Routine Care of the Newborn: From Delivery to Discharge

According to Sri Lankan Pediatric Guidelines (Sri Lanka College of Paediatricians / Family Health Bureau / Ministry of Health)

Phase 1: Pre-Delivery Preparation

• Clean, warm, dry surfaces for both mother and baby
• All instruments and resuscitation equipment ready and functional
• Warm room temperature maintained
• Sterile cord clamping/cutting equipment prepared
• Identification band ready

Phase 2: Immediate Delivery Room Care (First minutes after birth)

Step 1 - Deliver onto Mother's Abdomen / Drying and Stimulation

• Ideally, the baby is delivered directly onto the mother's abdomen (skin-to-skin contact from the first breath)
• Immediately dry the baby with a warm towel, especially the head, discarding the wet towel
• Stimulate the baby by rubbing the back gently while drying
• Wipe the mouth and nose with gauze as the head is delivered (practiced in ~69% of Sri Lankan deliveries per observed data)
• Do NOT handle the baby upside down, slap the feet, or pinch the chest

Step 2 - Assessment of Breathing / Apgar Score

• Assess the baby's breathing and heart rate immediately after drying and stimulation
• If the baby cries and breathes spontaneously - proceed with routine care
• Apgar score is recorded at 1 minute and 5 minutes after birth
• If the baby does NOT breathe after drying/stimulation - initiate Neonatal Resuscitation immediately (this takes priority over all other steps)

Step 3 - Delayed Cord Clamping

• Wait 2-3 minutes (or until the cord stops pulsating) before clamping and cutting the umbilical cord
• The cord should be clamped/tied only after the active management of the third stage of labour is complete and when both mother and baby are stable
• The cord is tied with a ligature or a disposable cord clamp
• Benefits: reduces risk of anaemia and intraventricular haemorrhage, especially in preterm infants
• This is a key area highlighted for improvement in Sri Lanka, as only ~50% compliance was observed in the JCCPSL study

Step 4 - Thermal Care / Prevention of Hypothermia

• Skin-to-skin contact (SSC) on the mother's chest, with the baby's body and head covered by a cloth or hat - practiced in ~83% of Sri Lankan deliveries
• If SSC is not possible, wrap the baby well and cover the head
• Do NOT bathe the baby immediately - delay first bath for at least 6-24 hours (delayed bathing prevents hypothermia)
• Target axillary temperature: 36.5 - 37.5°C
• For preterm/VLBW infants (<32 weeks): use a plastic bag for additional thermal protection; raise room temperature to 25°C

Step 5 - Identification of the Baby

• Place an identification band on the baby - this is performed in 100% of deliveries in Sri Lanka and is mandatory

Step 6 - Early Initiation of Breastfeeding

• Initiate breastfeeding within the first hour of birth (the "golden hour")
• Exclusive breastfeeding on demand thereafter; term infants should feed 8-12 times/day
• Rooming-in of baby with mother must be universally practiced
• Mother should be counselled and supported on correct breastfeeding technique

Phase 3: Subsequent Care (First hours to days after delivery)

Step 7 - Vitamin K Administration

• Vitamin K 1 mg IM (intramuscular injection) given at birth to all newborns
• Prevents haemorrhagic disease of the newborn (HDN) / Vitamin K Deficiency Bleeding (VKDB)

Step 8 - Eye Care

• Instillation of eye drops (antibiotic prophylaxis against gonococcal ophthalmia neonatorum) - note that this is not a standard routine practice in Sri Lanka (observed in only 5.2% of deliveries in the JCCPSL study), unlike in some Western protocols. It is given only when indicated based on maternal history.

Step 9 - Clinical Examination (Full Physical Assessment)

• Vital signs: heart rate, respiratory rate (normal: 40-60 breaths/min), temperature, oxygen saturation
• General appearance: skin color, posture, tone, activity
• Anthropometry: weight, length, head circumference (recorded at delivery and at discharge)
• Systematic examination: head (fontanelles, sutures), eyes (red reflex), ears, palate, neck, chest, cardiovascular system (heart sounds, pulses, capillary refill), abdomen, genitalia, spine, limbs, hips, neurological assessment
• Gestational age assessment

Step 10 - Monitoring in the Postnatal Period

• Blood glucose monitoring: performed if the infant is at risk (infant of diabetic mother, LGA, SGA, preterm, symptomatic)
• Monitor for jaundice: assess clinically for hyperbilirubinemia, accounting for risk factors; serum bilirubin if clinically indicated
• Monitor urine output and stool: at least 1 void and 1 meconium stool within the first 24 hours
• Monitor weight: alert for weight loss >10%
• Vital signs documentation: respiratory rate hourly in sick/at-risk infants

Step 11 - Cord Care

• Keep the cord clean and dry
• Dry cord care is recommended in clean facility settings (per WHO and Sri Lanka guidelines); no routine application of antiseptics to the cord stump in clean hospital births
• In high-infection-risk community settings, chlorhexidine application to the cord may be advised

Step 12 - Vaccination (as per National Immunization Schedule of Sri Lanka)

• BCG vaccine (intradermal, right shoulder) - for prevention of tuberculosis
• OPV-0 (Oral Polio Vaccine - birth dose) - given at birth
• Hepatitis B vaccine (birth dose) - given within 24 hours of birth, especially important for HBsAg-positive mothers

Step 13 - Newborn Screening

• Neonatal metabolic screening: performed ideally within the first 72 hours and at least 24 hours after feeding has been established (screens for hypothyroidism, PKU, and other metabolic disorders per the Sri Lanka newborn screening programme)
• Hearing screening: newborn hearing screening before discharge
• Critical Congenital Heart Disease (CCHD) screening: pre- and post-ductal pulse oximetry

Phase 4: Pre-Discharge Assessment and Counselling

Clinical Readiness Criteria

• Baby maintaining temperature (36.5 - 37.5°C) in room air
• Feeding well (breastfeeding established or alternative feeding method if needed)
• Weight loss <10% of birth weight (or steady weight gain if more than 1 week old)
• No signs of infection, jaundice requiring treatment, or respiratory distress
• Urine and stool passed
• Normal examination with no unresolved clinical concerns
• All required vaccinations completed

Documentation and Records

• Birth weight, head circumference, length recorded
• Vaccination record completed and handed to mother (Child Health Development Record)
• All screening results documented in the Baby Health and Treatment (BHT) records
• Identification verified

Discharge Counselling (Parent Education)

1. Thermal care: keep the baby warm, avoid hypothermia
2. Feeding: exclusive breastfeeding, feeding on demand, recognizing hunger cues
3. Cord care: keep dry and clean, signs of infection (redness, swelling, discharge)
4. Bathing: how to safely bathe the newborn
5. Sleep safety: safe sleeping position (supine), avoid co-sleeping hazards
6. Danger signs requiring urgent medical attention:
   • Fast/difficult breathing
   • Inability to feed or reduced feeding
   • Convulsions
   • Abnormal movements or high-pitched cry
   • Fever (>37.5°C) or hypothermia (<36.5°C)
   • Jaundice extending below the umbilicus
   • Umbilical redness/discharge/bleeding
   • Pallor or cyanosis
7. Follow-up: schedule for outpatient review and next vaccinations (6 weeks: DTP-1, OPV-1, Hepatitis B-2)
8. Referral to Well Baby Clinic / Midwife for ongoing community postnatal care

Summary Sequence at a Glance

• National Guideline for Newborn Care, Vol. 1 (2020), Family Health Bureau, Ministry of Health Sri Lanka (referenced throughout the Perinatal Society guide)
• Perinatal Society of Sri Lanka / Sri Lanka College of Paediatricians - Guide to Neonatal Intensive Care (2022)
• Peiris D et al. - Practices of Essential Newborn Care, JCCPSL 2023, 29(4):265 - observational data from Sri Lankan hospitals
• The Harriet Lane Handbook, 23rd ed. (Johns Hopkins) - p. 643, Section II, Routine Newborn Care
• Park's Textbook of Preventive and Social Medicine - p. 532, Immediate Newborn Care

Note on eye prophylaxis: Unlike many Western protocols, routine antibiotic eye drops at birth are not standard practice in Sri Lanka. They are given selectively based on risk (maternal STI history). Confirm with the specific institution's protocol, as practices can vary between facilities.