Umbilical cord clamping

Umbilical blood flow decreases rapidly after delivery to less than 20% of the fetal value by 40–60 seconds of age ( ). Physiological cord closure usually occurs within 3–5 minutes of birth but some cords pulsate for more than 15 minutes. There is no need to rush immediately to clamp the cord, since there are few risks associated with delayed clamping and there may be some benefits. Delayed clamping increases the risk of the neonate developing jaundice requiring treatment ( ). One randomised trial comparing time to cord clamping of 30 seconds versus 3 minutes showed benefit in haemoglobin levels both at 1 hour and 10 weeks in a group of 34–36-week gestation babies ( ). It is essential that there is a foolproof routine for clamping or ligating the umbilical cord, otherwise a fatal neonatal haemorrhage can ensue.

Umbilical cord care

Correct umbilical care during the first week significantly reduces the incidence of infection, not only in the neonate but also in the mother. Necrotic Wharton’s jelly is readily colonised by organisms from the environment, which may spread to cause skin, conjunctival or systemic infection in the baby, or breast abscess in the mother.

Umbilical cord colonisation can be reduced by using topical antibiotics ( ). Yet, in developed countries, there is no evidence that topical antibiotics or antiseptics reduce systemic infection, and moreover they delay cord separation. Simply keeping the cord clean and dry is a reasonable and safe mode of care ( ) and is the method adopted in the UK at present.

Prevention of eye infection

In many countries, it was routine to administer one drop of 0.5–1.0% silver nitrate into each eye immediately after delivery, to prevent gonococcal ophthalmia. Silver nitrate is effective, reduces the incidence of other types of conjunctivitis and is largely free from side-effects ( ), although babies find it uncomfortable and some studies have reported a chemical conjunctivitis in up to 90% of recipients ( ). A 2.5% solution of povidone-iodine is more effective ( ) and protects against chlamydial conjunctivitis, which is otherwise more difficult to prevent even with the use of erythromycin ointment. Whether or not prophylaxis is justified depends on the incidence and severity of neonatal conjunctivitis in the local population; it is not used in the UK. Many US states have now changed from silver nitrate to erythromycin.

Vitamin K

Haemorrhagic disease of the newborn is potentially fatal. It exists in an early and late form, and is primarily a risk in breastfed babies and those with liver disease ( Ch. 29.2 ). The condition can be prevented by giving 1 mg of vitamin K intramuscularly (i.m.) after delivery to all babies ( ). A study that suggested an increased risk of leukaemia in later childhood generated considerable anxiety about the practice of universal i.m. vitamin K administration ( ), but subsequent studies from different parts of the world – Sweden ( ), the USA ( ), Denmark ( ), Germany ( ) and the UK ( ) – have failed to confirm these findings.

Various oral regimens have been used, either to avoid giving injections or to avoid the putative risk of malignancy. From these studies it is clear that a single oral dose at birth does not eliminate the risk of haemorrhagic disease, particularly late-onset disease ( ), which in one series was 13 times more common after oral than after i.m. vitamin K prophylaxis ( ). Repeated doses of oral vitamin K have been suggested as an alternative to a single dose of i.m. vitamin K. Local practice in Britain varies, but the following are commonly used regimens. Konakion MM is the only licensed preparation currently available for prophylaxis against haemorrhagic disease of the newborn in the UK.

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  i.m. Konakion MM – a single 1-mg dose at or soon after birth or

  
  
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  oral Konakion MM Paediatric – 2 mg at birth and at 4–7 days for all babies, and a third dose at 1 month of age for exclusively breastfed babies.

Infants at increased risk of haemorrhagic disease because of maternal liver disease or maternal anticonvulsant or antituberculosis drugs, should receive i.m. or intravenous Konakion ( ). In addition, there remains a concern that the oral regimen may not prevent late haemorrhagic disease, particularly in breastfed babies. This is only in part because of the failure to administer a complete course ( ). This concern can be probably ameliorated by giving an oral dose of 2 mg at birth followed by 1 mg weekly for 3 months ( ; ).

Thermal care ( Ch. 15 )

The normal axillary temperature is 36.5–37.5°C ( Chs. 15 , 19 ).

The risk of developing hypothermia is greatest immediately after delivery. It is not uncommon for the body temperature of a normal full-term baby to drop to 35–35.5°C by 15–30 minutes of age. The adverse effects of hypothermia are detailed in Chapter 15 and include hypoglycaemia, acidosis, pulmonary hypertension and impaired surfactant production.

In order to prevent hypothermia the underlying mechanisms of heat exchange, namely evaporation, conduction, convection and radiation, must be considered ( Ch. 15 ). Evaporative heat loss, even from babies born into a water pool, is almost eliminated by prompt drying. Conductive heat loss is lessened by prewarming the towels and any other equipment that will be in contact with the baby. Convective heat loss is ameliorated by having a warm and draught-free delivery room and covering the baby. All doors and windows should be closed, air circulation systems likely to cool the baby should be turned off (or the baby placed away from the air vent) and the room temperature should be at least 20°C. Radiant heat is lost from the exposed skin of the baby to any surrounding surfaces that directly overlook the infant, and is proportional to the difference in temperature between these surfaces and to the distance between the surfaces. This problem is readily overcome by avoiding leaving the baby exposed and staying away from cold (external) windows and walls. Radiant heaters and heated blankets achieve a reversal of some of these processes and can allow the infant to gain heat.

Many mothers wish to have early skin-to-skin contact with their baby and this should be encouraged. Because the baby will be naked, it is sensible to increase the temperature of the room to a level comfortable for a naked and resting person (23–25°C) and/or use an overhead heat source. The baby should be dry and covered with a warm towel or sheet, and draughts should be excluded. These are all wise precautions that do not distract from an intensely personal experience. Babies cared for like this maintain their body temperature, cry less, have better blood glucose control and base-excess values than do cot-nursed babies ( ). They are also more likely to establish successful long-term breastfeeding ( ).

Bathing babies shortly after birth may cause neonatal hypothermia and should be avoided. Most blood, meconium and vernix is quickly and effectively removed during the initial drying in warm towels, and thereafter any surplus can be wiped clear with a tissue.

Measurement

Babies should be weighed shortly after birth. The head circumference should also be recorded at this stage.

Labelling and security

In hospital, as opposed to home confinements, it is essential to attach a nametag immediately after delivery to prevent incidents of confused identity. There seems to be little benefit, however, from the more complex procedure of footprinting the baby ( ).

Bonding

Developmental care is outlined in detail in Chapter 4 . In simple practical terms, both parents should be left alone with their baby immediately after birth, when babies are particularly bright-eyed and attractive. Putting the baby to the breast early is one of the most important determinants of successful lactation ( ) and, by releasing oxytocin, promotes uterine contraction, the milk ejection reflex, and complex maternal behavioural responses ( ). Moreover, simple skin contact at this stage has been shown to stimulate release of maternal oxytocin and prolactin and aid the first breastfeed ( ).