EINC & NB Assesment Lec Clinics .. teach me this very clearly according to Nelson pediatrics.. make me to understand throughly about this topic step by step with images needed everything

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EINC Essential Intrapartum Newborn Care protocol Philippines WHO steps

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🍼 EINC & Newborn Assessment — Complete Lecture Notes

Based on Nelson Pediatrics & EINC/Unang Yakap Protocol

🔷 PART 1 — WHAT IS EINC?

EINC = Essential Intrapartum and Newborn Care (also called "Unang Yakap" in the Philippines)

This is a WHO-backed, evidence-based protocol adopted by the Philippine DOH (Admin Order 2009-0025) to reduce neonatal mortality. It emphasizes a time-bound sequence of actions in the immediate post-birth period.

📌 Key Concept: 82,000 Filipino children die annually — most could have been prevented. The Philippines is among the 42 countries accounting for 90% of global under-five mortality.

🔷 PART 2 — EINC: THE FOUR CORE STEPS ("Unang Yakap")

These 4 steps must be performed in sequence immediately after birth for every stable newborn.

STEP 1 — Immediate and Thorough Drying ⏱️ First 30 seconds

Why?

Newborns lose heat rapidly (evaporation, radiation, conduction, convection)
Hypothermia leads to increased oxygen consumption, hypoglycemia, acidosis, and death

How to do it:

Dry the baby vigorously with a clean, warm, dry cloth
Stimulates breathing by tactile stimulation
Remove wet cloth and replace with a dry one immediately
Keep the baby on the mother's abdomen (do not transfer to a cold surface)
Room temperature must be 25–28°C, no drafts

⚠️ Do NOT do routine suctioning for a vigorous newborn with clear amniotic fluid — this is harmful and unnecessary.

STEP 2 — Skin-to-Skin Contact (SSC) 👩‍👧

When: Immediately after drying, before cord clamping in some protocols; at minimum within the first few minutes

How:

Place baby prone on mother's chest (between the breasts), skin-to-skin
Cover with a dry cloth (keep warm)
SSC should last at least 90 minutes (ideally until after the first feed)

Why? (Physiological Benefits):

Benefit	Mechanism
🌡️ Thermoregulation	Mother's chest acts as a "biological incubator" — her skin temperature adapts to baby's need
🍼 Breastfeeding	Triggers oxytocin, prolactin; baby self-attaches to nipple
🧠 Brain development	Reduces cortisol; promotes bonding
🛡️ Immunity	Transfer of maternal skin flora; reduces infection
❤️ Cardiorespiratory stability	Improves O₂ saturation, reduces apnea

STEP 3 — Properly Timed Cord Clamping ⏱️ 1–3 minutes after birth

Rule: Clamp the cord only after pulsations stop OR 1–3 minutes after birth — whichever is earlier.

Why delay cord clamping?

Blood flow continues from placenta → baby for 1–3 minutes
Baby receives 80–100 mL extra blood = ~30–35 mg/kg extra iron
Prevents iron-deficiency anemia in the first year
Improves hemoglobin, ferritin, and neurodevelopmental outcomes

⚠️ Do NOT clamp immediately — this deprives the baby of ~one-third of its blood volume!

⚠️ Do NOT do dry cord care with antiseptics (alcohol, povidone iodine) — dry cord care alone is recommended.

STEP 4 — Non-Separation of Mother and Baby for Early Breastfeeding 🤱

Goal: Baby should self-attach and latch within the first 90 minutes

The "Breast Crawl" Phenomenon:

When placed skin-to-skin, the newborn will instinctively move toward the breast using smell and rooting reflex
Allow this natural process — do NOT rush or forcefully latch

Why exclusive breastfeeding?

Colostrum = "liquid gold" — rich in IgA, leukocytes, growth factors
Reduces diarrhea, pneumonia, necrotizing enterocolitis (NEC)
Protects against SIDS, allergies, obesity

⚠️ Harmful practices to AVOID:

Prelacteals (glucose water, formula) — interfere with breastfeeding

Early bathing — removes vernix, causes hypothermia

Footprinting — unnecessary

Routine suctioning of mouth/nares in vigorous newborn

Immediate cord clamping

Use of "bigkis" (abdominal binders)

🔷 PART 3 — EINC CHECKLIST (Timed Sequence)

Time Period	Key Actions
Before delivery	Warm room (25–28°C), eliminate drafts, prepare clean dry towels, check resuscitation equipment
At delivery (0–30 sec)	Immediate thorough drying, remove wet cloth
0–3 min	Skin-to-skin contact, cord clamping 1–3 min
0–90 min	Non-separation, facilitate breastfeeding
Within 1–4 hrs	Eye prophylaxis (erythromycin ointment), Vitamin K IM
Within 6 hrs	Newborn physical examination, anthropometrics, weight
After 6 hrs	Bathing (optional), Hepatitis B vaccine, BCG vaccine

🔷 PART 4 — NEWBORN ASSESSMENT (NB Assessment)

(Nelson Pediatrics, Chapter 18, Section III)

A. VITAL SIGNS & BIRTH WEIGHT

Parameter	Normal Range
Heart Rate	100–160 bpm
Respiratory Rate	30–60 breaths/min
Temperature	36.5–37.5°C (axillary)
Blood Pressure	Related to gestational age and birth weight
SpO₂ (target)	≥94% after stabilization

Birth Weight Categories (Nelson Pediatrics, p.644):

Category	Weight
Extremely Low Birth Weight (ELBW)	< 1000 g
Very Low Birth Weight (VLBW)	< 1500 g
Low Birth Weight (LBW)	< 2500 g
Normal	2500–4000 g
Small for Gestational Age (SGA)	< 10th percentile for GA
Large for Gestational Age (LGA)	> 90th percentile for GA
Appropriate for Gestational Age (AGA)	10th–90th percentile

B. APGAR SCORE

(Assessed at 1 minute and 5 minutes; repeat every 5 minutes if score <7)

Dr. Virginia Apgar introduced this scoring system in 1953.

Dr. Virginia Apgar performing newborn assessment

Sign	0	1	2
Appearance (Color)	Blue/pale all over	Acrocyanosis (pink body, blue extremities)	Completely pink
Pulse (Heart Rate)	Absent	< 100 bpm	> 100 bpm
Grimace (Reflex Irritability)	No response	Grimace	Cough or sneeze
Activity (Muscle Tone)	Limp	Some flexion of extremities	Active motion
Respiration	Absent/irregular	Slow, weak cry	Good, strong cry

Memory Aid: Appearance • Pulse • Grimace • Activity • Respiration = APGAR

Score Interpretation:

Score	Interpretation	Action
7–10	Normal	Routine care
4–6	Moderate depression	Stimulate, supplemental O₂, reassess
0–3	Severe depression	Begin resuscitation immediately

📌 Clinical Pearl: The APGAR score is a snapshot, NOT a predictor of long-term outcome. It helps guide immediate resuscitation decisions. A low 1-minute score alone does not indicate brain damage.

C. GESTATIONAL AGE ESTIMATION — NEW BALLARD SCORE

(Nelson Pediatrics, p. 644–645, eFig. 18.1)

When to use: When obstetric dating (ultrasound or LMP) is not available

Best time: Most accurate at ~24 hours of life

The Ballard Score has two components:

Part 1: Neuromuscular Maturity (6 signs, each scored –1 to 5)

New Ballard Score — Neuromuscular Maturity

Sign	How to Assess	Immature (premature)	Mature (term)
1. Posture	Observe quiet, supine infant	Arms & legs extended (score 0)	Full flexion (score 4)
2. Square Window	Flex wrist fully; measure wrist–forearm angle	>90° (score 0)	0° (score 4)
3. Arm Recoil	Flex for 5 sec → extend → release; measure recoil angle	180° (no recoil, score 0)	<90° (brisk recoil, score 4)
4. Popliteal Angle	Thigh to chest, extend leg; measure popliteal angle	180° (score 0)	<90° (score 5)
5. Scarf Sign	Pull hand across neck toward opposite shoulder	Elbow crosses midline (score 0)	Elbow cannot reach midline (score 3)
6. Heel to Ear	Bring heel toward ear; observe resistance	Heel reaches ear easily (score 0)	Strong resistance (score 4)

Part 2: Physical Maturity (6 signs, each scored –1 to 5)

Sign	Immature (preterm)	Term (mature)
Skin	Sticky, friable, transparent (score –1) → Gelatinous, red (score 0)	Leathery, cracked, wrinkled (score 5)
Lanugo	None (–1) → Sparse (0) → Abundant (1)	Mostly bald (4)
Plantar surface	Heel–toe < 40 mm (score –2)	Creases over entire sole (score 4)
Breast	Imperceptible (–1)	Full areola, 5–10 mm bud (score 5)
Eye/Ear	Lids fused tightly (–2) → Lids open, pinna flat (0)	Thick cartilage, ear stiff (score 4)
Genitals (Male)	Scrotum flat, smooth (–1)	Testes pendulous, deep rugae (score 5)
Genitals (Female)	Clitoris prominent, labia flat (–1)	Majora cover clitoris and minora (score 4)

Scoring to Gestational Age Conversion:

Total Score	Gestational Age
–10	20 weeks
–5	22 weeks
0	24 weeks
5	26 weeks
10	28 weeks
15	30 weeks
20	32 weeks
25	34 weeks
30	36 weeks
35	38 weeks
40	40 weeks (term)
45	42 weeks
50	44 weeks

Gestational Age Classification:

Classification	GA
Extremely preterm	< 28 weeks
Very preterm	28–32 weeks
Moderate-to-late preterm	32–37 weeks
Term	37–42 weeks
Post-term	> 42 weeks

D. BIRTH TRAUMA — Extracranial Fluid Collections

(Nelson Pediatrics, Table 18.3 & Fig. 18.3)

Feature	Caput Succedaneum	Cephalohematoma	Subgaleal Hemorrhage
Location	At contact point; crosses sutures	Over parietal bones; does NOT cross sutures	Beneath epicranial aponeurosis; may extend to orbits or nape
Findings	Pitting edema, shifts with gravity, vague borders	Distinct firm margins; more fluctuant after 48 hr	Firm-to-fluctuant, ill-defined; crepitus or fluid waves
Timing	Maximal at birth; resolves in 48–72 hr	Increases 12–24 hr; resolves over weeks	Progressive; resolves over weeks
Severity	Minimal	Rarely severe	May be severe (especially with coagulopathy) ⚠️

🔑 Memory tip: Caput = "C" for Crosses sutures. Cephalo = "doesn't Cross." Subgaleal = most dangerous!

E. NEWBORN PHYSICAL EXAMINATION — Head to Toe

Perform within 6 hours of birth (EINC protocol).

1. General Appearance

Posture, tone, cry, color, symmetry
Normal: Flexed posture, vigorous cry, pink (may have acrocyanosis initially)

2. Head

OFC (Occipitofrontal Circumference): Normal = 33–37 cm at term

Head circumference measurement in newborn

Fontanelles:
- Anterior (diamond-shaped): Closes at 9–18 months
- Posterior (triangular): Closes at 6–8 weeks
- Bulging = ↑ICP; Sunken = dehydration
Cranial sutures: Check for premature fusion (craniosynostosis)
Extracranial hemorrhages: See table above

3. Eyes

Red reflex: Must be present bilaterally — absence suggests cataracts or retinoblastoma
Check for subconjunctival hemorrhage (common, benign)
Leukocoria = white reflex → refer urgently

4. Ears

Check position: Low-set ears (below imaginary line through outer canthi) → associated with chromosomal syndromes

Low-set ear — neonatal dysmorphic feature

Ear cartilage firmness used in Ballard scoring

5. Nose

Obligate nasal breathers — check patency
Choanal atresia: Cannot pass catheter through nostril

6. Mouth

Epstein pearls = white keratin cysts on hard palate → normal, resolve spontaneously
Ranula = retention cyst under tongue
Check for cleft lip/palate
Natal teeth (present at birth): remove if loose to prevent aspiration

7. Neck

Check for masses: thyroglossal duct cyst (midline), branchial cleft cyst (lateral)
Torticollis: Sternocleidomastoid (SCM) mass or spasm

8. Chest & Lungs

Normal: Barrel-shaped, symmetric expansion
Breath sounds: Clear bilaterally
Gynecomastia in both sexes = normal (maternal estrogen effect)
Accessory nipples (supernumerary) = benign variant

9. Heart

Auscultate all 4 areas
S1, S2 heard; split S2 normal
Murmurs: Up to 50% of newborns have a transitional murmur (PDA closing)
Pulse oximetry screening at 24–48 hr to detect critical CHD

10. Abdomen

Liver normally palpable 2 cm below costal margin
3-vessel umbilical cord: 2 arteries + 1 vein — single umbilical artery associated with renal anomalies
Omphalocele = abdominal contents herniate into umbilical base (covered by peritoneum)
Gastroschisis = bowel herniates through abdominal wall defect to right of umbilicus (no covering)

11. Genitalia

Male:

Testes should be descended bilaterally
Hypospadias: Urethral meatus on ventral surface of penis
Epispadias: Urethral meatus on dorsal surface
Hydrocele: Transilluminates; usually resolves by 1 year
Phimosis: Physiologic — foreskin non-retractile until 3–5 years old

Female:

Vaginal discharge/spotting = normal (maternal estrogen withdrawal)
Ambiguous genitalia → urgent evaluation (may be CAH)

12. Spine

Check for dimples, tufts of hair, masses over spine → spina bifida occulta/meningocele
Sacral dimple > 5 mm or > 2.5 cm from anal verge → ultrasound required

13. Extremities

Polydactyly: Extra digits (autosomal dominant variant common in African descent)
Syndactyly: Fused digits
Check for congenital hip dysplasia (DDH):
- Ortolani test: Gentle abduction — clunk = dislocated hip reducing ✅
- Barlow test: Adduction with posterior pressure — clunk = dislocatable hip ✅

14. Neurological Examination — Primitive Reflexes

Reflex	How to Elicit	Normal Response	Disappears by
Moro (Startle)	Sudden extension/drop of head	Arms abduct, extend, then flex and adduct ("embrace")	3–6 months
Rooting	Stroke corner of mouth	Turns head toward stimulus, opens mouth	3–4 months
Sucking	Place object in mouth	Rhythmic sucking	3–4 months
Palmar Grasp	Place finger in palm	Baby grasps firmly	3–6 months
Plantar Grasp	Press thumb on plantar surface	Plantar flexion of toes	8–15 months
Babinski	Stroke lateral sole	Dorsiflexion of great toe + fanning of others	12–24 months
Stepping/Walking	Hold upright, soles touch surface	Alternating stepping movements	2–3 months
Tonic Neck (ATNR)	Turn head to one side	"Fencing posture" — extension of limbs on face side, flexion on skull side	4–6 months

📌 Absence of primitive reflexes = neurological depression. Persistence beyond expected age = neurological abnormality.

🔷 PART 5 — IMPORTANT CONGENITAL ASSOCIATIONS TO KNOW

(Nelson Pediatrics, Chapter 18)

Syndrome	Mnemonic	Key Features
VACTERL	Vertebral, Anal atresia, Cardiac, TracheoEsophageal fistula, Renal, Limb	Multiple organ systems; no tracheo-esophageal fistula without VACTERL workup
CHARGE	Coloboma, Heart disease, choanal Atresia, Retarded growth, Genital anomalies, Ear abnormalities	Caused by CHD7 mutation
IDM (Infant of Diabetic Mother)	—	Hypoglycemia, polycythemia, TTN, sacral agenesis, cardiac defects, cardiomegaly

🔷 PART 6 — ROUTINE NEWBORN PROCEDURES (EINC Timed Sequence)

Procedure	Timing	Purpose
Eye Prophylaxis (erythromycin 0.5% ointment)	Within 1–4 hours	Prevent ophthalmia neonatorum (GC, Chlamydia)
Vitamin K₁ (phytonadione) IM	Within 1–4 hours	Prevent Hemorrhagic Disease of Newborn (HDN/VKDB)
Hepatitis B Vaccine	Within 12–24 hours (birth dose)	Prevent perinatal HBV transmission
BCG Vaccine	Within 24 hours	Prevent TB meningitis and miliary TB
Newborn Screening	48–72 hours	Screen for congenital hypothyroidism, PKU, G6PD, galactosemia, CAH, etc.
Hearing Screening (OAE/AABR)	Before discharge	Detect sensorineural hearing loss
Critical CHD Pulse Oximetry	24–48 hours	Detect CCHD (duct-dependent lesions)

🔷 PART 7 — CLINICAL REVIEW: "WHAT TO DO" vs. "WHAT NOT TO DO"

✅ DO:

Dry immediately and thoroughly
Skin-to-skin for 90+ minutes
Clamp cord at 1–3 min
Facilitate breast crawl and latching
Give Vitamin K within 1–4 hr
Perform complete head-to-toe exam within 6 hr

❌ DO NOT:

Harmful Practice	Why It's Harmful
Routine oropharyngeal suctioning (vigorous baby)	Causes apnea, bradycardia, mucosal injury
Immediate cord clamping	Deprives baby of iron-rich blood
Early bathing (<6 hrs)	Hypothermia, removes vernix protection
Prelacteals (glucose water, formula)	Disrupts breastfeeding, unnecessary
Cord care with antiseptics	Delays cord separation, damages tissue
Use of "bigkis" (belly binders)	Compresses abdominal organs
Footprinting	Unnecessary, no clinical benefit

🔷 QUICK REFERENCE SUMMARY TABLE

Topic	Key Points
EINC 4 Core Steps	Dry → SSC → Cord clamp (1–3 min) → Don't separate
APGAR	1 & 5 min; 7–10 normal; 4–6 moderate; 0–3 severe
APGAR letters	A-P-G-A-R = Appearance, Pulse, Grimace, Activity, Respiration
Ballard Score	Neuromuscular (6) + Physical (6) signs; most accurate at 24 hr
Total Ballard score 40	= 40 weeks' gestation (term)
Caput vs Cephalo	Caput crosses sutures; Cephalo does NOT
Dangerous head bleed	Subgaleal hemorrhage — can be life-threatening
Cord vessels	2 arteries + 1 vein; single artery → check kidneys
DDH tests	Ortolani (reduce) + Barlow (dislocate)
Moro disappears	3–6 months; absence = neurological problem
Routine Vit K	IM, within 1–4 hr — prevents VKDB/HDN

Sources:

Nelson Pediatrics Formulary (2023), Chapter 18 — Neonatology, pp. 643–649
EINC/Unang Yakap Protocol, Philippine DOH Administrative Order 2009-0025 / PhilHealth EINC Checklist (revised 2022)
PAFP EINC Module — Four Core Steps

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