The developed world has now emerged from the days when underinformed patients conveyed their decisions to professionals. The patient-professional partnership is now crucial. Information should be given to mother and partner as fully as possible, in verbal and written form. Such information should maintain perspective, while being spoken or written in language that the patient can understand.

Today our communities strive toward “natural” childbirth, emphasizing that birth should ideally be a normal physiologic phenomenon for a healthy woman and fetus. Nevertheless, even the healthiest pregnancy carries a small risk of maternal mortality and a significant risk of morbidity. For the fetus and neonate the risks are much higher: The perinatal mortality is usually between 6 and 10 deaths per 1,000 total deliveries in the developed world. The anticipated risk may change. New possibilities may emerge unexpectedly. Unforeseen emergencies occur without time to discuss them completely. Further-more, some pregnancies may appear to cause initial concern, and such worries may resolve as the pregnancy progresses. The clinician must address the question of whether the mother should be told of all possibilities, even those that may occur once in 500 events. In striving to do so, there is a chance that all perspective may be lost for the patient. A value judgment must be taken in each individual case. This risk, however great or small, is communicated to mother and a plan is chosen accordingly. Written information should capture the idea that the plan may have to change in light of forthcoming events.

Because labor is usually a tiring process for the mother, it is not an ideal time to discuss options that could be better addressed beforehand. Mode of feeding, vitamin K prophylaxis, and immunization schedules are examples of subjects that should be explored in depth before the mother enters labor.

In theory, there should be “fully informed consent at all times.” This is an important goal, but it is not entirely achievable. Pregnancy, labor, delivery, and the neonatal period are all times when unexpected events may arise. Anticipating them all is impossible and would be detrimental to the perspective that a woman and her partner require. Fully informed consent can be aimed at exploring all likely events and their outcomes, test findings, including the implications of false-positive and false-negative results, and
the concept of changing risk. These goals are commendable, very time-consuming, and potentially bewildering, even for educated parents. Compromises therefore must be embraced. Professionals should obtain written informed consent where possible, and those who administer, manage, and finance the health program must recognize that the informed consent procedure is time-consuming and requires increased staff resources.

There is great variation throughout the world in rates of breast-feeding. This variation is largely cultural in origin. Some parts of the developed world, including Europe, the United States, and Canada, have low rates of breast-feeding and physicians are required to provide mothers with clear information about the proven advantages of breast-feeding. Advantages include lower prevalence of maternal breast cancer, lower incidence of infant infections (1) (including necrotizing enterocolitis), lower prevalence of obesity in childhood (2), and lower incidence of sudden infant death syndrome (SIDS) (3,4). Breast-feeding may also provide some protection against allergic disease in childhood.

Hemorrhagic disease of the newborn (HDN) can cause significant neonatal morbidity and mortality. It may present in the early days of neonatal life as bleeding from the umbilicus, skin, or as intestinal hemorrhage. Late-onset HDN may cause intracranial bleeding, with consequent death or brain damage. Infants who are breast-feeding or born of mothers taking anticonvulsants are at particular risk (5). Because of these hazards, all parents should be advised to choose vitamin K prophylaxis for their newborn infants. One intramuscular dose of vitamin K can prevent almost all episodes of HDN. This is a simple and reliable method of prophylaxis. Some reports suggest that there is an increased incidence of childhood malignancy after intramuscular vitamin K prophylaxis, whereas other studies fail to confirm this.

Oral prophylaxis may be given on days 1, 8, and 28, and is effective at dramatically reducing the incidence of HDN (6). Oral prophylaxis requires a motivated parent to remember to administer the second and third dose, or else an efficient community support program must be in place to ensure that the infant is similarly protected.

Written information should be available for all parents to examine the evidence, and professionals should be available to discuss the issues and provide parents with a recommendation. Anxieties expressed in the literature, whether justified or not, should not lead parents to reject vitamin K prophylaxis altogether. HDN is a potentially lethal condition.

Throughout the world there are differences in immunization programs. These depend on varying risks of disease in different parts of the planet, availability of vaccines and ability to refrigerate them, and community education programs. Preterm infants should be immunized at the same postnatal age as their term counterparts. Provided the infant is clinically well, the timing of immunization should be unaffected by gestation. Table 20-1 shows an example of recommended immunization schedules in the developed world. Because each country has its own schedule, the pediatrician should check both the local and current recommendations.

The following principles are guides to the general care of the newborn in the early minutes of life:

The contents of the fetal bowel may have been passed prematurely and may have been inhaled during asphyxial gasping prior to delivery. Meconium is a chemical irritant to the lungs as well as a marker of fetal distress. In 9% to 11% of deliveries, meconium is present. The caregiver should thoroughly suction any meconium from the mouth and nares with the head on the perineum. Whether or not meconium should be aspirated from the newborn’s oropharynx is controversial (7); the current author is in favor of this practice, but recognizes that more data are required to support or refute this maneuver. It is clear that those infants who are vigorous do not require invasive care. Those who are in poor condition should be intubated and any inhaled meconium aspirated from the trachea.

Data are currently being gathered about the ideal time of cord clamping and whether the infant should be held for a
few seconds below the placenta in order to receive a gravitational transfusion (8). Consequences of receiving too much blood volume are fluid overload, polycythemia, and (later) hyperbilirubinemia. Until the data from research studies are complete, it may be reasonable to allow a 15-second delay to achieve a modest blood transfusion. Because delayed clamping of the cord increases the infant’s blood volume, it may be advantageous in extreme preterm infants to ensure an adequate intravascular volume, and perhaps to decrease the necessity for subsequent blood transfusion. There is no place for “stripping” of the cord by “milking” the blood from placenta to baby. The cord should initially be clamped several centimeters from the umbilicus and then be cut (9). Then the cord should be clamped 1 or 2 cm from the umbilicus using a disposable clamp, and cut with sterile scissors distal to the clamp. The cord clamp can be safely removed during the second day of life, at which time the cord should be inspected to insure that there is no residual hemorrhage.

The neonate is delivered covered in amniotic fluid that immediately extracts latent heat by evaporation from the infant’s body. Consequently, most infants should be thoroughly dried with warm towels.

Newborn infants lose heat by four physical mechanisms: evaporation, conduction, convection, and radiation. Evaporation is at its most important in the early seconds of life when the newborn is covered in amniotic fluid. Conduction in general contributes little to heat loss because the infant is in contact with warm garments of low conductivity. Convection losses become important when a child is exposed to drafts, and most especially when a child is being nursed naked on an open radiant warmer. Radiant heat loss occurs to cold surrounding objects, that is, the incubator wall in a cool room. Recognition of these physical principles allows heat loss to be minimized by early drying, warm clothing, freedom from drafts, and ensuring that incubators are double-walled with warm gas between the walls. Physical examination, weighing, and bathing of the infant should always be carried out in a warm environment. The neonatal unit and postnatal wards should audit the incidence of neonatal hypothermia and identify the sources of baby cooling. The areas or procedures at fault should be corrected and the quality of care surveyed prospectively.

Before leaving the delivery room, every infant should be identified by the fixing of a wristband and anklet; the parent(s) should witness the bands being attached. In addition, many institutions now routinely do footprinting, handprinting, and fingerprinting, although it is not yet clear that this is reliable and worthwhile (10).

Because of sporadic baby abductions in maternity units, each unit should have a written policy to protect the infants. Both antenatally and postnatally, parents should be given instructions to maximize the safety of the infant. Parents and staff must verify the identity of anyone requesting to remove the baby from the room. Parents should be encouraged, when in any doubt, to summon another member of the staff to check the identification of the person asking to take the child.

The early minutes and hours of a child’s life are important times for establishing a close bond between mother and infant. After the majority of deliveries it should be possible to put the infant immediately to the maternal breast for close physical contact even if the mother does not intend to breast-feed.

Even today infection is one of the major causes of mortality and morbidity in newborn infants. Gowning does not decrease bacterial colonization of the baby nor the incidence of neonatal sepsis (11). The maternity service, in all its departments, must have high-quality handwashing facilities. The troughs should be large with elbow-operated, knee-operated, or automatic taps that produce warm water. Soap must be plentiful. Alcohol rubs should be readily available wherever infants are cared for. Staff should be free of all clothes and jewelry from elbows to fingertips. Each institution should have regular (at least annual) education sessions for staff, and a culture of nonthreatening criticism by peers should be ever-present. All staff on entering a nursery must wash their hands and forearms with an antiseptic (e.g., chlorhexidine or hexachlorophene). Before and after touching each baby, staff should douse hands and forearms in at least 5 mL of alcohol rub or thoroughly wash their hands (12).

Throughout the developed world there is great variation in the use of eye prophylaxis. Each individual community should make a risk assessment depending on the incidence of identified Chlamydia and gonococcal infections. Erythromycin 0.5% and tetracycline 1% are effective antibiotics against sensitive gonococci, but penicillinase-producing gonococci are increasing in numbers and are best prevented with silver nitrate 1% (13).

If prophylaxis is to be given, the ointments should be instilled within the first hour of life into the lower conjunctival sac. The lids are then gently massaged. It is difficult to produce effective prophylaxis against Chlamydia. If conjunctivitis is identified, scrapings of the tarsal conjunctiva should be sent to the laboratory to identify typical cytoplasmic inclusion bodies. Treatment with combined
oral and topical erythromycin has the advantage of eradication of nasopharyngeal carriage of Chlamydia. Equally, if the mother is known to have gonococcal disease, prophylaxis with ointments is insufficient for the infant, who should be fully treated with parenteral antibiotics (13).