Essential Newborn Care Protocol

The ENC Protocol:

DOH Administrative Order
December 2009

Rationale

RP among 42 countries accounting for

90% of under-five deaths
Reductions in childhood death rates have
slowed down

Neonatal deaths declined the slowest

3/4 of under-five deaths occur in the

neonatal period
Half of all neonatal deaths occur in first 2
DOL

Rationale

Observational study of minute-by-minute

newborn care done in first hour of life in
51 hospitals showed:

Only 3% of newborns were dried prior to or with cord

cutting
Unnecessary delays and restrictions on immediate
and sustained skin-to-skin contact, early latching on,
rooming in and breastfeeding
Almost no newborn benefited from natural transfusion
through non-immediate cord clamping
Only 61.3% of newborns was initiated to
breastfeeding within the first hour
More than 80% exposed to hypothermia during
washing
Virtually all healthy newborns were suctioned

Objectives

In general, this policy aims to ensure the

provision of globally accepted evidencebased essential newborn care focusing on
the first week of life.
Specifically, it aims to:
Guide health workers and medical practitioners in
providing evidence-based essential newborn care
Define the roles and responsibilities of the
different DOH offices and other agencies in the
implementation of the ENC protocol

Scope of Application

AO applies to whole hierarchy of the DOH

and attached agencies
Also applies to:
Public and private providers of health care
Development partners implementing the MNCHN
strategy
All health practitioners involved in maternal and
newborn care

Guiding Principles

Evidence-based interventions
Integrated service delivery
Human-rights based approach
Life-cycle based intervention
Multi-sectoral collaboration

Specific Guidelines

Ensure Quality Provision of Time-Bound

Interventions:
This is the aspect of newborn care in RP that have not
met international standards, and should therefore be retaught and re-learned by all health care providers

Within the first 30 seconds:

Dry and provide warmth to the newborn

After thorough drying:

Facilitate bonding between the mother and her newborn through

skin-to-skin contact

Up to 3 minutes post-delivery:

Delayed or non-immediate cord clamping

Within 90 minutes of age:

Facilitate early initiation to breastfeeding

Proper eye care

Specific Guidelines

Non-immediate interventions
Vitamin K prophylaxis
Hepatitis B and BCG vaccinations
Examine newborn, check for birth injuries,
malformations or defects
Cord care

Newborn Resuscitation
Additional care for small baby or twin

Specific Guidelines

Unnecessary procedures
Routine suctioning
Early bathing/washing
Footprinting
Giving sugar water, formula, or other prelacteals
and the use of bottles and pacifiers
Application of alcohol, medicine and other
substances on the cord stump and bandaging the
cord stump or abdomen

Discharge instructions

Roles and responsibilities

LGU:

Adopt and implement the policy

Ensure availability of budget support
Conduct orientation/trainings for private and
public health workers on maternal and newborn
care policies including this protocol
Monitoring and evaluation

Development partners:

Support implementation of maternal and newborn

care policies and activities
Coordinate and collaborate with DOH and the
LGUs in the conduct of maternal and newborn care
practices

The Essential Newborn Care

Protocol (Unang Yakap)

The ENC Protocol

Within the first 30 seconds:
Dry and provide warmth to the
newborn
2. After thorough drying:
Facilitate bonding between the
mother and her newborn through
skin-to-skin contact
3. Up to 3 minutes post-delivery:
Delayed or non-immediate cord
clamping
4. Within 90 minutes of age:
1.

Immediate newborn care

Time band: at perineal bulging

Intervention: prepare for the delivery
Action:

Ensure that the delivery area is draft-free and

between 25-28C using room thermometer
Wash hands with clean water and soap
Double glove just before delivery

Immediate Newborn Care

(First 90 minutes)

Time band: First 30 seconds (call out time of birth)

Intervention: dry and provide warmth
Action:

Use clean, dry cloth to thoroughly dry the baby by wiping

the eyes, face, head, front and back, arms and legs
Remove the wet cloth
Do a quick check of babys breathing while drying

Note:
Do not ventilate unless baby is floppy/limp/not breathing
Do not suction unless the mouth/nose are blocked with
secretions or other material

Immediate Newborn Care

(First 90 minutes)

Time band: if after first 30 seconds of drying, baby

is limp/floppy/not breathing
Intervention: Re-position, suction and ventilate
Action:

Clamp and cut cord immediately

Call for help
Transfer to warm, firm surface
Inform parents that baby has difficulty breathing and
you will help the baby to breathe
Start resuscitation protocol

Notes for baby who is floppy/limp/not

breathing

Health worker not skilled at advanced

resuscitation (or skilled but not equipped with
intubation needs):

Clear the mouth

Start bag/mask ventilation
Refer and transport

Health worker with advanced skills at

resuscitation:

Intubate the baby and ventilate

Refer and transport as necessary

Immediate Newborn Care

(First 90 minutes)

Time band: if after 30 seconds of drying the baby

is breathing or crying
Intervention: Do skin-to-skin contact
Action:

Avoid any manipulation (such as routine suctioning) that

may cause trauma or introduce infection
Place baby prone in skin-to-skin contact on mothers
abdomen
Cover babys back with a blanket and head with a
bonnet
Place identification band on ankle

Notes for the baby who is breathing/crying

Do not separate the baby from the mother as

long as the baby does not exhibit severe chest
in-drawing, gasping or apnea and the mother
does not need urgent medical stabilization
(e.g. hysterectomy)
Do not put the baby on a cold or wet surface
Do not wipe off the vernix
Do not bathe the baby earlier than 6 hours of
life
Do not do footprinting

Within first 90 minutes of life

Time band: 1-3 minutes

Intervention: delayed or non-immediate cord
clamping
Action:

Remove first set of gloves immediately prior to

cord clamping
Clamp and cut the cord after cord pulsations have
stopped

Put ties around the cord at 2cm and 5cm from the
babys abdomen
Cut between ties using sterile instrument
Observe for oozing of blood

Note:

Within first 90 minutes of life

Time band: within 90 minutes of age

Intervention: Provide support for initiation of
breastfeeding
Action:

Remove the first set of gloves immediately prior to

cord clamping
Leave the baby on mothers chest in SSC
Observe the baby. Only when the newborn shows
feeding cues (opening of mouth, tounging, licking,
rooting), make verbal suggestions to the mother
to nudge her baby to move to the breast

Counsel on positioning and attachment: when

the bay is ready, advise the mother to:

Make sure the babys neck is not flexed or twisted

Make sure the baby is facing the breast, with the
babys nose opposite her nipple and chin touching
the breast
Hold newborns body close to her body
Support the babys whole body, not just the neck
and shoulders
Wait until her newborns mouth is opened wide
Move her newborn onto her breast, aiming the
infants lower lip well below the nipple

Summary of interventions after drying the

baby and placing baby in SSC

Do delayed or non-immediate cord clamping

Provide support for initiation of breastfeeding

Provide additional care for a small baby or twin
(KMC)

Remove 1st set of gloves immediately prior to cord

clamping
Place ties around 2cm and 5cm from babys abdomen
Oxytocin 10 IU IM to mother after cord clamping

Prepare very small baby (<1.5kg) or a baby born >2

months early for referral

Do eye care

Administer erythromycin/tetracycline/2.5% povidoneiodine after baby has located the breast

After first 90 minutes

Does the baby have signs of illness?

Is the baby visibly small?

After 90 minutes of age (after baby has

detached from breast):

Keep baby in SSC; cover with extra blankets;

prepare for referral if <1.5kg

Examine baby
Weigh baby
Inject Vit. K, Hepa B and BCG

Room in and continue exclusive per demand

breastfeeding

After first 90 minutes

Time band: 90 minutes 6 hours

Intervention: Vit. K prophylaxis, Hepa B andf
BCG
Action:

Wash hands
Inject Vit. K 1mg IM
Inject Hepa B and BCG

After first 90 minutes

Intervention: examine the baby

Action:

Thoroughly examine the baby

Weigh the baby and record

After first 90 minutes

Intervention: check for birth injuries, malformations or

defects

Bumps on one or both sides of the head, bruises, swellling on

buttocks, abnormal position of legs after breech presentation
or asymmetrical arm movement, or arm that does not move

If present: explain to parents that this does not hurt the baby, is
likely to disappear in 1-2 weeks and does not need special treatment
Gently handle the limb that is not moving
Do not force legs into a different position

Look for malformations: cleft palate or lip, club foot, odd

looking or unusual appearance, open tissue on head,
abdomen or back

Cover open tissue with sterile gauze before referral

Refer for special treatment

After first 90 minutes

Intervention: cord care

Wash hands
Put nothing on the stump
Fold diaper below the stump. Keep cord stump
loosely covered with clean clothes
If stump is soiled, wash with clean water and soap,
then dry thoroughly with clean cloth
Explain to mother she should seek care if
umbilicus is red or draining pus
Teach the mother how to treat local umbilical
infection 3x a day

Home cord care

Mother should wash hands with clean water

and soap before handling the baby
Gently wash off pus and crusts with boiled and
cooled water and soap
Dry the area with clean cloth
Paint with gentian violet
Wash hands
If pus or redness worsens or does not improve
in 2 days, refer urgently to hospital

Schedule of routine visits

Postnatal visit 1: at 48-72 hours of life

Postnatal visit 2: 7 days of life
Immunization visit 1: at 6 weeks of life
Schedule additional follow-up visits depending
on babys problems:

After 2 days: if with breastfeeding difficulty, LBW

in 1st week of life, red umbilicus, skin infection, eye
infection, thrush or other problems
After 7 days: if LBW discharged >1 week of age
and gaining weight adequately