Emel Yürük¹

1. Department of Nursing, Child Health and Diseases Nursing, Cukurova University, Faculty of Health Sciences, Adana, Turkey,  ORCID: 0000-0003-0823-9772

Received: 20 September 2024

Revised: 25 September 2024

Accepted: 30 September 2024

Published: 30 September 2024

Keywords:

Healthy newborn, care practices, delivery room management guide.

Corresponding author:

Emel Yürük.

Department of Nursing, Child Health and Diseases Nursing, Cukurova University, Faculty of Health Sciences, Adana, Turkey

ORCID: 0000-0003-0823-9772

emelyurukbal@gmail.com

eyuruk@cu.edu.tr  

doi: 10.5281/zenodo.13838511

Cite as:

Yürük E. Evaluation of Healthy Newborn Care Practices in the Delivery Room: Guide Observation. Med J Eur. 2024;2(4):74-83. doi: 10.5281/zenodo.13838511

ABSTRACT

The research was conducted descriptively and cross-sectionally to evaluate the healthy newborn care practices of midwives and nurses working in the delivery room. The research was conducted with a total of 22 midwives and nurses working in the delivery room unit of Seyhan State Hospital Marsa Gynecology and Obstetrics Additional Service Building hospital between 01 December 2023 and 02 February 2024. A personal information form prepared by the researcher in line with the literature and the healthy newborn care application steps of the Birth Room Management Guide (2021) prepared by the Turkish Neonatology Association were used as data collection tools. Study data were collected through ‘Natural observation’ steps. When the distribution of employees’ evaluation of healthy newborn care practices was examined, it was determined that most of the employees tried to implement them partially or adequately according to the Turkish Neonatology Association Delivery Room Management Guide (2021). However, it has been observed that they were inadequate in the implementation of some steps. It is important for midwives and nurses working in the delivery room to plan practical in-service training and training that will transform individuals into behavior, in the light of the latest guidelines and guides. It is possible to increase patient safety and quality of care by increasing sensitivity regarding the use of guides.

INTRODUCTION

A smooth transition of a newborn to postnatal life is possible with careful observation and proper approaches in the first minutes after birth. To contribute to the usability of evidence-based guide applications in newborns, applications to be performed in the delivery room in healthy newborns were examined. These applications include; initial evaluation in the delivery room, evaluation of the baby at birth, initial steps, timing and method of umbilical cord clamping, positioning the head and aspiration, drying and preventing hypothermia, eye, umbilical cord, skin care in the delivery room, vitamin K application in newborns, initial examination in the delivery room, and diagnostic procedures (1).

In the first minutes after birth, the APGAR score is used to assess the baby’s general health status. This evaluation is performed by looking at 5 basic criteria such as the baby’s heart rate, respiration, color, muscle tone, and response to stimulation for the first time in the delivery room (2,3).

Applications related to the evaluation of the baby at birth include information containing evaluations of respiration and circulation under a radiant heater. The baby’s head should be brought to slight extension, and secretion cleaning and evaluation of spontaneous respiration should be performed. During this application, efforts should be made to protect the baby from hypothermia and to initiate mother-baby bonding (1,4,5).

According to the 2021 Delivery Room Management Guide published by the Turkish Neonatology Society, the information on the initial steps in the delivery room has been updated. According to this information, the baby’s cord should be held at least 30 seconds at the level of the mother or below before the cord clamping procedure. The umbilical cord should be tied with a sterile, disposable umbilical cord clamp 4-5 cm from the skin (6-8).

Aspiration is not appropriate for babies with excessive secretions at birth, except in special cases. For babies with spontaneous respiratory effort, it is sufficient to wipe the inside of the mouth and nose with a sterile gauze (1,9,10).

Term babies should be dried with dry and warm sheets starting from the head. Wet sheets should be removed from the baby and a hat should be worn on the baby’s head, covering the ears (11).

Eye and umbilical cord care are performed in accordance with national protocols. For eye prophylaxis, 1% silver nitrate, 0.5% erythromycin, 1% tetracycline hydrochloride or povidone iodine are used depending on the country. There is no ideal preparation yet recommended for implementation. In our country, 0.5% erythromycin eye drops are not available, instead 1% azithromycin, 0.3 gentamicin or 0.3 tobramycin can be used (12).

To prevent bleeding problems that may occur in newborns, it is appropriate to administer 1 milligram of vitamin K intramuscularly to term babies weighing over 1500 grams immediately after birth (1).

Before giving the baby to the mother, the baby’s footprint and the mother’s fingerprint should be taken on paper, and a bracelet should be put on the baby’s arm with the mother’s name, surname, protocol number and baby’s date of birth written on it (1,13).

Finally, in the initial examination in the delivery room, the baby’s vital signs, height, weight and head circumference measurements, general appearance, extremity movements, heart-lung auscultation, and birth trauma and congenital malformations are evaluated (14,15).

Studies have shown that midwives and nurses approve of evidence-based practices in postpartum care, but do not demonstrate consistency in implementation. Research shows that one of the reasons behind this inconsistency is the difference in education level. The education level of midwives and nurses plays an important role in the adoption and application of evidence-based practices in postpartum care (16-19).

Providing healthy newborn postpartum care is important in reducing neonatal mortality rates. APGAR scoring, which is among these applications, is necessary for timely initiation of resuscitation applications that the newborn can support. Midwives/nurses will be effective in providing quality health services, increasing patient satisfaction and reducing costs by working using the current and accurate information specified in evidence-based practice guidelines for newborns. This study serves an important purpose by encouraging the use of evidence-based guidelines in newborn care. Facilitating access to evidence-based guidelines and increasing implementation rates will contribute to the care of newborns in a healthier and safer manner. It aims to increase awareness of the use of guidelines developed in midwife/nurse care practices with the information to be presented and thus improve patient safety and quality of care.

METHODS

Type of the Study

This study was conducted as a descriptive and cross-sectional study to evaluate the healthy newborn care practices of healthcare workers in the delivery room.

Study Setting

This study was conducted in the delivery room of Seyhan State Hospital Marsa Women’s Diseases and Delivery Annex Building, located in Seyhan district of Adana.

Universe and Sampling

The universe of the study was composed of the observation of postpartum newborn practices of midwives/nurses who will give birth in the Seyhan State Hospital Marsa Women’s Diseases and Delivery Annex Building Hospital, delivery room unit between December 1, 2023 and February 2, 2024. The delivery room unit of Seyhan State Hospital Marsa Women’s Diseases and Delivery Hospital has 22 midwives/nurses who are authorized to deliver babies.

Inclusion Criteria

The study included the observation of midwives/nurses who agreed to participate in the study and obtained written consent.

Exclusion Criteria

The study did not include the observation of midwives/nurses who did not agree to participate in the study, did not obtain written consent, and had risky deliveries and newborns, due to which healthy newborn care practices could not be applied.

Data Collection

The delivery room unit of Seyhan State Hospital Marsa Women’s Diseases and Delivery Annex Building Hospital has 4 delivery areas designed to perform deliveries and 4 pre-delivery pregnancy monitoring rooms with 6 beds each.

Observation Method

It was planned to observe events, situations and objects either in their natural environment or in a laboratory environment. In this study, the steps of “Natural Observation” were formed. Before the observation, the purpose, plan, tools and processes to be used by the observer were determined in advance. Natural observation is the observation that takes place in the environment where the person to be observed is located. In this observation, the observer remains passive and does not intervene in the observation environment in any way. It was tried to describe and record the situation or behavior that occurred in the natural environment.

3 Stages in the Observation Steps

1. Planning Stage: This is the stage where the preparation for the observation is made and the details regarding the observed person, the observer, the environment, the time and the observation tools are determined.
2. Observation and Recording Stage: This is the stage where applications are made for the purpose of using different observation types and their tools. Observation Centers: Observation centers are rooms used in the behavioral sciences to observe individual behaviors, individual behaviors within a group, and group dynamics. Use of Scales: In order for the observation results to be objective, reliable and not to include the observer’s interpretations, it is necessary to determine a recording system. Observation forms, observation recording charts, observation sheets, etc. scales will be helpful to the observer in this regard.
3. Reporting Stage: This will be the stage where the data obtained from the observation is interpreted and used (20,21).

Figure 1. Data collection process

Data Collection

Observation

Observers were present in the delivery rooms where deliveries were planned for the day beforehand. Four midwives/nurses are on duty 24 hours a day, five days a week. Deliveries between 08:00 in the morning and 08:00 the next morning are carried out sequentially among the four midwives/nurses within 24 hours. The practices of a total of 22 midwives/nurses in the delivery room were observed. The observer completed the “Healthy Newborn Care Practices Evaluation Checklist” in checklist form for the preparations made in the room before the delivery and the newborn care practices performed by the healthcare worker (midwife/nurse) responsible for the care immediately after the delivery. The healthcare worker on duty in the delivery room was not informed in advance about the content of the observation (Figure 1).

Interview

After the observation process was completed on the specified dates, that is, immediately after the observation process was completed in the delivery room, the team members were approached and informed about the study. Data collection was completed by interviewing the healthcare workers who agreed to participate in the study face-to-face and filling out the “Personal Information Form” containing their identifying characteristics.

Data Collection Tools

Personal Information Form

This form was prepared by the researchers in accordance with the literature and consists of 7 questions covering sociodemographic (age, gender, duty, education status, etc.) and occupational characteristics (department where he/she works, year of work in the current position, year of work in the profession, etc.).

Healthy Newborn Care Practices Evaluation Checklist:

The healthy newborn care practice guide prepared by the Turkish Neonatology Society Delivery Room Management Guide (2021) was used. The items on the checklist were evaluated by categorizing them as “Insufficient”, “Partially Sufficient”, “Sufficient”. In total, the “Healthy Newborn Care Practices Evaluation Checklist” consists of 32 items (1).

Data Analysis

The data collected within the scope of our research were coded and evaluated using the SPSS 22.0 program in a computer environment. In the evaluation process, two basic statistical methods, percentage and arithmetic mean test, which best reflect the nature and distribution of the data, were used.

Ethical Aspects of the Research

Before starting the research, ethical approval was obtained from Çukurova University Clinical Research Ethics Committee and official institution permission was obtained from Marsa Women’s Delivery and Children’s Hospital. Verbal and written consent was obtained from the midwives/nurses participating in the study by informing them about the purpose of the study.

RESULTS

When the findings related to the identifying characteristics of the individuals participating in the study were examined, it was determined that 36.3% of the participants were in the 29-38 age group, all of them were female, 90.9% were midwives, 50% had a bachelor’s degree, 59.1% were single, 50% had more than 11 years of experience in the profession, and two did not have an Newborn Care Practices (NRP) certificate. All participants work in the delivery room (Table 1).

Findings regarding the first evaluation in the delivery room; It was determined that 59.1% of the midwives and nurses working in the delivery room unit sought adequate answers to the questions ‘Is the baby term?, Is his tone good?, Is there a respiratory effort?’ in the first evaluation after birth. 45.5% of working midwives and nurses evaluated the APGAR score adequately at the first and fifth minutes. It was determined that 40.9% of the employees completed the APGAR assessment partially adequately. It was determined that 72.7% of midwives and nurses initiated the first contact by placing babies with sufficient APGAR scores next to the mother and against her body (Table 2).

Findings regarding the evaluation of the baby at birth; It was determined that 54.5% of the midwives and nurses working in the delivery room unit placed the baby under a heated cover and radiant heater after it came out of the birth canal. It was observed that 18.2% of the employees performed this process inadequately. It was determined that 54.5% of the employees adequately cleared the oral and nasal secretions by keeping the baby in slight extension to open the respiratory tract. It was observed that 63.6% of the employees dried the entire body quickly and thoroughly after cleaning the baby’s secretions. While searching for answers to the questions “Is the airway open? Is the heart rate sufficient? Is there cyanosis?” regarding the baby’s need for resuscitation after drying, it was determined that 40.9% of the employees evaluated the baby at a partially adequate and adequate level. It was determined that 72.7% of the employees started breastfeeding babies who did not need resuscitation by placing them on the mother’s breast, which was sufficient (Table 2).

Findings regarding the initial steps in the delivery room; It was determined that 81.8% of midwives and nurses working in the delivery room unit held the umbilical cord at or below the mother’s level for at least 30 seconds before clamping it. It was determined that 90.9% of the employees performed the clamping procedure adequately with a sterile, disposable umbilical clamp at a distance of 4-5 cm from the skin. It was determined that 45.5% of the employees kept their head in a slightly extended position while positioning the head at an inadequate level. It was determined that 45.5% of the employees cleaned the mouth and nose of the baby, whose respiratory effort was good, partially adequately. It was determined that 22.7% of the employees turned their heads to the side during aspiration and aspirated their mouth and nostrils inadequately (Table 2).

It was determined that 45.5% of the employees took the wet sheets away from the baby after drying them with the sheets. It was determined that 27.3% of the employees performed this process inadequately or partially adequately.

Table 1. Distribution of the ıdentifying characteristics of healthcare workers in the delivery room.

		n	%
Age	18-28 29-38 39-48 49 and over	7 8 5 2	31.8 36.3 22.8 9.1
Gender	Woman Male	22 0	100 0
Job	Nurse Midwife	2 20	9.1 90.9
Educational Status	High school Associate degree Licence	2 9 11	9.1 40.9 50
Marital status	Married Single	13 9	59.1 40.9
Years of working in the profession	0-5 years 6-10 years 11 and above	2 9 11	9.1 40.9 50
Training Program Attended	Newborn Care Practices (NRP) Breast milk and breastfeeding Emergency obstetrics	18 22 22	81.8 100 100

Table 2. Distribution of employees’ healthy newborn care practices evaluation checklist applications.

	Insufficient		Partially Sufficient		Sufficient
First Evaluation in the Delivery Room	n	%	n	%	n	%
First Evaluation in the Delivery Room The first evaluation of the newborn baby should be made immediately to answer these three questions: • Is the baby term? • Is his tone good? (Are the lower and upper extremities in semiflexion posture?) • Is there any respiratory effort?	5	22.7	4	18.2	13	59.1
The APGAR score (heart rate, respiratory effort, color, muscle tone, response to stimulation, color) measured in the first and fifth minutes should be evaluated. APGAR Score = ? Answer (in first minute)	3	13.6	9	40.9	10	45.5
Babies with APGAR scores between 7-10 should be given to their mothers and the first contact should be initiated	5	22.7	1	4.5	10	72.7
Evaluation of the Baby at Birth	n	%	n	%	n	%
As the baby comes out of the birth canal, the sterile cover is taken from the bottom and the baby should be placed under a radiant heater with this heated cover.	4	18.2	6	27.3	12	54.5
Secretions in the mouth and nose, if any, should be cleaned by keeping the head slightly extended to open the respiratory tract.	7	31.8	3	13.6	12	54.5
After cleaning (or aspiration) of secretions, the entire body should be dried quickly and thoroughly, starting from the head.	3	13.6	5	22.7	14	63.6
After drying, the baby should be evaluated to decide whether resuscitation is necessary. • Breathing (Is his airway open? Is he breathing?) • Circulation (Is the heart rate 100 beats/minute or above?) • Oxygenation (Is there cyanosis?, pulse oximetry?)	4	18.2	9	40.9	9	40.9
Babies who do not need resuscitation should be placed on the mother’s breast to start breastfeeding as soon as possible.	4	18.2	2	9.1	16	72.7
Starting Steps in the Birth Room
Clamping and method of the umbilical cord	n	%	n	%	n	%
All term and premature babies who do not require resuscitation should be held at or below the mother’s level for at least 30 seconds before cord clamping.	2	9.1	2	9.1	18	81.8
The umbilical cord should be tied with a sterile, disposable umbilical clamp, 4-5 cm away from the skin.	–	–	2	9.1	20	90.9
It should be cut by holding it with sterile gauze, and its tip should be wiped with povidone iodine.	22	100	–	–	–	–
Head Positioning and Aspiration	n	%	n	%	n	%
The baby’s head should be kept in a slightly extended position to keep the respiratory tract open.	10	45.5	5	22.7	7	31.8
Aspiration should not be performed on every baby; in babies who are active and have good respiratory effort, the mouth and nose should be wiped with a sterile cloth.	1	4.5	10	45.5	11	50
Babies with a lot of secretion can be aspirated. During aspiration, the head should be turned to the side and the mouth should be aspirated first, then the nostrils.	5	22.7	11	50	6	27.3
Drying and preventing hypothermia	n	%	n	%	n	%
Term babies should be dried with dry and warm sheets after birth, starting from the head, and wet sheets should be removed from the baby.	6	27.3	6	27.3	10	45.5
A hat should be worn on the head, including the ears.	4	18.2	5	22.7	13	59.1
For term babies, skin contact should be ensured by laying them on the mother’s body and their back should be covered with a warm sheet.	–	–	6	27.3	16	72.7
Premature babies born at <30 weeks should be placed in polyethylene plastic bags immediately after post-natal drying, put on a hat and placed under a radiant heater or in incubators.	–	–	2	9.1	20	90.1
The air given should be moist and heated to protect the newborn, whose respiratory support continues, from hypothermia.	–	–	–	–	22	100
Eye, Belly, Skin Care in the Delivery Room	n	%	n	%	n	%
Care should be taken after the baby is stable.	9	18.2	7	31.8	11	50
Residues on the skin should be dried and cleaned.	1	4.5	5	22.7	16	72.7
In our country, 1% azithromycin, 0.3% gentamicin or 0.3% tobramycin should be used for eye prophylaxis, and one eye drop should be instilled in each eye.	22	100	–	–	–	–
Blood on the baby’s head and skin, etc. It should be thoroughly cleaned during drying as residues may pose a risk of infection.	6	27.3	8	36.4	8	36.4
Vitamin K Application in Newborns	n	%	n	%	n	%
Administering 1 milligram of vitamin K intramuscularly (IM) immediately after birth (0.5 mg for those born <1500 g, 1.0 mg IM as a single dose for those born >1500 g is appropriate).	–	–	–	–	22	100
First Examination in the Birth Room	n	%	n	%	n	%
Vital signs of the newborn should be taken	13	59.1	–	–	9	40.9
The newborn’s height, weight and head circumference should be measured.	3	13.6	6	27.3	13	59.1
General appearance, extremity movements, heart-lung auscultation, birth trauma and congenital malformations should be evaluated.	10	45.5	6	27.3	6	27.3
APGAR evaluation should be performed again for the baby who reaches the 5th minute.	7	31.8	5	22.7	10	45.5
The baby should also be checked for birth traumas (caput suxadaneum, cephalic hematoma, peripheral facial paralysis, clavicle fracture, brachial plexus injury).	4	18.2	10	45.5	8	36.4
Diagnostic Process	n	%	n	%	n	%
Before the baby is given to the mother, the baby’s footprint and the mother’s fingerprint should be taken on paper.	–	–	–	–	22	100
A wristband with mother’s name, surname, protocol number and the baby’s birth date should be prepared.	–	–	–	–	22	100
After all postnatal procedures are completed, before the baby is handed over to the mother or her relatives, a pink barcoded bracelet should be worn for baby girls and a blue barcoded bracelet for baby boys, in accordance with the Quality Standards of the Ministry of Health (2020).	–	–	–	–	22	100

It was observed that 59.1% of midwives and nurses made babies wear hats. It was determined that 72.7% of working midwives and nurses cover the baby’s back with a warm sheet after providing skin-to-skin contact between the mother and the baby. It was determined that 90.1% of the employees performed the dressing process under radiant heater adequately. It was determined that all employees provided respiratory support with moist and heated air to protect the baby from hypothermia (Table 2).

It has been observed that 50% of the midwives and nurses working in the delivery room unit perform care procedures after the baby is sterile. It was observed that 72.7% of the employees cleaned the residues from the skin adequately. It was determined that not all employees used 1% azithromycin, 0.3% gentamicin or 0.3% tobramycin for the baby’s eye prophylaxis. Blood on the baby’s head and skin, etc. Since the residues pose a risk for infection, it was determined that 36.4% of the employees performed the process of thoroughly cleaning the skin residues during drying, partially adequately and at a sufficient level. It was determined that all working midwives and nurses applied 1 mg vitamin K intramuscularly immediately after birth (Table 2).

Findings regarding the first examination in the delivery room; It was determined that 40.9% of the midwives and nurses working in the delivery room received adequate vital signs of the baby, while 59.1% received inadequate vital signs. It was determined that 59.1% of the employees measured their height, weight and head circumference adequately, while 13.6% measured them inadequately. It was determined that 45.5% of working midwives and nurses made inadequate evaluations of the baby’s general appearance, limb movements, heart-lung auscultation, birth trauma and congenital malformations. It was determined that 45.5% of the working midwives and nurses performed the repeated APGAR evaluation of the baby at the fifth minute at an adequate level. It was determined that 45.5% of the employees performed the necessary examination of the baby in terms of birth trauma at a partially adequate level (Table 2).

Findings regarding the diagnostic process; All midwives and nurses working in the maternity unit take the baby’s footprint and the mother’s fingerprint before the baby is handed over to the mother and family. All employees prepare bracelets with the mother’s name, surname, protocol number and the baby’s birth date on them. Again, before the baby is delivered to the mother or her relatives, all employees put a barcoded bracelet on the baby, pink for baby girls and blue for baby boys, in accordance with the Quality Standards of the Ministry of Health (2020) (Table 2).

When we look at the distribution of employees’ evaluation of healthy newborn care practices, 80.3% of the employees evaluate the first evaluation steps of the delivery room, 79.6% evaluate the baby at birth, 80.3% evaluate the initial steps of the delivery room, and 70.9% evaluate the delivery room. It was determined that they performed the first examination of the hall. It was determined that all employees performed the diagnostic process completely (Table 3).

Table 3. Application distribution of healthy newborn care practices evaluation checklist stages.

	Not Applying		Applying
	n	%	n	%
First Evaluation in the Delivery Room	5	19.7	17	80.3
Evaluation of the Baby at Birth	4	20.4	18	79.6
Applying the initial steps in the delivery room	5	19.7	17	80.3
First Examination in the Birth Room	7	29.1	15	70.9
Diagnostic Process	–	–	22	100

DISCUSSION

The newborn undergoes a critical adaptation process in the first minutes and hours after birth. During this process, the basic procedures applied in the delivery room, such as drying, oxygenation, care and heating, are of great importance for the baby’s healthy transition to postnatal life. The correct and adequate implementation of these applications in the delivery room directly affects the baby’s health and development throughout its life. With adequate support and correct interventions, the baby can make a healthy transition to postnatal life.

Initial Evaluation in the Delivery Room

The findings regarding the initial evaluation in the delivery room; The first questions that midwives and nurses working in the delivery room unit need to answer in the evaluation of newborns in the delivery room are: “Is the baby warm?, is the tone good?, is there any respiratory effort?” Most of the midwives and nurses involved in the study sought answers to these evaluation questions and sought a sufficient level of response to the Apgar score evaluated in the first minute of delivery. However, it was determined that 40.9% of the midwives and nurses participating in the study made the Apgar evaluation partially sufficient. The Apgar score (heart rate, respiratory effort, color, muscle tone, response to stimulation, color) provides results on whether the baby is healthy or needs follow-up. Babies with Apgar scores between 7-10 are considered healthy babies with good general health and do not require special medical intervention (1). A low Apgar score suggests neonatal apnea, asphyxia, or respiratory distress syndrome. For this reason, it is important for the morbidity risk of the newborn due to the decision to resuscitate and the determination of oxygen support (22).

Skin-to-Skin Contact

It was determined that most of the midwives and nurses placed babies with a sufficient Apgar score on the mother’s body to initiate early contact. Studies have shown that initiating early contact between mother and baby during labor is important for the parent’s and baby’s sense of security, bonding between mother and baby, and initiation of breastfeeding (23,24).

Midwives and Nurses’ Awareness

Yılmaz et al. (2018) observed that midwives and nurses who received prenatal preparation training were effective in initiating early contact between the baby and the mother in the delivery room (25). The findings of this study support the existence of midwives and nurses who exhibit this sensitivity and awareness in the literature.

Findings on Newborn Evaluation

Thermal Care: It was determined that most of the midwives and nurses working in the delivery room placed the baby under a radiant heater with a heated blanket immediately after the baby emerged from the birth canal. Maintaining the body temperature of term babies after delivery is very important. Therefore, babies should be dried with dry and warm sheets starting from the head immediately after delivery. Wet sheets should also be removed from the baby without delay. A hat should also be worn to prevent the baby’s head from getting cold, covering the ears as well. The hat should be made of a soft and breathable material that fits the baby’s head and ears tightly (26,27).

Secretion Cleaning: It was observed that most of the midwives and nurses in the study dried the baby’s entire body quickly and thoroughly after clearing the secretions.

Airway Cleaning: It was determined that half of the midwives and nurses working in the delivery room held the baby in slight extension to open the airway and cleaned the mouth and nose secretions at a sufficient level. According to the information in the literature, the most appropriate position for keeping the airway open is with the head in slight extension. This position keeps the airway open and allows the patient to breathe comfortably (28).

Resuscitation Assessment: According to the Turkish Neonatology Society Delivery Room Management Guide (2021), the need for resuscitation is checked by answering the questions “Is the airway open?, is the heart rate sufficient?, is there cyanosis?” after drying to determine the newborn who needs resuscitation. (1) It was determined that 40.9% of the midwives and nurses working in the delivery room made a partially sufficient and sufficient level of evaluation. However, it is important to make this evaluation at a sufficient level for the early detection of a newborn who needs resuscitation (11).

Findings on Initial Steps

Umbilical Cord Clamping: It was determined that almost all of the midwives and nurses working in the delivery room held the umbilical cord at the mother’s level or below for at least 30 seconds before clamping it. It was determined that 90.9% of the employees performed the ligation procedure at a sufficient level with a sterile, disposable umbilical cord clamp 4-5 cm from the skin.

According to the World Health Organization (WHO), early umbilical cord clamping is performed when 1 minute has passed after delivery, and late clamping is performed when 2-3 minutes have passed (29).

The Turkish Neonatology Society (2021) and the International Liaison Committee on Resuscitation (ILCOR) recommend that the umbilical cord be clamped at the earliest 30 seconds after delivery, 4-5 cm from the skin, if resuscitation will not be applied to the newborn (30).

In its 2017 guidelines, the American College of Obstetricians and Gynecologists (ACOG) did not recommend late clamping for preterm babies, 30-60 seconds for term babies. Placental transfusion is a method of providing additional blood to the baby by allowing the blood in the placenta and cord to pass into the baby’s circulation after delivery (31).

It was observed that the midwives and nurses involved in the study performed the umbilical cord clamping method and timing in accordance with the literature.

Head Positioning and Secretion Cleaning: It was determined that 45.5% of the employees held the baby’s head in a slightly extended position while giving the head position at an insufficient level and cleaned the baby’s mouth and nose at a partially sufficient level with good respiratory effort. It was determined that 22.7% of the employees aspirated the mouth and nostrils at an insufficient level by turning the head to the side during aspiration. According to the literature, aspiration should not be applied routinely to every baby (32). Babies who show strong respiratory effort, good muscle tone, and a heart rate (HR) above 100/min are considered “active-vigorous” and it is sufficient to simply wipe the mouth and nose with a sterile gauze in these babies. Mouth and nose aspiration is a procedure used to clear mucus and fluids that have accumulated in the airways. This procedure can be used in newborns and babies with respiratory distress (10).

Aspiration: The decision to aspirate should be made by observing the newborn for signs of inadequate aspiration (1,28). Therefore, it is not expected that the midwives and nurses in the study did not resort to aspiration for this reason, but they should also pay attention to keeping the newborn’s head in extension.

Thermal Care: It was observed that half of the employees removed the wet sheets from the baby after drying them with sheets and put a hat on the babies. Heat loss is quite common in newborns after delivery and can lead to peripheral cyanosis, which is a bluish discoloration of the skin and mucous membranes. Cyanosis is a sign of inadequate oxygen intake (1,28). In Kutman et al.’s (2015) study, called the Golden Minutes, it was stated that gentle management of the baby in the delivery room reduces the damage that may develop in other organ systems, especially the lungs.

It was determined that almost all of the midwives and nurses covered the baby’s back with a warm sheet after providing skin-to-skin contact with the mother and the baby (11). It was determined that 90.1% of the employees performed the dressing procedure under a radiant heater at a sufficient level. It was determined that all employees provided respiratory support with humidified and heated air to protect the baby from hypothermia. According to the information in the literature, it is important that the room temperature in the delivery units is at least 26°C. This temperature helps to maintain the baby’s body temperature. Heated and dry towels should be kept ready to reduce the risk of hypothermia before the baby is born. In addition, the radiant heater should also be turned on before the baby is born. If the baby to be born is premature, in addition to these preparations, a polyethylene plastic bag and hat should also be kept ready. The polyethylene plastic bag helps to maintain the baby’s body temperature, while the hat warms the baby’s head (1,29,30). It was determined that most of the midwives and nurses involved in the study made the necessary preparations and procedures to protect the newborn from hypothermia and acted in accordance with the guide and guidelines.

Skin Cleaning and Eye Prophylaxis: It was observed that most of the midwives and nurses working in the delivery room cleaned the skin residues at a sufficient level. However, it was determined that 1% azithromycin, 0.3 g gentamicin or 0.3 tobramycin was not used for eye prophylaxis of the baby. Unfortunately, there is no eye drop containing 0.5% erythromycin in our country. In this case, alternative antibiotics should be preferred in the treatment of eye infections. As recommended, eye drops containing 1% azithromycin, 0.3 g gentamicin or 0.3 tobramycin can be used (1,28).

Eye Prophylaxis: It was determined that none of the midwives and nurses involved in the study implemented any eye prophylaxis.

Skin Cleaning: Since blood and other residues on the baby’s head and skin pose a risk of infection, 36.4% of the employees partially and sufficiently cleaned the skin residues during drying. In evidence-based practice-supported studies in the literature, washing should be postponed until later as heat stabilization in newborns is slower and more difficult, but there is no clear recommendation yet on how long this period should be (33,34).

In addition, according to the 2021 guide, vernix caseosa is a layer that protects the baby from heat loss. Those that are very intense after delivery can be wiped off, but they are not a reason for immediate washing. (1)

Vitamin K Injection: It was determined that all of the midwives and nurses applied vitamin K intramuscularly immediately after delivery. According to the literature, vitamin K deficiency is one of the leading causes of bleeding and even death in newborns. Vitamin K is a vitamin necessary for blood clotting. However, newborns have a short gestation period that does not allow for sufficient storage of this vitamin in the womb. Therefore, vitamin K supplementation is necessary immediately after delivery. For this purpose, all newborns should be given 1 mg vitamin K intramuscular (IM) injection within the first 24 hours after delivery. (1,35).

Vitamin K administration has been definitively shown to protect against early or classical hemorrhagic disease (36).

Initial Examination Findings

Vital Signs: It was determined that 59.1% of the midwives and nurses working in the delivery room took vital signs at an insufficient level. However, according to the WHO, it has been found that some of the deaths of newborns are directly related to the delay in the detection of risky situations. Respiratory rate and heart rate values should be used directly in the detection of resuscitation (37). However, it was observed that half of the midwives and nurses in the study evaluated these measurements rather than their quantitative outputs with the presence of cyanosis in the skin appearance or respiratory effort in the mouth and nose. In addition, 59.1% of the midwives and nurses found the quantitative measurement of height, weight and head circumference to be easier to evaluate at a sufficient level.

General Appearance and Other Assessments: It was determined that 45.5% of the midwives and nurses in the study evaluated the baby’s general appearance, extremity movements, heart-lung auscultation, birth trauma and congenital malformations at an insufficient level. According to the literature, the initial examination in the delivery room is roughly done to determine the presence of a serious problem. It is appropriate to perform the examination after the umbilical cord is cut and the first-step applications are completed. It is also necessary to detect any complications that may occur during and after delivery. For example, in newborns showing signs of dyspnea after delivery, it is important to evaluate the general condition of the respiratory system as well as check the nostrils for choanal atresia. This can be seen during the examination and will be effective in starting respiratory support for the child quickly (38). It was determined that almost half of the midwives and nurses in the study performed the necessary examination of the baby for birth trauma at an partially sufficient level.

APGAR Score: According to the Turkish Neonatology Society Delivery Room Management Guide (2021), it was determined that some of the midwives and nurses performed the repeated APGAR evaluation of the baby who reached the fifth minute at a sufficient level. Although the Apgar score applied in the 1st and 5th minutes after delivery provides valuable information about the newborn’s current health status, it does not have the ability to make long-term prognoses. This score, which is insufficient when taken alone, is not a sufficient indicator to predict the baby’s future health status (1,28).

Findings regarding the diagnostic process

All midwives and nurses working in the maternity unit prepare and wear a bracelet with the baby’s footprint, the mother’s fingerprint, the mother’s name, surname, protocol number and the baby’s birth date before the baby is handed over to the mother and family. These practices are important to avoid confusing the newborn and forgetting newborn information. These are the practices carried out by the Ministry of Health within the scope of its work to provide knowledge and correct habits in hospitals that provide birth services with the ‘Baby-friendly’ hospitals program (39).

Again, before the baby is delivered to the mother or her relatives, all employees put a wristband with a pink barcode for baby girls and blue for baby boys, in accordance with the Ministry of Health Quality Standards (2020) (40).

As a result, looking at the distribution of employees’ evaluation of healthy newborn care practices, it was determined that most of them tried to implement them partially or adequately according to the Turkish Neonatology Association Birth Room Management Guide (2021). However, it has been observed that they were clearly inadequate in the implementation of some steps. These include not paying attention to extension in the baby’s head position, evaluating the general appearance rather than taking vital signs, skipping the fifth-minute APGAR assessment, and being careless when performing a general examination of the baby. All these situations can slow down the detection of a risky newborn who may need oxygen support.

Based on this situation, practical in-service training should be given to midwives and nurses working in the delivery room, in the light of the latest guidelines and guides, and the practices should be transformed into behavior in individuals. In addition to these recommendations, supplies and newborn medicines that should be kept in the delivery room should be provided.

CONCLUSION

Clinical practice guidelines, by providing systematically organized and evidence-based summaries, ensure that the best available evidence is translated into clinical settings. In this way, patient safety and the quality of healthcare services provided can be improved.

However, the number and quality of guidelines that midwives and nurses can use in patient care seem to be insufficient. It is necessary to evaluate how applicable these guides are in the clinical setting.

The postpartum period is a critical period that directly affects maternal and newborn health, and therefore family and community health. The use of clinical practice guidelines during this period is of great importance in providing evidence-based, high-quality, holistic and comprehensive nursing care.

Despite this, the majority of maternal and infant deaths occur in the postpartum period. This is a clear indication of the need to base the care services provided during this period on the best evidence.

This article will provide an opportunity to evaluate by making observations on the importance of clinical guidelines and their transfer to the clinical setting.

Funding

No funding was received in this manuscript

Conflict of Interest

Data are available on request to the authors.

CC BY license  

This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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