medical officer staff nurse is desirable in addition to the one conducting the delivery or assisting C section to provide appropriate care at birth Training All staff posted at the labor rooms should be trained in providing essential care at birth and basic resuscitation Delivery room management of newborn Doctors and nurses working at the labor rooms OT should also have 5 days skill based training on Emergency Triage Assessment and Treatment ETAT and Care of Sick Newborn F Cost of setting up newborn care corner The following costs are indicative and may vary widely Equipment and furniture Tk 5 00 000 Tk 20 000 Tk 5 20 000 Capacity building Sub Total Consumables Tk 5 000 Maintenance cost Tk 10 000 Sub Total Tk 15 000 Summary 1 This document provides specific guidance for setting up newborn care services for different level of health services facilities e All health facilities where deli
30. al intervention instructions in English List of priced accessories List of priced spare parts Syringe pump 10 20 50 ml elec 220V Digital and self regulating volume controlled portable syringe pump Can be mounted on standard bed wall rail or mobile pole stand supplied with fixation Suitable for all intravenous and intra arterial infusions Continuous volumetric delivery with syringes 10 20 and 50 ml Open system suitable for different brands of syringes Programmable user entry infusion volume and time or flow rate Rate adjustable 1 to 999 ml h steps of 1 ml h Accuracy ca 1 96 of total volume delivered With occlusion detection and alarm Display reports systems errors end of infusion and built in battery status Audio visual alarm with silencing feature for audio alarm Automatic switch from mains to batteries in case of power failure Power requirements 220 V 50 Hz or internal re chargeable battery autonomy approx 6 hrs automatic recharge Power consumption 50W Device is produced by ISO 9001 certified manufacturer Certificate to be submitted Device is safety certified according CE 93 42 FDA 510k or equivalent Certificate to be submitted Supplied with 1 x spare battery 1 x spare set of fuses User manual with trouble shooting guidance in English Technical manual with maintenance and first line technical intervention instructions in English List
31. areas such as close proximity of the staff charting area to infant beds the design should nevertheless permit separate light sources with independent controls so the very different needs of sleeping infants and working staff can be accommodated to the greatest possible extent Care must be taken however to ensure that bright light from these locations does not reach an infant s eyes A 6 4 Day lighting At least one source of daylight be visible from baby care areas either from each room itself or from an adjacent staff work area When provided external windows in the rooms should be glazed to minimize heat gain or loss and should be situated at least two feet 0 6 metres away from any part of a newborn s bed to minimize radiant heat loss Placing newborns too close to external windows can cause serious problems with radiant heat loss or gain and glare Therefore provision of windows in the unit requires careful planning and design A 7 Ambient temperature and ventilation A 7 1 Temperature The unit should be designed to provide an air temperature of 78 8 F to 82 4 F 26 28 C A 7 2 Ventilation Ventilation in the unit should inhibit particulate matter from moving freely in the space in the space and to minimize drafts on or near the newborn beds General ventilation can be provided in two ways i exhaust only and ii supply and exhaust Exhaust fans pull stale air out of the unit while drawing fresh air in through ca
32. care services will also be strengthened through establishing Special Care Newborn Unit SCANU in the district hospitals and Newborn Stabilization Unit NSU in the Upazila Health Complexes UHCs MOH amp FW has planned to scale up SCANUs in 59 district hospitals and NSUs in 275 UHCs MCWCs by 2016 for the management of sick newborns In this backdrop Directorate General of Health Services DGHS of MOH amp FW has formed a Technical Committee on Standard Operating Procedure for Newborn Care Services was formed with representation from GOB managers Service Providers Professional bodies Clinicians and Development Partners A draft SOP was prepared by the technical sub committee and was shared in a national consultation workshop on 8 October 11 which was participated by relevant GOB programme managers experts professionals and development partners The final draft Standard Operating procedures SOP for Newborn Care Services for the Primary and Secondary Level facilities was then up loaded in the web site of DGHS to elicit public expert opinion The final draft Sop was then endorsed by the National Core Committee on Neonatal Health NCC NH and approved by the MOH amp FW It is envisaged that this SOP will help and guide the managers and service providers in provisioning of necessary infrastructure equipment logistics as well as skills required to ensure quality newborn care services at the primary and secondary level facilities as per WHO
33. e Measure baby s e Measure baby s e Sepsis if present temperature every hour temperature every 30 e Re warm ata rate of e Once temperature is minutes 1 2 C hour normal measure every e Once temperature is Oxygen IV fluids warm three hours for 12 hours normal measure every Injection Vitamin K1 mm Measure baby s temperature every 30 minutes e Once temperature is normal measure every three hours for 12 hours three hours for 12 hours Temperature measured by keeping the bulb of the thermometer in the axilla for 3 5 minutes Preterm lt 32 weeks or in whom full enteral feeds cannot be started START on Minimal Enteral Nutrition MEN 10 15mL kg Except Severe hemodynamic instability suspected or confirmed NEC perforation or ileus Increase 20 30mL kg daily STOP if aspirate is gt 3mLor bilious blood stained GRV gt 25 2 i Deduct the same amount from the total daily fluid requirement FLUID THERAPY IN NEONATES Preterm 60mL kg 60mL kg Day 1 Daily increment Daily increment 10 15 mL kg 15 20 mL kg 90mL kg 100mL kg Day 3 Potassium Potassium 2mmoL kg 2mmoL kg 150mL kg 150mL kg Potassium Potassium Day 7 2mmoL kg 2mmoL kg Composition of IV fluid Day 1 2 5 10 Dextrose in aqua Day 2 onwards 5 10 Dextrose in 0 225 sodium chloride Day 3 onwards Potassium 2mmoL kg day Inj potassium 1 ml 2 mmol Addition of
34. ed the milk already taken before giving any more When the infant has had enough he or she will close his or her mouth and will not take any more Do not force feed the infant Wash the cup with soap and water and then put in boiling water for 20 minutes to sterilize before next feed Steps Before starting a feed check the position of the tube Take a fresh syringe ideally a sterile syringe should be used and remove the plunger Connect the syringe to the inflow end of the gastric tube Pinch the tube and fill the barrel of the syringe with the required volume of milk Hold the tube with one hand release the pinch and elevate the syringe Let the milk run from the syringe through the gastric tube by gravity DO NOT force milk through the gastric tube by using the plunger Control the flow by altering the height of the syringe Lowering the syringe slows the milk flow raising the syringe causes the milk flow faster It may take about 10 15 minutes for the milk to flow into the infant s stomach Stop tube feed if the infant shows any of the following signs during feeding breathing difficulty change in colour looks blue becomes floppy or vomits Cap the end of the gastric tube between feeds if the infant is on CPAP the tube is preferably left open after about half an hour 12 DO NOT flush the tube with water or saline after giving feeds MANAGEMENT OF HYPOGLYCEMIA Blood glucose ii aa 2 6mmol l If blood glucose
35. element Ref HE 1 x Set of spare fuses Clear instructions for use diagrams for assembly in English Radiant warmer fixed height stand Mobile fixed height radiant warmer Antistatic castors 2 with breaks Hood integrates heating element and overhead light Overhead light 2 x 50W halogen spot with dimming function Heating element emitter with parabolic reflector and protected by metal grid Control unit allows air and skin temperature preset LED indicator and drives radiant heater output servo and manual Integrated timer 1 to 59 min with count up and count down feature Temperature range skin 34 to 38 C user pre settable Monitoring of skin temperature by means of sensor range 30 to 42 C Heater output 0 to 100 in increments of 5 Control unit audiovisual alarms according to timer and temperature presets avoiding overheating Display reports systems errors sensor failure Power requirement 220 V 50 Hz Power consumption 800 W Device is produced by ISO 9001 certified manufacturer Certificate to be submitted Device is safety certified according CE 93 42 FDA 510k or equivalent Certificate to be submitted Supplied with 1 x skin temperature probe including connection cable 1 x spare skin temperature probe including connection cable 1 x spare heating element 1 x spare set of fuses User manual with trouble shooting guidance in English Technical manual with maintenance and first line technic
36. es e Non pathological Jaundice e Developmental peculiarities e Superficial infections e Transitional stools e Minor birth trauma e Minor malformations These neonates are not categorized as emergency or priority cases ASSESSMENT AND TREATMENT OF NEWBORNS DISPLAYING EMERGENCY SIGNS Signs Assess for emergency signs Treat emergency In all cases Temperature Cold to touch Abdomen Rewarm hypothermic babies If Positive Rapidly rewarm if there is sever hypothermia lt 32 C upto 35 C and then gradually rewarming e Make sure neonate is warm Airway And Not Breathing or gasping or Breathing Central cyanosis or e Severe respiratory distress e Manage airway Respiratory rate gt 70 min e Provide tactile stimulation if apneic Severe lower chest indrawing ei e If still apneic or gasping Provide PPV Apneic spells e Give oxygen Grunting e Make sure neonate is warm Unable to feed Give oxygen Insert IV line and give 20 ml kg Normal Saline over 20 min Circulation Capillary Refill Time longer than 3 seconds If Positive e Weak and fast pulse gt 160 Proceed immediately to full assessment and treatment Make sure neonate is warm Convulsion Convulsions Manage airway If Give oxygen Convulsing Check amp Correct hypoglycemia Give anticonvulsant Give IV Calcium Make sure neonate is warm Any of the two signs
37. es are continuous Secure IV access and take samples for baseline investigations including sugar calcium sodium potassium sepsis screen if possible If hypoglycemic blood sugar 45mg dl 2ml kg of 10 dextrose should be given immediately For further management see hypoglycemia protocol If seizures persist start phenobarbitone 20mg kg stat over 20 minutes Brief history and quick clinical examination Seizures continue Seizure stops Repeat phenobarbitone 10mg kg dose till a Treat the total of 40mg kg including the loading dose underlying cause If seizure continues Start phenytoin 20mg kg dose If seizure continues Repeat phenytoin 10mg kg dose If seizure continues Repeat phenytoin 10mg kg dose If seizure continues Consider midazolam 0 05 0 15mg kg dose every 2 4 hrly infuse over 15 minutes Seizures Jitteriness Have both fast and slow components Slow movements 1 3 jerks per second Rhythmic movements 4 6 per second tremors are of equal amplitude Often associated with eye movements tonic deviation or fixed stare and or autonomic changes changes in heart rate Not associated with eye movements and or autonomic changes Not provoked by stimulation Provoked by stimulation Does not stop with restraint Stops with restraint Neurological examination often abnormal Neurological examination usually normal FLOW DIAGRAM ON WE
38. ewborn Annexure Annexure 1 Asepsis and Housekeeping Protocols 1 Basics 1 1 Basic requirements for asepsis in a baby care area Running water supply Soap Elbow or foot operated taps Strict hand washing Avoid overcrowding optimal number of nurses for care of more babies Plenty of disposables Rational antibiotic policy Obsession with good housekeeping and asepsis routines Guidelines for ENTRY in the baby care area Remove shoes socks woolens watch bangles and rings Roll up the sleeves up to elbow Put on the earmarked slippers wash hands with soap and water for two minutes follow six steps of hand washing Put on sterile half sleeve gown Personnel with active infection should not be allowed entry into the baby care area 1 2 1 3 Sterile gloves Always use sterile gloves for invasive procedures like sampling starting intravenous lines giving intravenous injections etc Wash gloved hands to remove the blood stains and secretions Remove gloves and put in the polar bleach bucket Wash hands again with soap and water Used gloves should be cleaned dried powdered and packed in paper e g a piece of newspaper for re autoclaving Adequate number of pairs should be prepared every day Once can use disposable gloves if available Full sleeve gowns and masks Use them for all invasive procedures e g lumbar puncture blood exchange transfusion etc 1 4 Other basics Keep separate sp
39. gen cylinder with flow meter Adhesive tape nasal catheter or face Sterile gloves k iis Antiseptic solution and Stethoscope cotton wool balls t nr Napkins diapers Asource of light f the baby is able to feed and the mother is not accompanying the baby carry expressed breast milk Rm e een EY icddr b Austraion Government T Save the Children
40. getables waste paper packing material empty boxes bags etc This waste is disposed of by routine municipal machinery b Yellow drums bags Infected non plastic waste e g human anatomical waste blood baby fluids placenta etc This type of waste requires incineration c Blue drums bags Infected plastic waste such as used disposable syringes needles first destroyer the needle in the needle destroyer Used sharps blade and broken glass should be discarded in puncture proof containers before discarding patients IV set BT set Et tube catheter urine bag etc Should be cut into pieces and disposed of in blue bag This waste will be autoclaved to make it non infectious This is then shredded and disposed of Annexure 2 Specifications of Newborn Care Equipment Table resuscitation newborn w access Technical Specifications Mobile newborn resuscitation table with radiant warmer Sturdy and stable construction on 4 antistatic ball bearing swivel castors 2 with breaks Two side handles facilitate positioning Table surface 0 75 x 0 60 m w x Side panels in transparent acryl drop down and lockable With 2 storage drawers under table surface Integrated support for two 10 L oxygen bottles Side rails to the table surface allows for mounting of accessories Fixed height hood above the table integrates heating element and overhead light Vertical column integrates controls and displa
41. global standards SECTION I Description of Newborn Care facilities at different levels Description of Newborn Care facilities at different levels Special Care Newborn Unit SCANU The Special Care Newborn Unit SCANU is a neonatal unit in the vicinity of the labour room that provides care to all sick newborns except for those requiring assisted ventilation or major surgery Details of services provided and requirement for equipment supplies training and human resources are available in Part 1 Newborn Stabilization Unit NSU The Neonatal Stabilization Unit is a facility within or in close vicinity of the maternity ward where most sick and low birth weight newborns can be taken care of All First Referral Units need to have a newborn Stabilization Unit in addition to a Newborn Care Corner Details of services provided and requirement for equipment supplies training and staffing are available in Part 2 Newborn Care Corner This is a space within the delivery room where immediate care is provided to all newborns This area is MANDATORY for all heath facilities where deliveries take place Details of services provided and requirement for training equipment and supplies are available in Part 3 The following table summarizes the required newborn care facilities at different levels Table 1 Newborn care facilities at different heath care levels Community Clinics Essential care Breast feeding thermal
42. h require high low voltage uninterrupted electric supply B 2 Renewables for SCANU Adaptor connector Meconium aspirator disposable for suction pump Glucostix Lancet safety sterile single use PAC 200 1 8mm Mask surgical disposable box 100 Cord clamp disposable set of 10 Extractor mucus 20ml ster disp 2 3 4 51 Cap surgical disposable box 100 6 7 8 Tube suction CH10 L50cm ster disp 9 Tube suction CH14 L50cm ster disp 10 Tube feeding CHO5 06 07 08 ster disp 11 Syringe dispos 1ml ster BOX 100 12 Syringe dispos 2ml ster BOX 100 13 Syringe dispos 5ml ster BOX 100 14 Syringe dispos 10ml ster BOX 100 15 Syringe dispos 20ml sterile BOX 80 16 Syringe dispos 50ml sterile BOX 80 17 Needle disp 23G 0 6x25mm ster BOX 100 18 Needle disp 25G 0 5x16mm ster BOX 100 19 Needle scalp vein 23G ster disp 20 Needle scalp vein 25G ster disp 21 Cannula 24G 22G ster disp 22 Gloves exam latex medium disp BOX 100 23 Gloves surg 6 7 ster disp pair 24 Infusion set pediatric with chamber 100ml ster disp 25 Cotton wool 500g roll non ster 26 Compress gauze 10x10cm n ster PAC 100 27 Compress gauze 10x10cm ster PAC 5 28 Connector 3 way stop cock valve ster disp 29 Disinfectant chlorhexidine 20 30 Disinfectant bleach perce
43. hould be in place e The stabilization unit should be separated from the labor female ward by partitions Aluminum and glass to prevent cross infection D Equipments and renewables required for a stabilization unit 4 6 Bed 1 Open care system radiant warmer fixed height with trolley drawers 2 E 0 bottles 2 Open care system radiant warmer fixed height with trolley drawers 2 E 3 Bag and Mask hand operated neonate 250 500ml 2 E 4 Scale baby electronic 10kg lt 5g gt 2 E 5 Pump suction foot operated 1 E 6 Thermometer clinical digital 10 E 7 Light examination mobile 220 12v 2 E 8 Stand infusion double hook on castors 4 E 9 Phototherapy unit single head high intensity 2 E 10 Pump suction portable 220V w access 2 E 11 Stethoscope neonate 6 E 12 Glucometer 2 D 13 Tape measure vinyl coated 1 5m 6 E 14 Infantometer plexi 372ft 105cm 1 E 15 Hub cutter syringe 1 D 16 Room thermometer 1 E 17 Oxygen hood S and M set of 3 each including connecting tubes 2 D Renewable Resources 18 IV cannula 24G 26 G X E 19 Microburette E 20 Extractor mucus 20ml ster disp Dee Lee X E 21 Tube feeding CHO5 CHO6 CHO7 ster disp X E 22 Oxygen cylinder 8F X E 23 Sterile Gloves X E 24 Syringe disp 1cc 3cc 5cc 10cc 20cc 50cc 25 Tube suction CH 10 L50 cm ster disp X E 26 Cotton wool 500g roll non ster
44. it for Setting up Special Care Newborn Unit B Equipment and renewables for SCANU B 1 Equipment TE ee ei i o aie 2 ri radiant warmer fixed E 4 X x Radiant warmer fixed height stand E 2 X X X Basinet on trolley neonatal with mattress E Phototherapy unit single head high intensity E X X X 6 in n mask penguin sucker neonate 250 E 6 X Us Laryngoscope set neonate E 2 X 8 Pump suction portable 220V w access E 2 X X X 9 Pump suction foot operated E 2 X 10 Surgical instrument suture Set E 2 11 Syringe pump 10 20 50 ml single phase E 2 X X X 12 Oxygen hood S and M set of 3 each E 6 including connecting tubes 13 Thermometer clinical digital 32 43 C E 20 14 Scale baby electronic 10 kg 5g E X X x 15 Pulse oxymeter bedside neonatal E X X x 16 Apnoea monitor D 3 live Stethoscope neonate E 12 18 Sphygmomanometer neonate electronic E 2 X X 19 Light examination mobile 220 12V E 3 X X 20 sob nude benchtop upto 12000 D 4 X X X 21 Photometer Hb estimation D 1 X X 22 Hub cutter syringe D 2 X 23 Tape measure vinyl coated 1 5m E 6 24 Tray kidney stainless steel 825ml E 8 25 Tray dressing ss 300x200x30mm 26 Stand infusion double hook on castors E 10 27 X Ray mobile D 1 X X X X 28 Glucometer E 2 X X Neonatalie Co
45. kel MD FAAP American Academy of Pediatrics and American Heart Assocoation 2006 10 Essential Newborn Nursing for Small Hospitals 2 Ed Editor Asoke Deorari Division of Neonatology Department of Pediatrics AIIMS New Delhi 2009 SECTION Il Management Protocols for Newborn Care HAND WASHING Wet hands up to wrists Apply soap make thick leather 1 Rub hands palm to palm 2 Right palm over dorsum of the left with interlaced fingers and left over the right A 3 Palm to palm with fingers interlaced 4 Backs of fingers to opposing palm fingers interlocked and vice versa 5 Rotational rubbing of left thumb 6 Rotational rubbing backwards and clasped in right palm and vice versa forwards with clasped finger tips of right hand in left palm and vice versa Rinse hands thoroughly with running water Air dry or dry with a single use towel Types of hand washing e Hand washing with soap and running water e Hand washing using alcohol based hand rub Norms for Hand washing e 40 60 second hand wash with soap and water in 6 steps has to be done before entering the neonatal ward Then wash hands with hand rub for 20 30 seconds before and after touching each baby For hand rub take a cupped palm full of alcohol based solution and follow the same six steps ALGORITHM FOR IMMEDIATE OR ROUTINE CARE AT BIRTH Steps of Routine Immediate Care
46. le and with more than 16 beds becomes unwieldy However an on site assessment of needs and review of available resources is advisable to determine the size of the unit Consideration of factors such as availability of resources management capacity technology and maintenance of a minimum level clinical experience point towards a minimum capacity of 10 to 12 beds Part 1 A 3 Minimum space requirements Each newborm space shall contain a minimum of 100 square feet 9 9 square metres of clear floor space excluding hand washing stations and columns The 100 sq ft per bed of space should be utilized as follows e Baby care area 50 sq ft per bed e General support and ancillary areas 50 sq ft per bed Part 1 A 4 Configuration of the unit The SCANU design should be driven by a systematic plan of space utilization projected bed space demand staffing requirements and other basic information related to the unit Opinions are too divergent on what is the best design for a unit that will satisfy all requirements The ideal design should provide constant surveillance of each bed area form the nurse s station with minimal walking distance for the staff the design should allow for flexibility and creativity to achieve the stated objective A 4 1 Baby care area The baby care area may be divided into two interconnected rooms separated by transparent observation windows with the nurses work place in between This facilitates temporary closure of
47. lighting Perception of skin tones is critical in a SCANU light sources should provide accurate skin tone recognition Light sources should be as free as possible of glare or veiling reflections No direct view of the electric light source or sun shall be permitted in the newborn spaces this does not exclude direct procedure lighting as described below Any lighting used outside the baby area shall be located so as to prevent any newborn s direct line of sight to the fixture Lighting fixture should be easily cleaned A 6 2 Procedure lighting in baby care areas Temporary increases in illumination necessary to evaluate a baby or to perform a procedure should be possible without increasing lighting levels for other babies in the room Since intense light may be unpleasant and harmful to the developing retina every effort shout be made to prevent direct light from reaching an infant s eyes Procedure lights with adjustable intensity field size and direction can help protect an infant s eyes from direct exposure and provide the best visual support to staff Procedure light that comes inbuilt with radiant warmers is often sufficient for procedures and no separate lights are required A 6 3 Illumination of support areas Illumination of support areas within the SCANU including the charting area medication preparation area reception desk and hand washing area should be adequate In locations where these functions overlap infant care
48. mask by palm of your hand Squeeze the bag 1 You should feet pressure against your hand u With higher pressure one can open pop off safety valve C Procedure Choose appropriate size of the bag and mask Position the baby in a sniffing position Slight extension Provide tight seal Use finger tips to generate enough pressure to move the chest of the baby observe for improvement in heart rate colour and chest movement Follow ate rhythm Squeeze two three to ensure 40 to 60 breathes per minute For prolonged bag and mask insert at orogastric tube and then continue bag and mask Do not use bag and mask for suspected diaphragmatic hernia and babies born through meconium stained amniotic fluid D Decontamination i Washing and rising Dissemble parts e Wash in warm water using as detergent e Rise in clean water ii Disinfection Sterilization Except reservoir whole bag can be boiled autoclaved or soaked in disinfectant clean with distilled water or running water Dry the valves and then reassemble Suction Machine Foot operated Parts e Suction catheter e Suction tubing e Suction bottles Using the foot suction 1 Connect suction catheter to patient end of silicone tubing of machine 2 Place the foot suction on floor across and in front of resuscitation trolley with bellows on right side if you use your right foot and fluid collection jar o left side 3 Ensure that foot suction is close to resuscitation trolley s
49. mplete Light Neo Natalie 29 Newborn Simulator Bag amp Mask Penguin D 4 X sucker General Equipment and supplies 30 IPS 25 50 KVA E 1 X X 31 Room Heater E 4 X 32 Computer with printer with accessories E 1 X X X 39 Wall Clock E 1 34 Gowns for staffs and mothers E 20 X X X 35 Washable Slippers shoe rack E E n X X 36 Liquid soap dispenser with Hand dryer E 1 37 Ain Conditions 1 5 2 ton E 1 X X X XX 38 Refrigeretor hot zone 110L E 1 X X 39 Washing machine E 1 X X x e Depending on the priority of services the listed items are classified as essential designated as E those must be available and desirable designated as D these could be available if resource are available For each of the items it has been identified whether installation commission and training is necessary e Equipment which has potential implication on civil mechanical and electricial systems of the unit are also identified in the list a Civil implications Equipment that has implications on the physical structure of the unit building such as item that are wall or ceiling mounted b Mechanical implications Items that have implications for the mechanical infrastructure such as items require hot cold water supply oxygen supply etc c Electrical implications Items that have implications for the electrical installation of the unit such as equipment whic
50. nificantly disrupt functions of the unit or impinge on the space designed for other purpose A 4 3 4 Linen washing laundry area If laundry facilities are not provided a separate laundry room can serve the functions of laundry Space should accommodate a washing machine with dryer which promotes the efficiency and effectiveness of the aseptic cleaning process A 4 4 Staff support space Space should be provided within the unit to meet the professional personal and administrative needs of the staff e These areas include doctors duty room nurses changing room etc e Rooms should be sized and located to provide easy access to the SCANU A 4 5 Step down area rooming facility An additional five bed step down area where recovering neonates can stay with their mothers before discharge is of added advantage to a SCNU This will relive the pressure on the SCANU to some extent However it depends on the availability of adequate space in the facility The additional space requirement should be about 40 50 sq ft per bed the space can be within the SCANU or in the vicinity or in the postnatal ward A 5 Electrical and mechanical needs Electrical and mechanical requirements of each newborn bed should be organized keeping in mind the safety easy access and ease of maintenance A 5 1 Electrical Needs Power supply The unit should have 24 hours uninterrupted established power supply Back up power supply is a must with one or two ou
51. ntage M TTL FTH FTH ITE ITE ETE ITI TH FTH FTH TI ITI TI TI ITI ITI ITI 31 Disinfectant handsoap E 32 Antiseptic betadine 33 Tape adhesive micropore 2 0 2 5cmx5m 34 Scalpel blade ster disp no 22 box of 100 E 35 Blood transfusion set D 36 Nasal prongs disposable neonate set of 3 D 37 Paper sheets crepe for sterilisation pack D 38 Tape adhesive for sterilization pack D C Technical specifications of the equipment Generic specifications of the medical devices need to be standardized taking into consideration the following perspectives e Functional services available in the unit e Capacity of the user in handling the equipment e Capacity of the facility for civil mechanical and electrical implications e Capacity for maintenance e And above all technical integrity and safety of the equipment as per defined standard Detail specifications of the newborn care equipment for SCANU are provided in Annex 2 D Asepsis and housekeeping protocols Maintenance of asepsis is extremely critical in newborn care units It requires laying down of clear housekeeping protocols and following them stringently Details of asepsis and housekeeping protocols are mentioned in Annexure 1 E Annual maintenance requirement for critical equipment Amechanism for maintenance of critical newbo
52. o and three and four and give ventilation when counting four and Continue the cycles for 30 seconds and evaluate color breathing and heart rate to take the next action on the basis of your findings Drugs Injectable adrenaline 1 1000 sol Mix 1ml with 9 ml of distilled water to make a 1 10 000 dilution Give 0 1 0 3 IV Additional Drugs Injectable dextrose 10 Give 2 4 IV Injectable naloxone 0 4mg ml Give 0 5ml kg if labouring mother received opiate within 4 hours of delivery 5Harmful resuscitation practices Slapping the baby on the back Hanging upside down by the feet Milking the cord Routine suction of baby s mouth and nose Throwing cold water on the baby s face amp body Giving glucocorticoid injections Blowing into the ears and nose Stimulating the anus Squeezing the rib cage Heating the placenta Dipping the baby s cord alternatively in hot and cold water Bending the legs on the abdomen Keeping the placenta amp cord attached for long time till baby cries RECOGNITION AND MANAGEMENT OF SEPSIS If any one of the DANGER signs present Not feeding well Convulsions Fast breathing 2 60 breath min on second count Severe chest indrawing Low body Temperature less than 35 5 C or 95 9 F Fever more than 37 5 C or 99 5 F Movement only when stimulated or no movement at all Admit the baby in health facility Investigation Se
53. o that it can be operated while resuscitating the baby 4 Ensure that suction catheter is placed on baby mattress and tube length is not short Use 8Fr to 10Fr catheters for oropharyngeal suction 5 Place right foot on bellows and press down ensuring that it slides down in contact with the central vertical metal plate This ensures that the bellows do not tilt outwards preventing slipping of foot 6 Foot pressure can be adjusted to ensure adequate suction pressure 7 Pinching that suction catheter end press bellows and check for suction pressure N B for safety of newborn maximum suction pressure is limited to 100mm Hg irrespective of foot pressure 8 In case thick mucous plug blocks the suction inlet switch suction tubing to alternate suction inlet provided on the rubber stopper Cleaning sterilization 1 The foot suction must be cleaned immediately after use Empty the fluid collection jar 2 The fluid collection jar and silicone tubing can be autoclaved at 124 C This can also the washed with soap and water 3 Wash the rubber stopper with soap and water and rinse thoroughly 4 Re assemble when dry 5 Replace in carry case N B Rubber lid for fluid collection jar cannot be autoclaved Wash thoroughly with soap water rinse and dry 6 Empty fluid jar immediately when filled to more than half mark Do s e Suction gently e Maintain asepsis during the suctioning procedure e Use only disposable suction catheters e Check
54. of priced accessories List of priced spare parts Bilirubin meter Bench top bilirubin meter Open system automatic Suitable for intensive care emergency departments or other low volume settings in hospitals With auto zero and self check With LCD display Built in printer Sample volume 1 capillary of 70 ul Dual wavelength measurement correcting for Hb at 550 nm Main light source 2 5 W tungsten lamp Measuring range 5 30mg dl or 85 510 umol l Please see remark below Accuracy of measurement 5 Read out switch able between mg 100 ml of umol L Fast analysis time 3s approx Alarm indicator informs abnormalities With built in USB port allowing data transfer Power requirements 220 V 50 Hz Power consumption 25W Supplied with 1 AC power cable 1 spare lamp 1 thermal paper roll 1 tube with 100 capillaries 1 bar of capillary sealing compound 1 dust cover Supplied with UPS of sufficient size to ensure uninterrupted sample testing in case of power variations or power interruption Supplied with Instructions for use for preventive maintenance and troubleshooting in English Neonatalie Resuscitator Includes Resuscitator mask size 0 mask size 1 directions for use Neonatalie Suction Bulb Suction Penguine Suction Neonatalie complete light Neonatalienewborn simulator lightcomplexsion with standard accessories amp resuscutati
55. on care kit Pulse oximeter portable w access Technical Specifications Compact portable pulse oximeter Robust design allow use in demanding environments Suitable for all patient categories neonate infant adult Monitors arterial blood oxygen saturation SpO2 pulse rate HR and signal strength Measuring range Sp02 30 to 100 min graduation 1 96 HR 20 to 250 bpm min graduation 1 bpm Accuracy SpO2 3 30 to 69 96 and 2 70 to 100 Large LCD has protective cover and allows distant reading Continuous display of SpO2 96 HR bpm signal strength and battery status Reporting of system errors such as probe malfunction loss of signal and power failure User pre settable low and high alarms for Sp02 and HR A Auditable pulse rate Alarms audio visual with silencing feature Automatic switch from mains to batteries in case of power failure Auto off when not in use Dimensions approx 0 15 x 0 15 x 0 30 m w x d Power requirements 220 V 50 Hz and internal battery autonomy approx 30 hrs automatic recharge Power consumption approx 50 W Supplied with 1 x Interconnect cable with MC connector and UN connector 3m bx 1 Ref OXY MC3 2 x Finger sensor with UN connector 1m bx 1 Ref OXY F UN Durable sensor for short term non invasive SpO2 monitoring of patients weighing 20 kg or more 2 x Wrap sensor with UN connector 1m bx 1
56. on feeds the Give oral feeds by baby opens mouth takes milk and spoon cup swallows without coughing spluttering e Able to take an adequate quantity to satisfy needs No Start intra gastric tube feeds 2 Progression to oral feeds Infants on IV fluids If hemodynamically stable Start Minimal Enteral Nutrition MEN by OG NG tube amp Monitor for feed intolerance If accepting well Gradually increase the feed volume Simultaneously taper to stop IV fluids Infants on OG NG tube feeds If accepting feeds well Try spoon feeds once or twice a day Also put on mothers breast If accepting well Gradually increase the frequency and amount of spoon feeds and simultaneously reduce OG feeds Infants on Spoon cup feed Put them on mothers breast before each feed Observe for good attachment amp effective sucking If able to breastfeed effectively Direct breastfeeding Taper and stop spoon feeds once mother is confident Feed with expressed breast milk Steps Infant should be awake and held sitting semi upright on caregiver s lap put a small cloth on his or her front to catch drips of milk Take a measured amount of milk in the cup Hold the cup so that the tip rests lightly on the infant s lower lip Tip the cup to pour a small amount of milk into the infant s mouth Feed the infant slowly Make sure that the infant has swallow
57. one section for disinfection A 4 2 Space for ancillary Supplementary Services Distinct support space should be provided for all clinical services that are routinely performed in the SCANU The ancillary area should include space for the following e Gowning area at the entrance e Hand washing stations e Examination area e Clean area for mixing intravenous fluids and medication e Mother s area for expression of breast milk breastfeeding and learning mother crafts Mini laboratory e Boiling and autoclaving A 4 2 1 Gowning room The unit should provide clear floor space excluding entry work area for gowning e Ahands free elbow operated hand washing station for hand hygiene and areas for gowning and storage of clean and soiled materials should be provided near the entrance e The room should have self closing devices on all exits A 4 2 2 Hand washing stations Hand washing stations should be so positioned that every newborn bed is within 20 feet 6 meters Hand washing stations should be no closer than three feet 0 9 meters from a newborn bed or clean supply storage Protocols for asepsis and hand washing are in Annexure 1 e t should be a hands free elbow operated hand washing station e Hand washing sinks should be large enough to control splashing and designed to prevent standing or retained water Preferably the hand washing sink should be 24 wide 16 front to back x 10 deep The size of a sink is also a
58. or gt 10mg day Indirect serum bilirubin level more than 20mg dl in term baby and more than 15 18 mg dl in preterm baby Prolonged neonatal jaundice i e jaundice persisting after 2nd week of life Jaundice with pale stool MANAGEMENT OF HYPOTHERMIA Hypothermia e Check room temperature e Axillary temp lt 36 5 C e Look for signs of infection e Cool hands and feet e Identify possible cause Mild 36 to lt 36 5 C Cold stress Moderate 32 to lt 36 C Severe lt 32 C e Remove cold and or wet e Remove cold and or e Remove cold and or clothing if present wet clothing if present wet clothing if present e Wrap the baby in warm e Wrap the baby in e Wrap the baby in warm clothes and a cap and warm clothes and a clothes and a cap and cover with a warm blanket cap cover with a cover with a warm blanket e Put skin to skin with warmi blanket Place the baby under mother e Skin to skin contact or radiant warmer or alternate Ensure breast feeding alternate method of method of re warming re warming e Ensure warm environment e Ensure breast feeding e Ensure warm environment Assess Assess Assess e Look for emergency signs e Look for emergency signs e Look for emergency signs e Measure blood glucose e Measure blood glucose e Measure blood glucose Treat Treat Treat e Hypoglycemia if present e Hypoglycemia if present e Hypoglycemia if present e Sepsis if present e Sepsis if present e Ensure breast feeding
59. ount for it Record keeping and reporting in SCANU Stabilization Unit Newborn Corner All type of newborn care units SCANU Stabilization Unit Newborn Corner should have appropriate record keeping and reporting tools Sample of record keeping registers for SCANU Stabilization unit and Newborn care corner in the Delivery Room have been given in this section of the SOP The following indicators need to be tracked and monitored in the SCANU Stabilization Unit newborn Care Corner Input Indicators 1 Number and percentage of service providers trained on ETAT and Sick Newborn Care 2 No stock out of medicine and supplies in the newborn care unit during last 3 months 3 Essential equipment in the newborn care unit available and functioning 4 Protocols for newborn care available and displayed in the newborn care unit 5 Number and percentage of sick newborn by disease admitted in the newborn care unit Output indicators 6 Number and percentage of newborn received essential newborn care 7 Number and percentage of sick newborn received appropriate management as per standard protocol 8 Number and percentage of newborn with asphyxia received resuscitation as per standard protocol 9 Number and percentage of newborn with infection sepsis received appropriate management as per standard protocol 10 Number and percentage of newborn with low birth weight received appropriate management as per standard protocol 11 Number and percentage
60. po tassium to IV fluid is required when a baby cannot be fed for a prolonged period of time This must be done with extreme caution because a small overdose can have serious con sequences Measure gastric residual volume GRV only if abdominal girth gt 2 cm above baseline 3Do not increase fluid volume if Weight gain Tachycardia Puffy eyes Y Edema lower limbs Y Urine output lt 1mL kg hr oliguria e Pale mottled e Cold extremities e Disturbed sensorium lethargy unconsciousness Manage airway optimize breathing circulation and temperature start oxygen if low SpO lt 90 Assess Heart rate B P Oxygen saturation Capillary refill time CRT Urine output Level of sensorium e Fluid bolus Normal saline Ringer s Lactate 10 ml kg over 20 min e Vasopressors Reassess e If does not improve and no signs of fluid overload repeat the same bolus e f unresponsive to fluid bolus persistent shock refer Cause History Examination Specific treatment Blood loss Ante partum Hemorrhage Blood loss internal external Age Day 1 Fluid bolus Blood transfusion Asphyxia Need for Resuscitation for poor respiratory effort at birth HIE signs refer post asphyxia Fluid boluses Vasopressor Sepsis Predisposing factors for infection Age Day 3 or gt Fluid bolus Antibiotics Vasopressor Severe dehydration Loose stool vomiting failure to feed
61. ptic profile Complete blood count with platelet count Blood C S C Reactive protein if available CSF study if available Supportive Investigations X ray chest or abdomen if respiratory distress or abdominal distention Serum electrolytes Serum glucose and bilirubin Management Specific management e antibiotics Ampicilin5Omg kg dose every 12 hourly if age is less than or equal to 7 days thrice a day if age is more than 7 days plus Gentamicin 5 mg kg once daily Consider to switch to second line of antibiotics ceftazidime plus amikacin after 48 hrs if there is no clinical improvement or on clinical deterioration or according to C S report Supportive management Thermal care Oxygen if required Monitor vital signs peripheral perfusion and urine out put Fluid bolus if there is poor peripheral perfusion capillary refill time gt 3 secs give normal saline 10 I V bolus The same vol can be repeated Continue maintenance fluids Treat convulsions if present according to guidelines Referral If admission or lab facilities are not available refer Give 1st dose of antibiotic s and other pre referral management prior to referral Send a referral slip with the baby Low birth weight lt 2500 grams or prematurity delivery Foul smelling and or meconium stained liquor Prolonged rupture of membranes gt 18 hours N 2 o 2 Feb
62. rile illness of mother with the evidence of bacterial infection during or within 2 weeks prior to Single or more unclean or gt 3 sterile vaginal examination s during labor Prolonged labor sum of 1 and 2 stage of labor gt 24 hrs Severe perinatal asphyxia Apgar score lt 4 at 1 minute Components Abnormal value Total leukocyte count lt 5000 mm Absolute neutrophil count Low counts Immature total neutrophil gt 0 2 Micro ESR C reactive protein C RP gt 15 mm in 1st hour gt 10 mg dl Diagnosis Duration Meningitis with or without positive blood CSF culture 21 days Blood culture positive but no meningitis 14 days Culture negative sepsis screen positive and clinical 7 10 days course consistent with sepsis Culture and sepsis screen negative but clinical course 5 7 days compatible with sepsis Culture and sepsis screen negative but clinical course not 3 days compatible with sepsis Only risk factors present FLOW CHART MANAGEMENT OF LBW Wash hands before touching each baby LBW lt 2500 gm Assess condition of the baby od baby Sick baby i Routine care Isolate Continue watch for danger sign s 1f danger signs Minimal handling present Keep baby warm No danger sign Give oxygen if needed Give inj Vitamin K1 Start iv fluid Routine care Send for investigations CBC BG CRP CXR Start iv antibiotics Inj Ampicillin pl
63. rite and betadine swab containers stethoscope tape measure and thermometer for each baby Change intravenous sets daily or as per set routine Feeding tubes as long as baby can keep Do not keep FOMITES e g files X ray films pens etc on the baby cot Change antiseptic solution in SUCTION BOTTLES and sterile water in oxygen humidification chambers everyday and sterlise the bottles chambers daily by dipping in 2 gluteraldehyde for 4 to 6 hours Nursery environment Floor should be cleaned with diluted phenyl once in each nursing shift and when required No dry mopping only wet cleaning should be done Clean the walls with 2 of bacillocid once in each nursing shift Dustbin should be washed daily with soap and water Polythene should be changed daily or whenever full Hand Washing It is the single MOST IMPORTANT means of preventing nosocomial infections It is VERY SIMPLE and CHEAP Hand washing norm Two MINUTES hand washing 6 steps to be done before entering the unit 20 second hand washing with alcohol based hand rubs to be done before and after touching babies Steps of effective hand washing Roll Sleeves above elbow Remove wrist watch bangles rings etc Using plain water and soap wash parts of the hand in the following sequence Palms and fingers and web spaces 1 Back to hands 2 Back of hands 3 Fingers and knuckles 4 Thumbs 5 Fingers tips 6 Wrists and forearm up to elbow Once you have washed your hands
64. rks windows or fresh air intakes Exhaust only ventilation is a good choice for units that do not have existing ductwork to distribute heated or cooled air Supply and exhaust ventilation is a good choice for units with heating or cooling ducts as it is an inexpensive way of providing fresh air A 8 Acoustic environment The acoustic conditions of the unit should favour speech indelibility intelligibility normal or relaxed vocal effort speech privacy for staff and parents and physiological stability uninterrupted sleep and freedom from acoustic distraction for the newborn and the staff Noise generating activities and gadgets Such as telephone sounds staff areas and equipment should be acoustically isolated Note Must be ensured IO CILOSOY 5 i gt Z ve 9 z Hd 2 8 E 5 S B NS AM 5 VI 3 8 E Y iV Adero oyd e e i f Jourqe EN ET VI ET 07 eoeds eudsoH 121 1 25 OL jo ajdwes e4n614 _ Figure 2 Electrical Drawing for 10 Bed SCANU Figure 3 Sample Layout Design of an ideal SCANU Level Il Care at the secondary Tertiary level Hospital OUTBORN UNIT6mx6m SHED UNIT 48 mX3 6m STEPDOWN UNIT 3 7mx7 6m Adapted from Indian Toolk
65. rn care equipment is essential to ensure effective functioning of the medical devices their longevity and best possible services The maintenance starts right from the time of installation and training of the users are critically as important as maintenance Thus on site user level training should include user training technical training and basics of the clinical application of the device The technical training should enable hospital technicians to undertake first line corrective intervention that do not require specific spare parts They should also be able to recognize and report correctly the technical malfunctions requiring on site services of the supplier Annual maintenance covers both preventive maintenance and on call corrective interventions Preventive maintenance The objective is to ensure maximum uptime of the medical equipment assuring accuracy efficiency and clinical efficacy Preventive maintenance therefore consists of at least two planned technical visits per year and includes and covers e Exchange of information with the end user and technical staff about the status of the device e Function and performance check up of the device e Technical check up of device based on the manufacture s technical checklist e Assessment of wear and tear of the device with notification if incorrect use of the device is noted e Cleaning parts beyond reach or capability of the end user e Adjustment and calibration of the device e
66. rst clean with sprite swabs then use Betadine soaked sterile cotton to cover the stopper of the bottle e Change the burette set every 24 hours or as per policy of your unit e Use syrups within 1 weak of opening write the opening date e Antibiotics vials to be changed after 24 hours E g injections Ampicillin or Cefotaxime e There is no need for flushing with heparins saline to keep the IV line patent e Use separate IV line of giving antibiotics do not open the IV fluid line for giving injection Safe disposal of hospital waste Proper disposal of hospital waste is important to keep the environment clean The waste should be disposed of in a proper way All health professionals should be well conversant with their local hospital polices for waste disposal which may vary from place to place Disinfection protocols line blanket Blanket Baby Cover Wash and autoclave Use autoclaved linen each time Cotton gauze Autoclave as required Every time use autoclaved cotton Feeding utensils cup spoon etc Wash with soap and water before each use then boil for 10 minutes Swab container injection and medicine tray wash with soap and water autoclave Daily morning shift use separates swab containers for each baby Sets for procedures Autoclave After each use every 72 hours if unused Chattel forceps Autoclave Daily Put in sterile autoclaved bottle contain gin dry sterile cotton
67. sible for the clinical standards of the care of newborn babies While the available manpower for SCANU will differ by level of care the basic principles are At least two dedicated staff nurses per shift are necessary for a 10 bedded unit Thirty per cent extra staffing is recommended to account There should be an adequate number of doctors to be able to take a round of the newborns once in each shift every eight hours and to be on call round the clock Dedicated support staff should be there to clean the unit at least once every shift and more often depending on the need For a 10 bed unit the recommended staffing is Staff Nurses 8 Consultant 1 Medical officer 3 Support Staff 4 Training It is suggested that the medical and paramedical staff working in an SCANU should undergo G An initial skill based training on Emergency Triage Assessment and Treatment ETAT and Sick Newborn Care training program for 5 days in the designated training centers with provision of SCANU NICU and Hands on training at medical college hospital or an equivalent facility with SCANU SCABU NICU for at least four weeks Cost Cost can be broken down into capital cost and recurrent cost While the cost will vary widely due to various factors an indicative cost for a 10 beds unit is summarized below Renovations and civil works Tk 15 00 000 25 00 000 20 00 000 Highly variable depending on the status of the health
68. sor is not does not work it requires changing connected properly or if it is not functioning properly Skin temperature This alarm operates in servo Change to manual mode with maximum alarms High or mode only It sounds when the output if baby is having low temperature Low patient temperature differs from and adjust the temperature to try and the SET temperature by gt 0 5 C normalize the baby s temperature If baby is having fever shift to manual mode and set appropriate heater output Check for signs of infection Heater Failure Indicate heater is not working Change warmer needs repair Phototherapy Unit Protect the eyes from light using eye patches once the lights are on Keep baby naked with a small nappy to cover the genitalia Change position supine to prone after each 3 hourly Place the baby as close to the lights as the manufactures instructions allow Use white curtains or linen as slings so as to reflect back as much light as possible to the baby making sure not to cover top surface of unit which allows air flow for cooling the bulbs Encourage frequent breast feeding No need to supplement breastfeeding with any other type of feed or fluids Temporary interruptions for feeding or procedures re allowed But not for oro gastric feeding or for IV fluids If baby is on IV fluids or expressed breast milk increase the volume by 10 Monitor for and ensure urinary frequency 6 8 times day Monitor
69. the display panel registers zero e Check for and adjust zero error e Place the clan cloth paper e Press the knob to reset the reading to zero or else you will have to subtract the weight of the cloth form the total weight when baby is weighed along with the sheet e Place the baby over the cloth paper e Keep the baby in the middle of the weighing pan hold the remaining tubes and lines in hand e Detach as many tubes equipment as possible prior to weighing Keep the naked baby on the towel and record the weight subtract the weight of the cloth if the scale has no facility to reset to zero e Read the weight to nearest 5 10 gms e Record weight on baby record and plot on growth chart Do s e Put the weighing scale on a flat stable surface e Record weight prior to feeding e If using pre weighed splint reduce the weight from baby s weight e Always look for and adjust zero error e Remove excessive clothing e Record weight only when display is stationary amp not fluctuating Don ts e Do not stack up line or other objects on the weighing pan when not in use e Do not pour water on the electronic display Cleaning and disinfection e Clean with soap and water use damp cloth to clean e Wipe with sprit swab between patient use Troubleshooting e Place on a flat firm surface e Check for power cord e Check for fuse e Calibrate using a known standard weight every two weeks e Record zero error if it cannot be corrected and acc
70. tlets To ensure this a generator with 25 50KVA capacity and voltage stabilizer 3 Phase of the same rating is needed Monitors must have UPS Electrical outlet for individual beds To handle equipment 6 8 central voltage stabilized outlets are required per bed 4 of them should be of 5 amperes and another 4 of them should be of alternate sockets for mobile bed side X ray equipment or USG machine need to be planned Lighting of the unit The unit should be well illuminated with adequate daylight Panel of lights with cool white fluorescent tubes preferably CFL or LED light emitting diodes will be required for adequate illumination A 5 2 Mechanical needs Floor surfaces Floor surfaces should be easily cleanable and should minimize the growth of microorganisms Materials should permit cleaning without the use of chemicals At the same time floors should be highly durable to withstand frequent cleaning and heavy traffic Vitrified tiles are preferred Large sized tiles should be used to minimize junctions Walls Ease of cleaning durability and acoustical properties of wall surfaces must be considered Walls should be glaze tiled up to a height of at least seven feet Large sized tiles should be used to minimize junctions Water Supply The unit should have 24 hour uninterrupted running water supply To ensure water supply it is useful to have a separate overhead tank with a capacity of 1 000 to 2 000 liters A 6 Lighting A 6 1 Ambient
71. tween 36 5 37 5 C e Once the baby s temperature is between 36 5 37 5 C switch on the servo mode skin mode e f baby is in supine position place the skin probe on the right hypchondrium when in prone position place the probe on the lion area To prevent skin injury place tegaderm and fix the probe on it with an adhesive e Ensure that the babys head is covered with cap and feet secured in socks and the baby is clothed or covered unless it is necessary for the baby to be naked or partially undressed for observation or for a procedure e Place only one baby frequently while under the warmer if possible e Check the temperature of the warmer and of the room every hour and adjust the temperature setting accordingly Record the heater output in each shift every 6 hours Any sudden increase in heater output is an early indicator of sickness e Move the baby to be with the mother as soon as the baby no longer requires frequent procure and treatment If servo mode the heater output is 2096 it safe to shift the baby to mothers side Servo Mode Set temperature at 36 5 c heater output will adjust automatically to keep baby at set temperature If baby temperature is below the set temperature the heater output will increase if baby is at set temperature or higher the heater output will become zero Look for probe displacement when the baby is in servo mode Check for and ensure proper probe placement every hour Manual Mode e Once connected to mains
72. us Discharge single dose gentamicin Vomits everything NPO Continue iv fluid Hypothermia Convulsion Jaundice Re warm Give IV Treat jaundice Phenobarbitone v v Apnea Not feeding well Hypoglycemia Signs of severe Resuscitate Watch for signs of Correct blood bacterial sepsis AOP give NEC glucose level Send inv if possible Aminophylline Continue change iv antibiotics No sign of NEC Signs of NEC Start MEN with Stop feeding cup spoon or Give antibiotics and oro nasogastric tube supportive treatment AOP Apnoea of Prematurity NEC Necrotizing Enterocolitis MEN Minimal Enteral Nutrition 1 Stable baby Baby has no breathing problems Sucks well and stays warm Active Sick baby Baby has respiratory problem s or is lethargic Unable to suck feed or to maintain normal temperature e Vomits every time FEEDING OF LOW BIRTH WEIGHT AND SICK NEONATES 1 Deciding initial feeding method Assessment Action Is the baby clinically stable is R Start intravenous fluids Y Yes Is birth weight more than 1250 g E Start intravenous fluids Yes Is the baby able to breastfeed effectively Yes e When offered the breast the baby roots 1 Initiate breastfeeding attaches well and suckles effectively e Able to suckle long enough to satisfy needs Is the baby able to accept feeds by alternative methods Yes e When offered cup spo
73. ve necessary treatment before transfer Prepare for transport Counsel the parents and family regarding need for transport Communicate with and write a brief note to the referral team Arrange a healthcare provider mother and a relative to accompany Assemble supplies and equipment to carry and arrange for transport vehicle i Care during transport Carry the equipment amp supplies Monitor frequently temperature airway and breathing circulation IV cannula and infusions Ensure that the baby receives feeds or fluids Stop the vehicle if necessary to manage problems Feedback after transport Communicate with referral team for e condition of the baby at arrival e outcome of the baby Indications have to be individualized for each facility depending upon capabilities and infrastructure of referring and referral facilities S T A B L E S Sugar T Temperature A Airway B Blood pressure circulation CRT L Lab work Lines E Emotional support to family 3 Supplies and equipment to carry Equipment and supplies Drugs amp fluids Source of warmth Fluids amp feeds Any drug e g antibiotics blanket the baby is receiving if a RE Dun dose is anticipated during Resuscitation equipment o gastric tubes the trip bag o IV infusion set IV fluid appropriate sized mask suction apparatus Syringes and needles various sizes and types oxy
74. veries are conducted must have skilled staff and facilities for care at birth to all newborns and to provide resuscitation of those who require it e In addition FRUs should be equipped to provide initial care and stabilisation of sick newborns and care of most low birth weight newborns that do not require intensive care e Every district hospital or sub district hospitals that conducts more than 3000 deliveries should have a Special Care Newborn Unit that is equipped to provide special care to most sick newborns except those requiring mechanical ventilation or surgical interventions 2 There should be agreed procedures for transport of sick newborns form one level of facilities to another 3 SCNU within the district hospital must have continuous availability to qualified medical and nursing staff and resources to meet the needs of all sick babies 4 Technical specification standard for the expected levels of equipment have been established and should be adhered to Local systems for procurement maintenance and replacement of equipment are necessary 5 All neonatal units should comply fully with e Clinical guidelines e Quality assurance e Follow up of high risk survivors e Monitoring service provision and access e Training and containing education Mothers should be encouraged to be involved in care of their sick newborns at every level All units should provide the environment that supports mothers to be involved in the care of their n
75. ys Overhead exanimation light 2 x 50 W halogen Heating element emitter with parabolic reflector and protected by metal grid Preset skin temperature range approx 34 to 38 C increments 0 1 C Temperature preset drives heater output in servo mode Easy switch between servo and manual mode Skin temperature monitoring via sensor range 30 to 42 C sensitivity 0 2 C Sensor thermistor based and factory calibrated Preset heater output O to 100 96 in 5 96 increments Integrated timer preset 1 to 59 min with up down count feature increments 1 min Auto off at time elapse Audiovisual alarm on skin temperature 1 1 C of preset value and time elapse Large LED display shows Heater output preset in Watt Mode servo or manual Preset skin temperature Actual skin temperature Air temperature Elapsed or remaining time Display reports system errors such sensor malfunction low high temperature Mattress covering entire table surface thickness 5 cm Cover is waterproof flame retardant and resistant to common disinfection and cleaning solutions Dimensions 1 10 x 0 65 x 1 90 m I x w x h Power requirement 220 V 50 Hz Power consumption 1100W Supplied with 1 x Mattress 1 x Reusable skin temperature probe incl connection cable and plug Ref BH 2 x Spare reusable skin temperature probes incl connection cable and plug Ref BH 1 x Spare heating

F Cost of setting up newborn care corner

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