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🍼 EINC & Newborn Assessment — Complete Lecture Notes

Sources: Harriet Lane Handbook (23rd ed.), Textbook of Family Medicine 9e, Morgan & Mikhail's Clinical Anesthesiology 7e, WHO/DOH EINC Protocol (Unang Yakap), PAFP EINC Module

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PART 1: EINC — Essential Intrapartum and Newborn Care

What is EINC?

Key Principle: For the vast majority of healthy newborns, all they need are these four steps — no suction, no immediate bathing, no separation from mother.

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Why EINC Matters

• ~82,000 Filipino children die annually — most deaths preventable
• The Philippines is among 42 countries accounting for 90% of global under-5 mortality
• These four core steps address the leading causes of neonatal death: hypothermia, infection, and failure to establish breastfeeding

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THE FOUR CORE STEPS OF EINC

🔵 STEP 1 — Immediate and Thorough Drying (within the first 30 seconds)

1. Place baby on the mother's abdomen immediately after delivery
2. Use a clean, dry towel — dry the face, head, trunk, and limbs thoroughly and vigorously within 30 seconds
3. Discard the wet towel immediately (it becomes a cold source)
4. Assess breathing while drying — if baby is not breathing → go to resuscitation

⚠️ Do NOT suction the mouth and nose of a vigorous baby with clear fluid — this is no longer recommended and can cause bradycardia.

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🔵 STEP 2 — Skin-to-Skin Contact (immediately after drying, minimum 1 hour)

1. Place the naked baby prone on the mother's bare chest/abdomen
2. Cover both with a fresh, dry linen
3. Put a bonnet on the baby's head
4. Check for multiple births — palpate mother's abdomen for a second baby

✅ Skin-to-skin can restart at any time if interrupted for medical procedures.

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🔵 STEP 3 — Properly-Timed Cord Clamping (1–3 minutes after birth, or when cord stops pulsating)

1. Wait 1–3 minutes (or until cord pulsations stop)
2. Clamp using a sterile plastic clamp at 2 cm from the umbilical base
3. Apply a second clamp at 5 cm from the base
4. Cut close to the plastic clamp
5. Count the vessels in the cord stump — normal: 2 arteries + 1 vein

⚠️ Single umbilical artery → associated with chromosomal and anatomic anomalies → evaluate kidneys and heart

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🔵 STEP 4 — Non-Separation / Rooming-In (for early breastfeeding)

• Baby stays with the mother at all times
• No transfer to nursery unless medically necessary
• First breastfeed should happen during skin-to-skin (baby will root and self-attach)
• Mother is supported with positioning and latching

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OTHER KEY INTRAPARTUM CARE PRACTICES (Evidence-Based)

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Routine Procedures in the First Hours

Within 0–6 Hours:

All newborns are Vitamin K–deficient at birth — breast milk is low in Vitamin K. IM administration is more effective than oral (Zipursky, 1999).

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PART 2: NEWBORN ASSESSMENT (Head-to-Toe)

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A. VITAL SIGNS & BIRTH WEIGHT

Birth Weight Classification:

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B. THE APGAR SCORE

The APGAR Mnemonic:

Scoring Interpretation:

• If 5-min score < 7 → repeat every 5 minutes up to 20 minutes
• 1-min score correlates with survival
• 5-min score has limited relationship to neurological outcome

⚠️ A low Apgar score (0–3) does NOT by itself predict neurologic outcome or confirm an intrauterine hypoxic event. The Apgar score should never delay resuscitation.

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C. GESTATIONAL AGE ESTIMATION — NEW BALLARD SCORE

Neuromuscular Maturity (6 Signs):

Physical Maturity (6 Signs):

• Score –10 = 20 weeks | Score 0 = 24 weeks | Score 10 = 28 weeks | Score 20 = 32 weeks | Score 30 = 36 weeks | Score 40 = 40 weeks | Score 50 = 44 weeks

If there is a >1 week discrepancy between Ballard score and dates → use the earlier gestational age.

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D. HEAD-TO-TOE PHYSICAL EXAMINATION

1. HEAD

Memory tip: Caput → Crosses suture lines, Cephalohematoma → Confined within sutures

2. EYES

• Subconjunctival hemorrhages — common, benign, from birth pressure
• Red reflex — must be present bilaterally (absent = congenital cataract, retinoblastoma)
• Eye discharge within 24–48h from prophylactic drops = chemical conjunctivitis (benign)

3. NOSE

• Newborns are obligate nasal breathers
• Pass catheter through both nostrils to rule out choanal atresia

4. MOUTH

• Epstein pearls — white cysts on hard palate midline (benign)
• Examine for cleft lip/palate
• Pass catheter to stomach to rule out esophageal atresia

5. NECK

• Examine for masses: thyroglossal duct cyst (midline), branchial cleft cyst (lateral)
• Torticollis — asymmetric neck rotation; may have SCM mass
• Clavicles — palpate for fracture (crepitus, decreased movement, pain)

6. CHEST & RESPIRATORY

• Normal: 30–60 breaths/min
• Breast engorgement (both sexes) — due to maternal estrogen; normal, resolves in weeks
• Listen for air entry bilaterally
• Grunting, nasal flaring, retractions → respiratory distress → investigate
• Transient Tachypnea of the Newborn (TTN): most common cause of tachypnea; delayed clearance of fetal lung fluid; resolves by 12–72 hours

7. CARDIOVASCULAR

• Assess capillary refill, PMI
• Heart rate: 120–160 bpm
• Auscultate along left sternal border
• Murmurs in first 24h — often transient (PDA closure, peripheral pulmonary stenosis); benign
• Concerning murmur: harsh, pansystolic, grade ≥ III/VI, abnormal S2
• Palpate femoral pulses — absent/asymmetric → suspect coarctation of the aorta

8. ABDOMEN

• Normal: soft, symmetric, slightly protuberant
• Liver: palpable 1–2 cm below RCM (normal)
• Scaphoid abdomen → diaphragmatic hernia
• Distended abdomen → obstruction, organomegaly
• Umbilical hernia: monitor; most resolve by 1–5 years
• Omphalitis: periumbilical erythema + foul discharge → treat promptly

9. GENITALIA

• Inspect labia majora, minora, clitoris, urethral orifice, vaginal opening
• Imperforate hymen — check vaginal opening
• Vaginal tags and milky/blood-tinged discharge — normal (maternal hormone withdrawal)

• Measure stretched penile length: mean = 3.5 cm at term
• Urethral meatus midline on glans
• Hypospadias = ventral displacement; Epispadias = dorsal displacement
• → Do NOT circumcise if abnormal meatus
• Palpate both testes in scrotum
• Hydrocele = fluid around testis; transilluminates; resolves by 1 year
• Inguinal hernia = non-transilluminable, reducible

10. MUSCULOSKELETAL

11. SKIN

12. NEUROLOGICAL

• Primitive reflexes — assess all of these:

Absence of Moro reflex = severe brain damage or brachial plexus injury Asymmetric Moro = Erb's palsy or fractured clavicle

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E. BIRTH TRAUMA

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NEONATAL RESUSCITATION ALGORITHM

Step-by-step approach:

1. Term gestation?
2. Good muscle tone?
3. Breathing or crying?

1. Warm, dry, stimulate
2. Position airway (sniffing position), clear secretions if needed
3. Assess: Apnea/gasping? HR < 100?
   • YES → PPV (Positive Pressure Ventilation) + SpO₂ monitor
4. If HR still < 100 → check chest movement, corrective steps, consider ETT/LMA
5. If HR < 60 → Chest compressions (3:1 ratio) + PPV 100% O₂ + IV access (UVC)
6. If HR still < 60 → IV Epinephrine + consider hypovolemia/pneumothorax

Targeted Preductal SpO₂ After Birth:

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F. GLUCOSE SCREENING

• LGA (infant of diabetic mother)
• SGA
• Preterm
• Post-term (> 42 weeks)
• Signs of hypoglycemia (jitteriness, poor tone, apnea)

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QUICK SUMMARY TABLE — EINC vs NB Assessment

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What's Covered:

PART 1 — EINC (Unang Yakap Protocol)

• Why EINC exists and the public health context
• 4 Core Steps explained step-by-step with rationale:
  1. Immediate thorough drying (30 seconds)
  2. Skin-to-skin contact (≥1 hour)
  3. Properly-timed cord clamping (1–3 min)
  4. Non-separation / early breastfeeding
• Evidence-based vs. harmful practices table
• Timeline for Vit K, Hep B, BCG, eye ointment, bathing

PART 2 — Newborn Assessment

• Vital signs & birth weight classification (ELBW → LGA)
• APGAR Score — full table + mnemonic + interpretation + when to act
• New Ballard Score with both visual charts (neuromuscular + physical maturity)
• Head-to-toe exam: head (caput vs. cephalohematoma), eyes (red reflex), nose (choanal atresia), mouth, neck, chest, cardiovascular (femoral pulses, murmurs), abdomen, genitalia, MSK, skin (all common neonatal rashes), neurology (all primitive reflexes table)
• Neonatal Resuscitation Algorithm — both flowcharts with target SpO₂ table
• Birth trauma summary table
• Quick reference summary table at the end