Newborn Fatality and Midwifery

CHAPTER-I

INTRODUCTION

“Every child born into the world is a new thought of god an ever fresh and radiant possibility� -Kate dauglas Wiggin Health is the most important, sought-after thing in the world by all, no matter who we are, when well- cared for their earliest years, children are more likely to survive grow up the first month is crucial importance, in terms of health care. The health of women and children is the basis of a healthy family and a healthy nation. This is particularly true of children whose healthy future depends on proper care during the first year life (UNICEF, 2002).Newborns are the blessings for today and tomorrow.

The newbornâ€s body is most supersensitive, delicate, immature and susceptible from which can easily harmed if not taken care of newborn. The birth of a baby is an event a moment which creates a great joy and wonder of godâ€s gift, a gift of god in the life of parents. From the moment of birth, many parents are loved to involve in the care of the newborn. The first care given to a neonate include placing him/her in a warm environment , suctioning the oropharynx and nose , cleaning the eyes , clamping and cutting the cord ,checking the weight , tying the identification tag and mummifying the baby. First time the mother smiles when the newborn is cry and she forgets the pain. The newborn, once separated from the mother in the process of delivery, undergoes certain fundamental changes in which he/ she leaves the sterile environment of the uterus and moves into the outside environment .This separation occurs through the severing of the umbilical cord. After birth, the cord is no longer needed, and is cut, leaving a short stump Behind on-pathogenic bacteria such as coagulate –negative staphylococci, e-coli, and streptococci, clostrium tetani may also be present on the skin and can track up the umbilical stump causing infection (ZUPAN et a l …, 2005). The UNICEF report released at the National conference on child survival and development in New Delhi, claims that out of nearly 26 million children born in India each year, 1.2 million die during the first 4 weeks .This is the 30% of the 3.9 million global neonatal deaths. According to current report (neonatal mortality) of 44/1000 live birth accounts for nearly 2/3rd of all infant deaths (death before the age of one) and nearly half of under – five children deaths in India. Indiaâ€s NMR significantly from 69/1000 live births in 1980-50/1000 –live births in 1990 .In recent years NMR has remained static only dropping four points from 48-44/1000 live birth in 1995 and 2000. The main causes of neonatal deaths are low birth weight and infections (Indian express, 2004). One million newborn infants die every day by multiple of organisms which often enter in to the body via the umbilicus. The other contributing causes of umbilical cord infection includes maternal factors like maternal infections e.g. amionitis, repeated vaginal examinations during labour, duration of rupture of membrane, unhygienic practice of delivery, delivery conducted by untrained dais, environment factors like cleanliness of the ward and caregiver with severe infection, upper respiratory infection and neonatal factors like small for gestational age, preterm newborns ,birth condition during labor like me conium stained liquor, umbilical cord infection had caused many neonatal death before aseptic technique were used .In developing countries umbilical cord infections constitute a major cause of Neonatal morbidity and pose significant risk for mortality, in the environment as the umbilical outbreaks of cord infection continue to occur even in developed nurseries (Zupan et al 2000). The hospitalized neonates may get infection from various sources like tube feeding, unhygienic cloth, avoidance of baby bath, using many cosmetics, etc. Environment as the umbilical cord is a means of entry for systemic infective agents that colonize the skin of the newborn. Umbilical cord is the only route of entry for microbes, because it has opening in the umbilicus, even though the cord clamp was there in the cord It is therefore essential to keep the cord clean to prevent infection and promote a normal healing until the stump dries up and falls off by giving umbilical cord care during the transition period.

SIGNIFICANCE OF AND NEED FOR THE STUDY

In midwifery practices, the newborn care is an important aspect and the kind of care and attention given immediately after birth and later is greatly valued. Umbilical cord care is very important since infections of the cord can be so fatal that it may even lead to the death of the neonate. Despite the importance of umbilical cord care, both traditionally and medically, there have been few randomized trials investigating the impact of different cord care regimen on rates of local or systemic infections, particularly in developing countries (Mullany et al 2003) Also, nursing studies and literature pertaining to the care of umbilical care relatively limited and the procedures adopted for umbilical cord care is varied. The present study intends to investigate the effectiveness of lukewarm water application on the umbilical cord of newborns in terms of occurrence of umbilical cord infection. Bain (1994) undertook a study to find the effect of four different cord care regimens in preterm babies. The evidence of the trail suggested that cleaning the cord with alcohol, wiping and dusting with sterzac powder resulted in less cord related infection and a shorter time for cord separation compared to any other cord care regimen. All these conclusive evidences prove that the policy of leaving umbilical cords untreated is not a safe practice. In many studies reported clean the umbilical cord with warm water compare than antiseptic solution. Antiseptic solution may cause delay in healing and form the pus (NNT 2010). Zupan and Garner (1998) carried out a study on the effectiveness of topical agents for umbilical cord care to prevent cord care infection, illness and death in newborn infants in developed countries. They have included newborns of any gestation, using any of the following interventions – topical antiseptic applications. Clean with warm water, Including the newborns who were born outsides well as inside the hospital, the incidence of umbilical sepsis was2001-10 cases,2002-24case,2003- 19 cases.,2004( Jan out) -15 cases. Early onset of neonatal sepsis is clinically apparent within 72 hours of life , with an overall mortality rate of 15-50% .Late onset neonatal sepsis is usually present after 72hours of life and includes nosocomially acquired infections .The overall mortality rate of late onset sepsis is 10-20% Bobak et al (1995).The UNICEF report released at the National conference on child survival and development in New Delhi, claims that out of nearly 26 million children born in India each ye1.2 million die during the first 4 weeks .This is the 30% of the 3.9 million global neonatal deaths. According to the current report (neonatal mortality) of 44/1000 live birth accounts for nearly 2/3rd of all infant deaths (death before the age of one) and nearly half of under – five children deaths in India. Indiaâ€s NMR significantly from 69/1000 live births in 1980-50/1000 –live births in 1990 .In recent years NMR has remained static only dropping four points from 48-44/1000 live birth in 1995 and 2000.India contributes to 20% global birth and highest number of neonatal death within a country, each year, 26 million infants are born in India of these 1.2 million die during the neonatal death period before completing the first four weeks of life. Two newborns deaths occur every minute in this vast country. The current neonatal mortality rate (NMR) is around 40/1000 live birth of less than five mortality rate. Between 1995and 2000, there was only a legible decrease 4 points in NMR – from 48-44/ 1000 live birth. The tapering off the rate decline is a cause of concern requiring serious planning and newer strategies. The main causes of neonatal deaths are low birth weight and neonatal infections; maternal infections (Indian express, 2004). One million newborn infants die every day by bacterial infection which often enters the body via the umbilicus. The other contributing causes of umbilical cord infection includes maternal factors like maternal infections e.g. amionitis , repeated vaginal examinations during labour, duration of rupture of membrane, place of delivery, environment factors like cleanliness of the ward and caretaker with URI , technical factors like method of cord care , hand washing technique, and transfer of infant and neonatal factors like gestational age, birth condition during labor , umbilical cord infection had caused many neonatal death before aseptic technique were used. In developing countries umbilical cord infections constitute a major cause of Neonatal morbidity and pose significant risk for mortality, in the environment as the umbilical outbreaks of cord infections continue to occur even in developed nurseries (Zupan et al 2000). The traditional practices of cord care in this area include application of hot fermentation (31.5%), use of rag and latern(19.5%), use of Vaseline (9,5%), ash/charcoal(9.3%), groundnut/palm oil (8.3%), use of powder (6.5%),and red sand (3.5%), These practices are harmful because these substances are often contaminated with bacteria and spores, thus increasing the risk of infection.(Konduga local government area of born state-2005) Traditional nursing procedures are being gradually substituted by more modern Practices. As technologic advance, Nursing practices also change. As many routine procedures like predelivery perineal shave, predelivery enema are questioned, the efficacy of the antiseptic solution usage for umbilical cord care has also become a question and a study is necessitated through comparing the existing practices with the key outcomes .Therefore, the investigator strongly felt need to do study, comparing the use of antiseptic solution with lukewarm water for umbilical cord care in order to find out the effectiveness of lukewarm water.

STATEMENT OF PROBLEM

An experimental study to evaluate the effectiveness of umbilical cord care using lukewarm water among newborns in selected hospital at Madurai district.

OBJECTIVES

To assess the umbilical cord after cord care experimental group and control group. To compare the effectiveness of cord care experimental group and control group. To find the association between experimental group with selected demographic variables To find the association between control group with selected demographic variables. HYPOTHESIS There will be significant difference between experimental group and control group after cord care. There will be significant association between experimental group with selected demographic variables. There will be significant association between control group with selected demographic variables

OPERATIONAL DEFINITION

Effectiveness

In this study it refers to the outcome of an experimental study indentified with help of significant difference between tests among newborns.

Newborn

In this study it refers to the period from birth to28 days of life is called period and the infant in this period is termed as neonate or newborn baby.

Umbilical cord care with lukewarm water

In this study it refers to warm water with a degree of 70-97â—¦f or 26-36â—¦c to clean the umbilical cord and the cord is left dry and open.

ASSUMPTION

Application of lukewarm water will prevent infection of the umbilical cord. Application of lukewarm water it promotes early healing of umbilical cord.

DELIMITATIONS

`The study is limited to the newborn of the mothers who had LSCS. The study is confined to selected hospitals.

PROJECTED OUTCOME

The result of the study would help the investigator to identify the effectiveness of cord care using lukewarm water among newborns. The study will help to promote a early healing of the umbilical cord and to reduce the infections. The findings on demographic variables would help to identify the factors which affect the newborns with infection

CHAPTER-II

REVIEW OF LITERATURE

Review of literature is an important, essential aspect of scientific treatment .It involves the systematic identification, location scrutiny and summarization of the written material that contains information on a research problem. It broadens the understanding and provides the insight necessary for the development of a broad conceptual context into which the problem fits (polit & hungler, 1995). A review of related research and non- research literature was undertaken and an attempt was made to organize the materials. This includes Umbilical cord care Review on studies related to umbilical cord care using lukewarm water Review on studies related to cord care.

UMBILICAL CORD CARE

Umbilical cord

Inspect the Umbilical cord area for the correct amount of blood vessels, two arteries and one vein. The umbilical vein is larger than the umbilical arteries. A yellow – brown or green tinge to the cord indicates the me conium was released. The umbilical cord should be checked for bleeding or oozing during the early hours after birth. The clamp must be securely fastened with no skin caught and tissue injury.

Pathophysiological background

The umbilical cord is a tissue, which of consisting of two arteries and one vein covered by a mucoid connective tissue called Wharton’s jelly and a thin mucous membrane. During pregnancy, the placenta supplies all nutrients for fetal growth and development and removes waste products. Blood flowing through the cord brings nutrients and oxygen to the fetus and carries away carbon dioxide and metabolic wastes. After birth, until the placenta separates and while the cord is still pulsating, a small volume of blood may be transfused from the placenta to the newborn. The amount transfused depends on when the cord is cut and the level at which the baby is held in relation to the mother at the time of cord clamping

Umbilical cord healing process

The cord darkens and shrivels as it dries and falls off within 7-14 days. The cord should be dry and not have any drainage. After the cord falls, a small pink, granulating area about a quarter of an inch in diameter may remain. This should also be left clean and dry until it has healed (about 24- 48 more hours). umbcord

Umbilical cord infection

In umbilical cord if the ulcerous area has remained as long as one week it indicates of sign of infection.

Source of infection

Unhygienic environment of delivery Contaminated cord cutting instrument Infected hands of care giver or infected clothing

Causative organisms

Staphylococcus E-coli Clostridium tetani

Signs and symptoms

Swollen and moist per umbilical tissue with redness Foul smelling Serous or purulent discharge Delayed falling of umbilical cord Fever

Management

Umbilical cord should leave uncovered rather than application of dressing. Systemic antibiotic is given in complicated cases.

Complication

Jaundice Hepatitis Peritonitis Umbilical granuloma

Prevention

Aseptic technique and clean practices at birth. Administration of tetanus toxoid to antenatal mothers.

Prognosis

Prognosis depends upon the nature of infection, intiation of management and nursing care. Prevention of umbilical cord infection is more easy and important in neonates.

Cord care DOâ€s and DONTâ€S

Doâ€s

Cut the cord with a clean instrument. Tie the cord tightly with clean or sterile thread or clamp. Tie napkin or diaper below the umbilical cord. Donâ€ts Bandages are unnecessary and may delay in cord healing and introduce infection to the newborn. Alcohol cleaning may delay in healing and cause pus. Apply traditional remedies to the cord may cause infection World Health Organization, (1999) Current standards of cord care is based on the principles of aseptic techniques. The aim of WHO to prevent the cord infections. However, the introduction of infection in neonatal care unit and well baby clinic for newborns in hospitals in the 1940s increased the risk of staphylococcal skin and cord infections by facilitating the spread of bacteria among infants in hospital. Clean the cord at birth and in the days following birth is effective in preventing cord infections and tetanus neonatrum. Clean cord care practices at birth include washing hands with clean water and soap before delivery and again before cutting and tying the cord, laying the newborn on a clean surface and cutting the cord with a sterile instrument and sterile clamp. Clean cord care in the postnatal period includes washing hands with clean water and soap before and after care and keeping the cord stump dry and exposed to air or loosely covered with clean clothes. If soiled, the cord should be washed with clean warm water (cleaning with alcohol seems to delay healing). The napkin should be folded below the umbilicus.

REVIEW RELATED TO CORD CARE USING LUKEWARM WATER

Kimberly Dow,(2010 ) reported news about the umbilical cord, After the umbilical cord is cut at birth, a stump of tissue remains attached to the umbilical cord. The cord will dry and shrinks. It is important to keep the umbilical cord stump and surrounding skin clean and dry. This cord care helps to prevent infection. It may also help the umbilical cord stump to fall off and the cord to heal 90% more quickly; gently clean the umbilical cord once a day. Soak a cotton swab in warm water. Squeeze out the excess water. Gently wipe around the sides of the cord and around it. Wipe away any wet, sticky, or dirty substances. Gently pat dry the area with a soft cloth. The stump usually falls off in a week or two but sometimes it takes longer. Continue to clean around the umbilical cord at least once a day until the cord has completely healed. Keeping the area Wyeth (2010) reported news about the umbilical cord. Keep the stump of the umbilical cord clean and dry until it falls off, which usually happens within a few weeks Clean the cord at each napkin change to help to dry out and to prevent entry of infection Wipe gently around the cord with a damp cotton swab .Keep the napkin folded below the navel area to keep the cord from being soaked with urine. Evidence-based clinical practice guidelines(2010) was reported about umbilical cord Sometime between five and 15 days after birth, the cord will dry up, turn black and drop off, leaving a small wound that may take a few days to heal. It must be kept clean and dry to prevent infection. Harmful bacteria that live naturally on the skin can enter in to the cord causing infection. Avoid the traditional practice of taping a coin to retract the belly button as it may encourage infection and delay the healing process. Avoid the cord stump getting urine by folding the napkin down away from it, leaving the cord exposed to the air. If the cord gets urine, wash it off using clean warm water or just water alone. When the stump falls off, it may shows of signs of little blood on the umbilical cord which is normal. In the past, cord stumps have been cleaned with antiseptic tissues or sprinkled with an antiseptic powder. Studies of the healing process have found no advantage to using antiseptics over simply keeping the cord clean, unless the baby is premature or in intensive care. Antiseptics also cause the cord to take longer to fall off, which causes anxiety to parents and increases the number of postnatal consultations with doctors. Satish Chandra. V.Naik etal (2009) in pune, study was to conduct impact of training of traditional birth attendants on the newborn care. The setting of the study was PHC, 45 TBAs attended 2 days training programme. Different AV- aids were used to interact the sessions by LCD, flipcharts, videoclipings. Pretest evaluation showed that there was a difference in the depth of knowledge regarding newborn care between previously trained tai and untrained tai .this difference was statistically difference p(<0.05). Umbilical cords assessed by 2 methods clean with warm water and application of herbal preparation. The results in pretest for trained TBA for warm water 17(85%) post test 19(67.8%) and application of herbal preparation for untrained TBAs pretest 26(86.6%) post test 19(67.8%). In this study the practice of keeping the umbilical cord stump clean and dry, progressively improved from 15% and 53.3%and0-52% among warm water and application herbal preparation. It reported a 25% in reduction of NMR (NNT)* Luke C Mullany.g.etal (2009) reported a study was to conduct cluster-randomized, community-based trial to assess the impact of three cord care regimens either A large community-based trial in rural southern Nepal conducted between 2002 and 2006 randomized babies within clusters to receive one of three cord care regimens: (1) 4.0% chlorhexidine cleansing for 7 of the first 10 days after birth or (2) soap and warm water cleansing for 7 of the first 10 days after birth, or (3) dry cord care. Overall, mortality among enrolled infants was 24% lower in the chlorhexidine group compared to dry cord care. Clinical evidence of a protective of warm water cleansing among this newborns subset was increased. Warm water cleansing reduced severe infection by 87% and mortality by 34% among those enrolled within 24 hours. Alam .M. Ali .etal (2008) in Bangladesh, the study conducted by cluster- randomized. Unstructured interview (n-60), structured interview (n=20), rating and ranking exercises (n=40),83% of umbilical cord care revolved around the bathing. Over all 40% of newborns are clean with warm water during newborn age of period only 9% of reported of infections and other application of cord care (83%) of reported of infections.