Field Care For Your Newborn, by T.S.H., MD

Thursday, Dec 20, 2012

Modern neonatal care in a fully equipped and staffed hospital connected to a power grid will be all but a memory in TEOTWAWKI. In the event of SHTF where professional medical services are no longer available it is completely up to the parent(s) to assist the newborn in the traumatic transition from womb to world. Knowledge of basic neonatal field care will increase the chances of survival for a newborn. This article is divided into three sections: Pregnancy, Transition, and First 48 Hours.

Pregnancy

The first section of this article deals with pregnancy. To begin our discussion of field care for your newborn, it is prudent to address women’s lifestyle choices today that will directly impact the success rate of their pregnancies and infant health tomorrow. In anticipation of potential TEOTWAWKI, we maximize our survival chances through diligent stockpiling, training and construction. In the same spirit, women should maximize their future children’s survival chances through healthy lifestyle choices that could contribute to a more robust pregnancy.
Women who have medical conditions such as diabetes, asthma and/or high blood pressure are at increased risk of having infants with difficult transitions. In addition, women who smoke, drink and/or use controlled substances during pregnancy are also increasing the risks for their future children. I thereby urge women to adopt and maintain healthy diets, exercise regularly, and break any addictions to nicotine and/or alcohol ASAP. Healthy lifestyle choices apply just as strongly for men, of course. Pursued jointly as a couple, healthy lifestyles can be more easily achieved and maintained. When SHTF, we must be in prime condition because there will be nobody and nowhere to run to for help.
It is estimated that approximately 15-30% of pregnancies end in miscarriage regardless of access to professional medical care. Of the uncomplicated, full-term pregnancies that result in delivery, 90% of infants transition without need for any intervention. 10% of infants will need some form of help, and of those, 1% will need intensive intervention. It is crucial to be prepared to assist the 10% with the acknowledgement that there is little that can be done for the 1% with intensive needs. Simply put, out of 100 babies born, 9 will need your help to survive the transition.

Transition

The second section of this article covers transition. The “transition” for a newborn is generally the first six hours of life. A newborn needs to be immediately evaluated to determine its initial state of health. Doctors have developed a simple system to do this called APGAR, which stands for APPEARANCE, PULSE, GRIMACE, ACTIVITY, and RESPIRATION. Each criteria are given a score from 0–2 based on the appearance and behavior of the baby. All scores are added up to determine whether your newborn is healthy or needs immediate help. The scores are calculated as follows:
APPEARANCE: blue=0; pink with blue extremities=1; pink=2
PULSE: no pulse=0; pulse<100=1; pulse>100=2
GRIMACE: (response to rubbing/scratching) no response=0; weak cry=1; loud cry/pulling away=2
ACTIVITY: floppy limbs=0; some flexing of limbs=1; flexing of limbs against resistance=2
RESPIRATION: absent=0; weak and irregular=1; strong, crying=2
The sum of these scores gauges the initial health of the baby as follows:
NORMAL: 7–10
LOW: 4–6
CRITICALLY LOW: 0–3.
APGAR can be administered by anybody. But in the heat of the moment, rational behavior and memory can be impaired. I suggest that you write down the basic APGAR scorecard on an index card and pack it in your BOB. If the APGAR guidelines are lost or forgotten, remember these basic guidelines: a baby born at term, crying or breathing with pink color and good tone can stay with the mother; a baby born floppy, silent or bluish must immediately be resuscitated.
Basic resuscitation is begun by briskly rubbing down the baby with a clean towel or cloth. This stimulates crying and reduces the risk of hypothermia. Infants who are not in severe danger should respond fairly quickly to physical stimulation. If they do not, they need advanced neonatal resuscitation. Infant CPR, unfortunately, is far beyond the scope of this article. While many individuals might have training or have cursory knowledge of basic adult CPR, all of it goes out of the window when it comes to infants. Infants are extremely delicate and can be fatally injured with even the most delicate efforts and loving intentions. This is why as a professional physician I direct parents and young couples to attend Infant CPR and/or Neonatal Resuscitation classes that are offered by the American Red Cross and American Heart Association as well as numerous institutions recommended. Go to www.redcross.org or www.heart.org to learn more.
Keep in mind that it is well within your abilities to rescue an infant in jeopardy. Nearly one half of all newborn deaths occur within the first 24 hours after birth. Many of these deaths are caused by asphyxia (inability to breathe). This means that with proper training, you could be equipped to effectively deal with a common complication among newborns. If you expect to become a parent within the next ten years, equip yourself with this valuable training and knowledge while it is still available.

First 48 Hours

The final section of this article covers general newborn field care topics including delayed cord clamping, umbilical stump care, skin-to-skin, breastfeeding, and nutrition.
The average newborn has about 300mL of blood (one can of soda) with a portion of the blood still in the placenta after delivery. If you were to place your hands on the umbilical cord before the placenta was delivered, you could feel the cord pulsating; this signifies that blood is being transfused back into the baby from the placenta. People pay thousands of dollars to collect and store the umbilical cord blood, with the hope that in the future the stem cells in the cord blood can be used if needed. There are OBGYNs who encourage the use of delayed cord clamping to auto-transfuse the baby with its own stem cells. The process is simple: do not clamp and cut the cord until you feel the cord stop pulsating. If there is concern for fetal compromise and resuscitation must be performed quickly , milk the cord several times towards the baby before clamping and cutting. Make sure to use sterilized instruments for cord clamping and cutting. In a survival scenario, submerge all knives, instruments and towels in a pot of boiling water for five minutes or more. Note that the tool or implement with which you retrieve the sterilized items from the pot must itself be sterilized first. A simple workaround is to pour the boiling water out of the pot and handle the knives and instruments upon actual intended usage.
There is no evidence that there needs to be any further care of the umbilical cord stump if the umbilical cord was clamped/cut in an aseptic (free from disease-causing bacteria) manner. In a sterile environment, dry cord care (keeping the stump clean and dry) is effective. Take care that the infant’s diaper is folded down below the umbilical stump. Dry cord care is recommended when sterile instruments have been used during delivery but this cannot be guaranteed without an autoclave machine. Therefore umbilical stump care may be necessary. Studies have shown that cleaning the umbilical stump with chlorhexidine reduced the rate of infection and newborn mortality. In the absence of chlorhexidine, use an antiseptic ointment or rubbing alcohol. The umbilical stump will separate after one week.
Skin-to-skin care – also called “Kangaroo Care” – describes a way of holding a newborn so that there are no clothing barriers between the infant and the mother. This form of mother-infant interaction has been shown in multiple studies to be beneficial. The benefits include assisting the baby to sleep better, breastfeed sooner, breastfeed better and increase weight gain faster. Research shows that this form of contact helps regulate the baby’s physiologic processes including pain responses, temperature, breathing, and heart rate. Preterm and low-birth weight infants who are born in resource-poor settings particularly benefit from kangaroo care. In a typical labor and delivery floor, stable infants are immediately placed on the mother’s abdomen in this manner to ease the stressful transition they undergo in childbirth. In a resource-poor setting, kangaroo care should be initiated immediately after childbirth for at least 30 minutes, but can last as long as the mother is able to tolerate. There are no guidelines for how long skin-to-skin care should continue, but many proponents encourage multiple daily episodes (short or long) for up to six weeks postpartum. Fathers may also contribute to this process and perform skin-to-skin care.
Breastfeeding is the recommended form of infant feeding by multiple medical associations because of the numerous benefits to the infant as well as to the mother. Breast milk promotes intestinal growth/motility, protects against infections or certain chronic diseases, and provides optimal nutrition. This process can be frightening and frustrating for some parents. Adequate positioning and latch are important for successful breastfeeding.
For good positioning, place a pillow on the mother’s lap for support, and then place the infant on the pillow. Using the arm opposite the breast that is being used to breastfeed, cradle the infant so that his/her head is supported by a “C” formed with the hand around the base of the skull. An effective latch is characterized by the infant’s mouth covering the entire nipple and much of the areola. The baby should not be sucking the nipple only.
Newborns in a hospital receive a regimen of standard care: eye ointment for the prevention of gonococcal infection, vitamin K to prevent bleeding, hepatitis B vaccine, and blood sugar and bilirubin monitoring. This battery of care will of course not administered in TEOTWAWKI. Certain steps can be taken, though, to evaluate and improve the health of the baby with the means at hand.
Infants are born with nutritional stores that will supplement them during the first few days after birth. Weight loss is normal in infants in the first week of life. However, weight loss greater than 10% is cause for concern. Signs of infant dehydration include: lethargy, loose skin, decreased urine output, and delayed capillary refill time. Capillary refill can be assessed by applying pressure on the infant’s sternum for 5 seconds; if the color fails to return in less than 3 seconds, this suggests dehydration. Monitoring of input and output ought to be done as well. Newborn babies feed every 2-3 hours during the first month of life. Also, urination and defection should occur within the first 24 hours of infant life. Consider supplementing with formula if available.
In summary, this article has attempted to promote awareness about TEOTWAWKI field care for your newborn. Hopefully it has provided numerous touch points from which you can launch your own study, training, and preparation. While all our means of shelter, sustenance, and defense will ensure our personal survival in a WROL, only our children ensure our collective survival.

Disclaimer: This article for educational purposes. It is not a substitute for medical care under the direct supervision of a physician or in a hospital.


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