SNCU Toolkit

PRESENTED BY NCRC & DEPT OF NEONATOLOGY IPGMER kolkata

COMPLETE GUIDE LINE AND TOOLKIT FOR BUILDING UP A FULLY FUNCTIONAL SNCU(SICK NEWBORN
CARE UNIT) .

SNCU TOOLKIT
PRESENTED BY NCRC AND DEPARTMENT OF NEONATOLOGY SSKM(KOLKATA)

Editor-in-chief
Dr Arun Kr Singh ,MD , Prof & Head, Dept of Neonatology, IPGMER

A COMPLETE GUIDE LINE AND TOOLKIT FOR BUILDING UP A FULLY FUNCTIONAL SNCU
(SICK NEW BORN CARE UNIT)

Contributors

Dr Arun Kr Singh ,MD, ,Prof & Head, Dept of neonatology, IPGMER

Dr Suchandra Mukherjee , MD, Associate professor, Dept of neonatology, IPGMER
Dr Syamal Kr Sardar , MD, Associate professor, Dept of neonatology, IPGMER
Dr Ranajit Mukherjee , MD, Assistant Professor, Dept of neonatology, IPGMER
Dr Anshuman Paria , MD, RMO, Dept Of Neonatology , IPGMER
Dr Anindya Kr Saha , MD,RMO, Dept Of Neonatology , IPGMER
Dr Ipsita Banerjee , MD, RMO, Dept Of Neonatology , IPGMER
Dr Dinesh Munian , MD , RMO, Dept Of Neonatology , IPGMER
Dr Sudipta Dasgupta , MBBS, MO ,Dept Of Neonatology , IPGMER
Sist Parul Dutta , MSc (Nursing) Senior Nursing tutor, Dept Of neonatology, IPGMER
Dr Sukanta Debnath , Training Coordinator, Newborn care resource centre , Kolkata
Mr.Abhisekh Basu, Technical Coordinator, Newborn care resource centre , Kolkata
Mr. Krishnendu Karmakar, audio visual support ,Newborn Care Resource Centre, Kolkata

Sri Mrinal Chakrbarty , Asst Superintendent, SSKM Hospital, Special cell for Monitoring and evaluation
of SNCU
Md Siddique , Assistant Program Manager , Special Cell for Monitoring and evaluation of SNCU
Sri Avijit Samanta , Data Entry Operator cum Data Manager , Special Cell for monitoring and evaluation
of SNCU

Preface:

This book is a compilation of the years of experience gathered by Dr AK Singh and his team
from the Department of Neonatology , IPGMER, Kolkata in the field of development ,
functioning , supervision, capacity building and evaluation of the Sick New born Care Unit
throughout the country with a vision to improve the quality of facility based newborn care . The
book is developed as a cook book for building sick new born care units with unique
operational challenges. The concept was first materialized with the pioneering work of
PURULIA MODEL in 2003 and it is now regarded as an essential intervention for reduction of
the NMR of the whole country.. The publication is an attempt to share the immense experience
behind the evolution of this novel concept. It is also going to focus on the status report from
existing sick new born care units of west Bengal . The most useful technical details for
establishment of sick new born care units is brought out in this publication by the effort of a
group of doctors, engineers, statisticians , public health specialists and nursing educators
concentrating on newborn health at the department of Neonatology, IPGMER, Kolkata.

ACKNOWLEDGEMENT

Prof. Amitava Sen

MD, FNNF (Senior Consultant, Neonatology), EX HEAD- DEPARTMENT OF

PEDIATRICS , IPGMER, KOLKATA.

DR Dilip Mahalanabis, MBBS, FRCP, DCH , DIRECTOR,SOCIETY FOR APPLIED STUDIES, KOLKATA.
Sri Samar Ghosh, CHIEF SECRETARY, GOVT OF WEST BENGAL.
DR M N Roy , ADDITIONAL CHIEF SECRETARY, GOVT OF WEST BENGAL.
Sri Dilip Ghosh , MISSION DIRECTOR, NRHM, GOVT OF WEST BENGAL.
Shri Ashim Kumar Das,

DR J M Chaki ,

DR Papri Nayek ,

EX-COMMISSIONER AND EX-OFFICIO SECRETARY, GOVT OF WEST

BENGAL.

STATE FAMILY WELFARE OFFICER & JT .DHS , DEPT OF HEALTH & FAMILY
WELFARE ,GOVT OF WEST BENGAL.
DADHS (MCH), DEPT OF HEALTH & FAMILY WELFARE ,GOVT OF WEST
BENGAL.

DR Kalyan Ranjan Mukhopadhyaya , TECHNICAL OFFICER , SPSRC, SWASTHYA BHAVAN, GOVT

OF WEST BENGAL.

CONTENTS

TOPIC

PAGE NO

INTRODUCTION

1-3

GENERIC PLAN PIC

4-5

GENERIC PLAN

6-26

MANPOWER

27-28

HR MANUAL

29-34

EQUIPMENT

35-41

HOUSE KEEPING

42-46

RUNNING COST

47-51

SNSU

52-55

ADMISSION CRITERION

56-

SICK NEWBORN CARE UNIT

India has a formidable task of providing care
to newborn against a background of the
worlds largest share of births (20%) and
neonatal deaths (30%). Meeting the
commitment of reaching the Millennium
Developmental Goal of reducing infant
mortality rate to about 27 from its present
value of 57(NFHS 3) in India is only possible
through improved neonatal survival. 66% of
infant deaths in the country at present occur
during the first 28 days after birth. About 40%
of these neonatal deaths occur on the first
day of life, almost half within three days and
nearly three-fourth in the first week of life.
Nearly 50% of the neonatal deaths occur
among the LBW newborn. Neonatal mortality
in India after an initial decline has been static
with barely a point decline every year.
Preventable factors like Hypothermia,
Asphyxia, Sepsis, Pneumonia etc. contribute
significantly to the NMR.

Unfortunately proper basic newborn care

(Level I) are still not adequately available at
many of the facilities where newborn are
delivered and admitted. Till recent past,
barring a few medical colleges, we hardly had
any adequately functioning and appropriately
equipped facility dedicated for newborn in the
public sector.
The non-availability of
adequately sick newborn care at fixed
facilities such as the district hospitals and
below largely negates the value of early
referral of sick neonates. . It has long been
concluded that emergency Newborn Care is
required apart from Essential Newborn Care
to bring down the neonatal mortality rate
(NMR). However strengthening of clinical
services to deliver such emergency care, a
much-needed component, had traditionally
been largely ignored by health planners.
Our country requires Level 1 care for all
deliveries as this provides basic care for all
uncomplicated neonatal patients. Level 2 (Sick
Newborn care unit)is for those sick newborn
who require special care and level 3 care or
Neonatal intensive care unit is earmarked for
those extremely sick or grossly premature
babies who would need mechanical
ventilation .These babies are usually are less
than 1500gm or less than 28 weeks . It has
been assessed that 85% of the newborn
would require Level 1 care, while Level 2 and
Level 3(NICU) is required by 10% and 5% of
the newborn respectively resulting in
requirement of minimum of 3 lac level II beds
and 40,000 level III beds for our country.
Ideally, there should be supervised neonatal
care facilities (level I) at all the primary and
community health centres. Similarly, each
district hospital should have 20 bedded levelII care neonatal units and each teaching
hospital should have a 20 bedded neonatal

The commonest causes of Neonatal

mortality in our country are infections
including Sepsis and Pneumonia (33%),
Asphyxia (21%), Prematurity (15%), Low Birth
Weight, varieties of congenital malformations
and surgical conditions. For most of the Term
Newborn and a proportion of the Preterm and
Low Birth Weight Newborn, Neonatal
Mortality Rate (NMR) can be reduced by
spreading the care to the communities with
Skilled Health Workers. However, to bring
30 per 1000 Live Births, neither community
nor Outpatient based care is adequate. This
requires Facility Based Newborn care without
which we cannot deliver the Community or
Outpatient Based Care of the Newborn
effectively.

ICU (level III). Development of proper

coordination between level I, level II and level
III units through a proper referral, transport
and feedback system supplemented by
outreach education program would be a
prerequisite for effective neonatal care.

has led to the concept of Nursing Aides or

the Neonatal Aides or Newborn Aides
from the local community and this measure
substantially alleviated the human resource
constraint for SNCU and SNSU in smaller
peripheral hospitals for care of newborn at an
affordable cost.

Newborn intensive Care Units like any other

Intensive Care Units requires significant
investment. Hence, a trade-off needs to be
done to bring about the balance between the
need and the resource available. A substantial
reduction in neonatal mortality can be
achieved by improving the components of
newborn care that do not require highest
level of sophistication and technology. These
include clean care at delivery, prevention and
management of birth asphyxia, feeding of
newborn including breastfeeding, early
detection and treatment of common neonatal
illnesses. The need of the hour is to improve
the quality of newborn care both at the block
and district level where most of the deliveries
take place and the illnesses are encountered.
This felt need was transferred into action by
building up a network of Newborn corners at
all places where childbirth occurred, sick
newborn stabilisation units (SNSU functioning
as level I units) at BPHCs and sick newborn
care units (SNCU functioning as level II units)
in the district hospitals with provision of
optimum transportation of sick neonates.

After the SNCU in Purulia was established, it

was shown that the NMR in the district had
decreased by 10/1000Live Births for three
consecutive years. No other single
intervention could decrease the NMR. It also
became the centre for capacity building (esp.
hands-on training) of various district level
health programs related to newborn, e.g.
newborn component for IMNCI, ASHA, ANM,
AWW and other health workers. Thus, SNCU
will provide both service and capacity building
related to newborn health.
This pioneering work, called the PURULIA
MODEL, was acknowledged by Planning
Commission, GOI in Good Practises Resource
Book , as well as a replicable model by
Goldsmith and Karotkin in their book named
Assisted Ventilation of the Neonate. Owing
to their pioneering work and immense
experience in all aspects of facility based
newborn care, both in terms of infrastructure
planning and in human resource training,
Department of neonatology, SSKM
was
selected as a newborn care resource centre
by NIPI-UNOPS.

The SNCU concept evolved from a pioneering

work of department of neonatology, SSKM
Kolkata headed by Dr. A.K.Singh and Society
for Applied Sciences, represented by Dr.
Amitava Sen, who played a stellar role in
establishment of the first Sick New Born Care
Unit at Purulia in 2003. Before the
establishment of SNCU in Purulia, peoples
confidence in primary health care based
programs was low, as the sick neonates
referred to health care facilities did not
survive. The limited number of nursing staff

This high toll of a million infant deaths per

year has made all stakeholders, including the
governments
aware of the daunting
challenge and impetus have been given to
building neonatal health care infrastructures
in form of sick new born care units, but
training and building up human resources in
field of neonatology have been lagging
behind.

The department has planned and helped in

operationalization of SNCUs in Port Blair,
Rajasthan, Madhya Pradesh, Orissa and Bihar.
In the last few years, the Government of West
Bengal has established six SNCUs at the
district level, while many more are on the
verge of completion in near future.
In order to streamline the activities of SNCU
establishment, monitoring, supervision and
evaluation and training of human resources
,in short, all activities pertaining to
operationalization of SNCUs ,a Special Cell for
Monitoring and Evaluation Sick Newborn
Care Units was set up in 2008 December in
the Department of Neonatology, SSKM
Hospital, Kolkata.

REFERENCES
Ref.Newborn Aides: an innovative approach in sick
newborn care at a district-level special care unit.Sen A,
Mahalanabis D, Singh AK, Som TK, Bandyopadhyay S,
Roy S.J Health Popul Nutr 2007 Dec;25(4):495-501.

Ref: Prematurity in India: What does the future hold? Ex

Prof. and Head, Dept. of Pediatrics and Neonatology,
PGIMER Chandigarh Journal of Neonatology, Year: 2007,
Volume:
21,
Issue:
2
Print ISSN: 0971-2179.

Ref. Journal of Neonatology, Year: 2006, Volume: 20,

Issue: 3 Challenges of neonatal intensive care in India
BhakooO.N.,Ex Prof. and Head Dept. of Pediatrics and
Neonatology, PGIMER Chandigarh

Ref. Goldsmith Jay P, Karotkin Edward H, Assisted

Ventilation of the Neonate, Fifth edition, Saunders
Elsevier, Page 525
Ref. Social Sector Service Delivery, Good Practices
Resource book, Planning Commission Govt. Of India,
United Nations Development Programme India, 2009,
Page 39

CHAPTER 1
GENERIC PLAN FOR DISTRICT LEVEL SICK NEWBORN CARE UNITS .

GENERIC PLAN FOR DISTRICT LEVEL SICK NEWBORN CARE UNITS (LEVEL II)
Sick Newborn Care Units (SNCU) are a special newborn unit meant primarily to reduce the case fatality
among sick children born within the hospital or outside, including home deliveries within first 28 days of
life.

0VERVIEW:

a.
b.
c.
d.
e.
a.

Components of a SNCU.
Description of individual components.
Minimum space requirement for each room.
Specifications.
Guidelines regarding electricity.

COMPONENTS OF A SNCU:

Main Sick Newborn Care Unit: This should have at least 12 - 16 beds, which would cater to the sickest
child in the Hospital. It will have space for nursing work station, Hand Washing and Gowning at the point
of entry.
Step down Unit: This is an additional 6- 8 bed Step down Unit where recovering neonates can stay i.e.
neonates who dont need intensive monitoring.
Newborn Ward: This is an additional 10 - 20 beds, where both the mother and the newborn can stay
together. This facility is to be used

for neonates who require minimal support such as for

phototherapy, for uncomplicated low birth weight babies (esp. weighing more than 1800gm) requiring
only observation and those stable babies who require only intravenous antibiotic therapy.
Neurodevelopmental Follow up clinic: While having this facility is not mandatory to start a sick newborn
care unit still a dedicated follow up clinic catering to the NICU graduates, which can also function as OPD
for newborns can complement the therapeutic activities of the sick newborn care unit .

Newborn corner:
with facilities for neonatal warmer and resuscitation at the labour room and Obstetrics Operation
Theatre.

Ancillary area:

Side Laboratory Room

Store room

Teaching and Training Room.

Duty Room for doctors and Nurses

Day and Night Shelter for mothers of

Power room

out born neonates with I.E.C. facilities

Place for Promotion of Breast feeding

drying and autoclaving

e.g. T.V. with Audio- Video facilities

and learning mother craft

b.

Place for In-house facility for washing,

Sluice room and janitors closet.

DESCRIPTION OF INDIVIDUAL COMPONENTS:

Sick Newborn Care Unit:

Sick Newborn Care Units (SNCU) should be ideally established in a facility in a resource poor
area where not less than 1000 deliveries occur per year.

The SNCU should have at least 12-16 warmer beds providing 24 hours service.

Location of the SNCU:

Should be located near the Labour Room, Labour Ward and Obstetrics Operation Theatre.

Should not be located on the top floor.

Should be accessible from the main entrance of the hospital.

The SNCU can be divided in two parts:

Patient care area

Ancillary area

Patient care area

The patient care area comprises of 5 facilities

a)

SNCU main area

b)

Step down unit

c)

Neonatal ward

d)

Isolation room.

e)

Triage room.

FIG:1.2

The space between two adjacent beds should

be 4 ft. and the distance between the wash
basin and the bed should be at least 3 ft. It has

a) SNCU Main Area:

to be also ensured that every infant bed be

within 20 ft. of a hands-free hand washing
The main SNCU area should be divided into two

station. For this purpose there should be 4 wash

interconnected rooms (600 - 800sq.ft for each)

basins (1 in each corner) in each of the SNCU

separated by transparent observation windows.

main rooms. (FIG:1.2)

The nursing station (200sq.ft.) should be in

A slab, 3 ft. from the floor and 1.5 ft. wide all

between the two rooms. This would facilitate

temporary

closure

of

one

section

around the room, satisfies the dual purpose of

for

ensuring minimum 2 ft. distance of the warmer

disinfection. A couple of beds can be separated

from the wall as well as acting as an immediate

for barrier nursing of infected neonates. The

storage area.

nursing station should be separated from both

Beds in the SNCU should preferably have its

main SNCU rooms by full length glass partition in

separate oxygen supply and suction outlet.

order to facilitate proper visualization.

Space requirement:
Minimum space requirement for each bed area
is 100sq.ft. This would be divided as follows:
a) 50sq.ft per bed would be for individual
patient care area.
b) 50sq.ft per bed would be for ancillary
area.
3 glass door concept. (FIG:1.3,1.4)
A 3 glass door concept was introduced in order

FIG:1.3

to minimize the chances of infection. This 3

glass door concept when strictly adhered to
ensures strict hand washing and gowning
protocol. Between door 1 and 2 would be
present the hand washing and gowning areas.
There should be provisions of 2 hand washing
stations in this area, one on each flank. The door
3, one on either side, is in between the door 2
and the nursing station. This door 3 gives access
to the main SNCU room.

b) Step Down Unit

An additional 6-8 bed Step down Unit where

recovering neonates can stay i.e. neonates who
dont need intensive monitoring. This would be
of added advantage to the SNCU as it would
relieve the pressure to some extent. The space
requirement would be at least 70sq.ft.per bed.
This area should also have two wash basins.
FIG 1.4

c) Neonatal Ward

There should be uninterrupted water and

electric supply.

This is an additional 15 - 20 bed, where both the

The ward should be well lit and well

ventilated.

mother and the newborn can stay together for

neonates who require minimal support. A

Room temperature should be maintained

by DUCT A.C.

warmer should be present separately in the unit

where minor procedures such as IV cannulation
can be performed. In order to accommodate at
least these many numbers of beds within the
neonatal ward a half wall of 3.5 ft. high can be
built in the middle of the ward while not
compromising the easy access. Wall mounted
warmer could be placed if required adjacent to
beds 1, 2,14,15,16,17 and 18.(FIG:1.5)
Physical structure of the neonatal ward:

Single bed for mother and her newborn.

Adequate place should be there between

two beds for access and placing the
phototherapy units.

Ideally the floor area should be than that

of the main SNCU for accommodating
more number of patients.

Should be located near the main SNCU &

FIG:1.5

within the unit.

There should be at least one wash basin.

Floor and walls should be washable

Tiles should be there up to 7 ft. The

colour should not be yellow/ blue.
Preferably the colour should white/ off
white.
10

d) Isolation room

e) Triage Room

An isolation facility, capable of accommodating

It is a facility, approx 160 sq. ft. where 2

3 beds, adjacent to the neonatal ward should

warmers and all equipments for neonatal

be present. This will be required to isolate those

resuscitation should be present. This facility is

babies who are born to mothers with Hepatitis

meant for initial assessment and emergency

B, HIV and Chicken Pox. A glass wall should

management of out born babies.

preferably separate the neonatal ward and the

One of the beds of the step down unit can be

isolation ward in order to facilitate the

used for the same purpose for in born babies.

visualization of the babies in the isolation ward

by the same nursing personnel in order to enter

2 hands free hand washing station and

the isolation ward the nursing personnel should

provisions for oxygen and suction outlet should

go through the process of mandatory gowning

be present in the triage area.(FIG:1.7)

and hand washing in the dedicated area in front

of the isolation ward (FIG:1.6)

FIG:1.7

FIG:1.6

11

Ancillary area
The ancillary area should include separate
areas for

1. Teaching Room:
The SNCU also serves as a
teaching and hands-on-training centre
for the entire district. Thus with every
unit there should be a room allotted for
teaching and training. This space can
also be utilized for patient party
meetings. The departmental library can
be set up in this place. In order to aid
the teaching activities a computer and a
projector should be present. This area
can also double up as an area for video
conferencing.

2. Hand washing and gowning area

within the Main SNCU
3. Nursing Work Station within the
Main SNCU (FIG:1.8)
4. Fluid preparation area within the
Main SNCU
5. Space for X-ray within the main

FIG:1.8

SNCU unit
6. Store: A 3 zone storage area is
desirable (FIG:1.9,FIG:1.10)
12

a. First

storage

area

(central

cannula, feeding tubes etc. This

storage area) :- Should act as

can also act as charting area for

the central supply of the unit

the nursing staff.

(S1 & S2 in the LAY OUT) there,

S1 can act as store for the
disposables and linen, while S2
can

act

as

an

FIG:1.9

equipment

storage room.

b. Second storage area (clean

storage area) :- It is the clean
utility area (Scu in the LAYOUT)
which should be adjacent but
acoustically separated from the
infant area, clean lien, cover
gowns,

charts,

information

booklets, syringes and needles,

IV infusion sets & sterile trays
may be stored in this space.

c. Third storage area (immediate

storage area) :- The third
storage

area

can

be

the

concrete slab 3 from the floor,

1.5 wide attached to the wall
present all around the room.
This

will

contain

FIG:1.10

individual

supplies of each baby such as

trays containing sterile diapers,
cotton, specific medications, IV
13

7.

Side Laboratory: the side lab should

contain (FIG:1.11)

Microscope and
provision for staining

Provision for bilirubin

estimation( bench top
micro centrifuge
machine, capable of
rotating at 12000 rpm,
Bilirubinometer)

Automated cell
counter(desirable, not
mandatory)

Electrolyte analyzer

Blood gas analyzer (if

this is provided, then
electrolyte analyzer
becomes optional)

The side lab should have a 2 ft wide

concrete slab, 3 ft from the floor all around
the lab for placing the equipment. Voltage
surge free uninterrupted power supply is
mandatory for smooth running of the
laboratory. The electrical outlets (at least
12 in number) should be 5/15 ampere
sockets. All power supplied in the
laboratory should be clean power.
FIG:1.11

14

8. Breast

feeding

room/area

cum

learning mother craft: (FIG:1.12)

It acts as mini Breast milk Bank
for the facility as well as a space for
expiration of breast milk by breast
pumps. This area can be utilized to
dispense information and education
regarding breast feeding and mother
craft to the new mothers, using
appropriate audio visual media. Ice
FIG:1.12

lined refrigerator(ILR), present in this

room will act as a mini breast milk bank.

FIG:1.13

9. Doctors Room(FIG:1.13)
10. Nurses room
11. Sister-in-charges Room
12. Washing, Drying

and

Autoclave

Rooms:- (FIG:1.14)
Infant clothing, sheets and
gown should be laundered on a regular
schedule and as needed. Space for
commercial grade washing machine and
a dryer should be accommodated.
Dryer should be vented through an
outside wall this same facility can also
accommodate the ETO machine and the
autoclave.
FIG:1.14

15

13. Out born mothers Room :

utility/holding room shall be engineered

to have negative air pressure with air

as a shelter for out born

mothers who would require to be be

100%

exhausted

present at close proximity of the SNCU

outside.(FIG1.15)

to

the

to facilitate supply of breast feeding.

15. Janitors Closet: It is the room for

14. Sluice Room: This room will contain a

storage of clean mops, materials for

water reservoir with both inlet and

cleaning, gloves and boots which are

outlet. Minimum dimension will be

worn

4ft.wide x3ft.front to back x 2ft. deep.

during

cleaning.

Other

housekeeping objects such as three

Not only will this water reservoir be

bucket trolley can be kept here.

used to clean dirty mops but this same

reservoir

will

also

be

used

to

16. Clean Utility/Holding Area(s): For

preliminary clean linen soiled by fecal

storage of supplies frequently used in

matter, urine, vomitus etc. before

the

putting them in the washing machine.

The ventilation system in the soiled

FIG:1.15

16

care

of

newborn

c.

MINIMUM SPACE REQUIREMENT

FOR EACH ROOM:
7. Nurses work Station-100sq.ft
8. Shelter for out born mothers-250 sq.ft

1. Main SNCU 1600sq.ft (for 16 bed unit)

9. Nurses Room-100 sq.ft

2. Step Down Unit -550 sq.ft (for 7-8 bed

10. Doctors Room -100sq.ft

unit)

11. Teaching and Training Room-400sq.ft

3. Neonatal ward -1100 sq.ft (for 18-20

12. Sister-in-charges Room-50 sq.ft.

bed unit)

13. Room for breast feeding and learning

4. Side laboratory-100 sq.ft

mother craft-100sq.ft

5. Store Room- preferably 75-100 sq.ft

14. Sluice room -50 sq.ft

6. Washing, Drying and Autoclave room-

15. Clean Utility/Holding Area 50 sq.ft

75-100 sq.ft

16. Neurodevelopment

clinic=650sq.ft

17. Total space required = 9000 sq.ft

17

d. SPECIFICATIONS:
Yellow and blue tiles should not be used

WINDOWS: Properly designed day lighting is

the most desirable illumination for nearly all

at all.
Tiles should be given up to 7ft

care giving tasks including charting and

evaluation of infants skin tone. The window
should have following criteria:

Should be easily cleaned

Should be there as a source of natural

WATER SUPPLY

light

Should be made of fixed glass with

facilities should be such that it should

sliding opaque glass shades [ denoted

be within 20ft (6m) of any infant bed,

as W1 in the layout]

apart from the entrance to SNCU.

( to provide

shades as an when required while also

ensuring minimum color distortion

Should have 24 hrs uninterrupted

running water supply

from the transmitted light. )

The ideal number of Hand washing

Should be at least 2 feet away from

There should be

wash basins with

elbow/foot operated tap in the

the cots & the glass should be Isolated

a.

glass to minimize heat gain or loss.

washing and gowning area (at

least 2)

W2 in the layout denotes normal glass

b.

windows.

main SNCU ( 4 in 4 corners of

the room)

c.

W3 in the layout denotes windows with

Step Down Unit ( 2 corners of

the room)

polarized glass which allows visibility only from

d.

inside the room.

Neonatal ward(1 corner of the

room)

There should be wash basins in the

Ordinary type) Laboratory ,Toilets and

WALLS

Sluice Room
Should be made of washable tiles
The colour of the tiles should be white
or off-white

HAND WASHING SINK

18

splashing

They shall be large enough to control

and

designed

to

Walls adjacent to hand washing sinks

avoid

shall be constructed of nonporous

standing or retained water. Minimum

material. Non-absorbent wall material

dimensions for a hand washing sink are

should be used around sinks to prevent

24 inches wide /16 inches front to back

the growth of mold on cellulose

/10 inches deep (61 x41 x 25 cm3) from

material.

the bottom of the sink to the top of its

Space shall also be provided for soap

rim. (FIG1.16)

and

towel

dispensers

and

for

washing

appropriate trash receptacles. Non-

instructions shall be provided above all

absorbent wall material should be used

sinks.

around sinks to prevent the growth of

Space

for

pictorial

hand

mold

FIG:1.16

19

on

cellulose

material

cleaning and highly durable nature. It

FLOOR

should be latex-free.
Cleaning: Infection control is crucial in

the SNCU, so a ooring material for

tiles, but should be of white/off-white

patient care areas should be such that

colour.

can be easily cleaned and is essential

requirement. Stain resistance is an

to minimize glare.

be used where spills of blood, iodine-

containing compounds, or other such

Rubber: Rubber ooring is the most

growing

choice

in

Small floor tiles should be strictly

avoided as they harbor dirt and fluids.

materials are common.

rapidly

Reflectance should be less than equals

to 40% and gloss value <30 gloss units

important aspect for ooring that will

Other choice could be made of vitrified

WALL :- wall surfaces should be easily

cleanable

newly

constructed SNCUs due to its ease of

CEILING :- should be easily cleanable.

Table 1.1 : Summary of flooring considerations.

Flooring type

Comfort/sound

Environmental

Maintenance

Suggested

control

impact

cost

use

medium

poor

good

medium

Supply areas

Low

medium

poor

fair

medium

Supply areas

Low

medium

fair

fair

medium

none

Medium

low

good

good

high

Public areas

High

high

good

Very good

low

Initial costs

durability

linoleum

Low

Vinyl
Cushioned
vinyl
carpet
rubber

VENTILATION
20

Patient cure
area

The ventilation should preferably be provided by a duct air conditioning system capable of both
temperature control as well as exchange of air. It has to be so devised that a minimum of 6 exchanges
/hour with 2 changes being outside air can be ensured. The filters of this ventilation system should be
located outside infant area for them to be easily & safely changed. Fresh air should be at least 25 ft.
away from the exhaust outlet of the ventilating system and all forms of noxious fumes and vehicular
exhaust.

TEMPERATURE

AND HUMIDITY INSIDE

SNCU
The temperature inside the main SNCU
should be maintained at (22- 26C), round
the clock preferably by thermostatic Control.
While the babies in the main SNCU and step
down units can be kept warm by use of
warmers

at

the

prescribed

temperature,

arrangement has to be made to separately

control temperature in the neonatal ward at a
higher level so that hypothermia can be
avoided.(FIG:1.17)
Relative humidity of 30 % 60% should
be maintained while avoiding condensation on
wall and window surfaces.

ACOUSTIC CHARACTERISTICS

Background sound should not be more

than 45 db

Peak intensity should not be more than

80 db

21

Control :

ILLUMINATION
All lighting fixtures should

be easily

Both natural and electric light sources

should preferably have controls that

cleaned.

allow immediate darkening of any bed

position sufficient for transillumination
when necessary.

Inside SNCU:

Well Illuminated but adjustable to suit

Night illumination:

the need of the baby

Adequate

day

light

for

natural

0.5 ft candle at Neonates level

illumination for examination of color

Cool white fluorescent tubes

or CFL

unit with reflection grid providing 10-20

Procedure light:

ft candle shadow free light

separate procedure lighting capable of

providing not less than 2000 Lux at the
plane of infant bed, framed suitably so

Illumination at the level of Neonates:

that not more than 2% of the light

Avoid exposure of the infant to direct

output extend beyond its illuminating

ambient lighting. Direct ambient light

has a

field.

negative effect on the

development of the infants visual

neural architecture and early exposure
to direct light may adversely affect the
development of other neuro sensory
systems.

Ambient lighting levels in infant spaces

shall be adjustable through a range of at
least 50 to no more than 600 lux
(approximately 5 to 60 foot candles), as
measured at each bedside.

22

manner to the power boards belonging

e. GUIDELINES REGARDING

to three different phases.

ELECTRICITY

(Based on suggestions prepared jointly from

5) In case duct AC is not used, at least

Department of Neonatology, IPGMER, Kolkata

two

and Jadavpur University, Electrical department

air-conditioners

should

be

connected per room to emergency

for SNCU)

power to take away the heat load in

the case of power outage.

1) A dedicated earthing pit for the SNCU

should be created. Earth resistance

6) Smoke detectors with fire alarm as

should be measured twice in a year

well as fire extinguishers should be

and logged.

installed in the SNCU without further

delay.

2) A wall mounted digital display should

be installed to show earth to neutral
voltage in the SNCU. This voltage

7) The emergency exit / fire escape

should normally be within the range 3-

should be built in such a way that the

5V.

be

babies under treatment could be

informed immediately if this exceeds 5

evacuated within a very small span of

V.

time in the case of any emergency in

PWD

personnel

should

the SNCU. In case of fire, a write-up

describing
3) The manufacturer should be asked to

members.

4) The power boards within SNCU should

8) Fire extinguishers should be installed

be marked to show the phase to which

in the vicinity of the panel boards in

it belongs. The SNCU staff should take

that

the

equipment

for

should be made available to SNCU staff

output of the voltage stabilizers.

so

procedure

emergency shut off, main switch

mention in writing the quality of

care

the

front of the SNCU.

is

connected in an evenly distributed

23

9) The voltage stabilizers being the most

raw power. Necessary raw power

important item in providing quality

boards should be provided within the

power to the major equipment in

SNCU.

SNCU, best quality material should be

chosen for any future procurement of

11) Necessary

information about

the

such stabilizer. If possible, a back-up

power requirement of the equipment

stabilizer may always be kept.

should

be

available,

e.g.,

X-ray

machine, autoclave, hot air oven etc.

10) The ethylene oxide sterilizer, portable
X-ray machine, autoclave and the hot

12) The distance between two warmers is

air oven is preferably operated from

kept

around

feet.

Table 1.2

Equipment

Approximate Power
Consumption (Watt)

Type of
Power

800 W (700 W + 100 W for Bulb)

Raw

Radiant Warmer

Infusion Pump

9W

Clean

Syringe Pump

12 W

Clean

Phototherapy Machine (CFL)

150 W (18 W x 6 bulbs + 28 W fan)

Raw

Compressor

550 W

Raw

Main Unit

140 W

Clean

Humidifier

150 W

Raw

5
Ventilator

Spotlight

100 W

Raw

Weighing Scale

150 W

Clean

X- Ray Machine

2150 W

Raw

24

USG Machine

850 W

Clean

10

Ethylene-oxide
gas sterilizer

3500 W

Raw

16) Check for any Unbalance of current in

the three phases at the output of the

13) UNDER NO CIRCUMSTANCE

switch-gear.

EXTENSION CORD, OR MULTIPIN

SHOULD BE USED TO GET POWER from

17) Check for Power that is received at the

one switch and share it. Individual

feeding point .

switch should be provided for each

equipment.

14) In order to supply 24 hour

18) Check for the adequacy of the

uninterrupted stabilized power supply,

transformer for the entire hospital

three-phase servo-controlled voltage

stabilizers should be used, each rated
15 kVA to 25 KVA X 3 such. Total
requirement is 3. Two stabilizers work
at a time to provide redundancy in the
system. The system should be capable
of bearing extra load. A vertical power
distribution board is preferable.

15) AT LEAST 30kVA DG (Diesel Generator)

set is exclusively required for the
SNCU.

25

ELECTRICITY OUTLET FOR INDIVIDUAL BEDS

19) Each warmer bed in main SNCU room,

step down unit, triage room and
neonatal ward should be provided with
10 central voltage stabilized outlets
with a combined 5 /15 amperes [or at
least 50% should be 5 amps and 50%
should be 15 amps to handle all
FIG:1.18

equipment]. Half of these electrical

outlets should be supplied by clean
power, while rest is to be supplied by
raw power.(FIG:1.18)

20) Additional points for portable X-Ray:

at different corners of main SNCU
room and in step down unit additional
points for portable X-Ray should be
present so that X ray machine is
accessible to all beds.

21) Each bed in neonatal ward should have

access to 2 electrical outlets(5/15
ampere, raw power).

26

CHAPTER 2
MAN POWER NEEDED FOR SNCU

Manpower Requirement for SNCU

Calculated for SNCU 12 Beds, Step Down Unit 6 Beds, Triage 2, 10 bedded neonatal ward and
3 bedded isolation ward.

Particulars
Doctor with one in charge
Nurse

In charge
Staff Nurse

GDA
Sweeper
Rogi Shahayak
Data Entry Operator
Lab. Technician
Critical Care Technician
Neonatal nursing aides
Table 2.1

No. of Personnel
6
2
21
6
9
2
1
1
1
8

All Nursing staffs are to be sent to Dept. of Neonatology, IPGME&R, Kolkata to attend 1 month
neonatal nursing training programme. Especially the Sister-in-charges require 1 month hands on
neonatal nursing orientation training programme before starting their SNCU duties.

MANPOWER REQUIREMENT FOR A 12 BED

SICK NEWBORN CARE UNIT:
Doctors:

The medical officers must have a

special qualifications & / or training &
/ or experience in sick newborn care
in a level II SNCU.
They should ideally have full time
involvement and be exclusively
involved in the care of neonates
They are primarily responsible for the
complete care of sick neonates
admitted in the SNCU, Step Down
Unit and Special Care Baby Unit

27

They should also cover the neonates

beyond SNCU e.g. resuscitation call
for difficult deliveries in labor room
and Obstetrics OT, taking rounds of
neonates in the postnatal wards,
taking care of sick neonates in the
Pediatric Ward ( who are not
admitted in the SNCU due to lack of
space) and running the follow up
clinic.
They should also be involved in the
training programs related to newborn
health for nurses, medical officers and
health workers conducted for the
entire district.
Considering the work load at least 4
medical officers would be the

minimum requirement for running

such a unit.
The medical officers with requisite
qualifications who have worked in a
district level SNCU for at least 2 years
should be considered favourably for
promotion.

postnatal wards and Pediatric ward where the

neonates are not looked after properly.

Neonatal Aides/Yashodas/Mamta
Eight (2 per shift, 2 for covering day
off, leave, sickness etc.) would be of immense
help.

Nursing personnel:

STAFF NURSE

Other staff:

Laboratory Technician for side laboratory

21 for 12 SNCU beds and 6 Step Down

Unit beds
For SNCU -Nurse-baby ratio = 1:3-4 in
each shift
For Step Down Unit- Nurse-baby ratio
=1:6-8 in each shift
To cover day off, leave, sickness 30%
extra.

Maintenance Staff ( for routine electrical,

equipment and other maintenance)
Computer data entry operator
Group D staff ( 2 per shift)

Nurse-in charge/Nursing Supervisors

Preferably should have experience in

accredited Level II unit.
Should have good managerial skills.
Should be clinically sound so as to
take care of the neonates in the
absence of doctor.
There should 1 for every shift with 1
extra to cover day off, leave, sickness
etc.

Designated Nurse For conducting inservice trainings/Public Health Nurse

One should be exclusively attached to

the unit.

Additional Staff Nurse

This should be mandatory for providing care
to the neonates at birth, neonates in the

28

CHAPTER 3
HUMAN RESOURCE MANUAL

Human Resource Manual

DUTY MANUAL FOR GUARDS

Changes into the uniform provided for

them.
Removes all hand ornaments and
follows the hand wash protocol for
2mins before starting work.
Prepares the 3 buckets with clear
water in all three buckets and phenyl
or Lysol in one of the buckets. (
bucket 1 clean/ bucket 2 clean /
bucket 3 disinfectant).
Then he cleans the floor starting from
inside then coming outside ONCE in
EVERY SHIFT.
After each sweep of the floor he dips
the mop in the buckets in the order of
bucket 1 then bucket 2 then bucket 3.
Then he cleans the tables, chairs and
computers with a dry cloth ONCE in
MORNING SHIFT.
Then he cleans the walls, again from
inside out with bacillocid solution
(20ml dissolved in 1L) ONCE in EVERY
SHIFT.
Then he cleans the windows and
doors with soap water ONCE in
MORNING SHIFT.
Then he empties the dustbin
according to hospital waste disposal
colour coding, cleans the dustbins
with soap and water , puts new
coloured plastics in the dust bins ,
prepares and pours polar bleach
solution in each and replaces. This
should be at least ONCE in EACH
SHIFT or whenever necessary.
1. Black bag - waste papers, medicine
vials- disposed off by municipality .

Sign in the attendance register kept in

the sister in charge room with time.
Change into the uniform allotted to
him.
Sits in the chair given for him at the
gate.
Keep the SNCU doors closed, only to
be opened for mothers coming for
breast feeding, or with sick babies or
when the doctor calls any relative of
the patient for discussion.
If they need to leave the gate for
some reason they should inform the
sister in charge when possible and ask
a sweeper or a ward boy to be at the
gate till his return.
They should ensure that anybody
entering the SNCU should leave their
shoes outside.
They should always maintain polite
behavior with anxious relatives of the
patient.
They should leave duty only when the
other guard has arrived.
Shifts 8am to 2pm, 2pm to 8pm and
8pm to 8am.

DUTY MANUAL FOR SWEEPERS

Signs in the attendance register kept

at the sister in charge office with
time.

29

2. Yellow bag- non plastic human

anatomical waste- incineration.
3. Blue bag- plastic disposable sharp
items like iv sets, cannula- autoclave
and disposed off .
Then he will collect all discarded
gowns and soiled linens wash in tap
water and dip in hot water.
Clean the slippers with soap and
water.
Clean the wash basins with soap and
water.
Then he cleans the toilets
Then he cleans his mops and three
buckets thoroughly with soap and
water.
Every Sunday he cleans the AC and
fans with soap and water, empties the
refrigerator and defrosts it and cleans
it.

DUTY MANUAL FOR DATA ENTRY OPERATOR

DUTY MANUAL FOR WARD BOYS

Wash the dirty linen already dipped in

hot water in the washing machine and
dry them.
Pack the drums for autoclave and take
for autoclave once in each shift.
Fumigation when required.

Two ward boys in each shift, reports

in time and signs the attendance
register kept at the sister in charge
office.
Removes all hand ornaments and
washes hands for 2mins.
Wears gown and prepares nappies,
splints and name tags in numbers
specified by sister in charge on the
table allotted for this purpose.
Hand wash again.
Clean radiant warmers except the cot,
syringe pumps, phototherapy units,
pulse oximeters with clean wet cloth.
If blood stained use soap and water
once in morning shift.
Check all oxygen lines and wash the
humidifiers bottles with soap and
water , pour fresh clean water once in
morning shift.

Two operators should report to the

sister in charge .
Duty hours would be from 10 am to
5pm.
Should be maintain patient data in the
format we have provided.
Should maintain instrument list
Should send monthly raw data to
monitoring cell at IPGMER, Kolkata.
Female data entry operator can be
trained to give mothers advice on
benefits and techniques of breast
feeding.
Sunday will be on rotation and those
who are working on Sunday would get
one weekday off.

DUTY
MANUAL
TECHNICIAN

30

FOR

PATHOLOGY

one of them would be on duty from 8

am to 2pm and another from 2pm to
8pm.
they would report to the sister in
charge.
keep record of the investigations
done.
they are responsible for maintenance
of all laboratory equipment.
they inform the sister in-charge for
indent of the required reagents
They would be trained to do sepsis
screen,
use
centrifuge
and

bilirubinometer and the semi

autoanalyser.
Cleanliness of the laboratory is also
the technicians responsibility

DUTY MANUAL FOR NURSING STAFF

Changing dress and hand washing for

2mins.
Handover followed by allotment of
babies to individual nursing staff by
the on duty doctors.
Preparing the at least one emergency
bed and the bed allotted to them in
the MORNING SHIFT DAILY. Procedure
as follows:
Clean cot of the radiant warmer with
soap water.
Use fresh autoclaved linen and
discard the previous linen.
Keep oxygen hood and oxygen source
ready.
Keep new suction catheter ready.
Keep the bedside ready with small
containers filled with spirit, betadine,
autoclaved cotton, thermometer,
adhesive tape, measuring tape and
stethoscope.
Stethoscope,
measuring
tapes,
thermometer, pulse oximeter probe
to be cleaned with spirit.
Oxygen hood cleaned with soap water
On SUNDAY or after every use on
infected baby resuscitation bag and
reservoir should be cleaned with soap
and water after dismantling the unit,
then dipped in 2% glutaraldehyde for
6hours, then thoroughly cleaned with
normal saline or distilled water
wrapped in autoclaved cloth and kept
in the resuscitation tray.
Laryngoscopes should be cleaned
DAILY with spirit swab thoroughly

31

every day. If used in an infected baby

clean with soap and water, then
dipped in glutaraldehyde 2% for 6 hrs
after REMOVING THE BULBS then
washed with distilled water. It should
be kept wrapped in autoclaved cloth.
Face masks should be cleaned DAILY
and after every use with soap and
water, immerse in 2% glutaraldehyde
for 20 mins , rinsed thoroughly with
distilled water, dried and kept
wrapped in autoclaved cloth in
resuscitation tray.
Cheattles
forceps
should
be
autoclaved DAILY and kept in
autoclaved bottle with sterile cotton
inside.
Medicine tray and resuscitation trays
should be cleaned with soap and
water DAILY.
Weighing the baby in weighing
machine after removing all clothes
and cleaning the tray with spirit.
Patient care includes administration
of medication, feeding as advised by
the doctor, assisting the doctor while
blood sampling or any procedure like
putting an iv channel.
Procedure of setting up an iv channel
set
Sterile cotton
Sterile gloves
Adhesive tape
Autoclaved splint
Neoflon removed from the cover
Normal saline flush in 2ml syringe
Ensure that proper skin preparation
technique
is
followed
during
venepuncture.
Wash hands and dry.
Wear sterile gloves.
Locate the vene puncture site.
Swab with alcohol and dr.
Swab with iodine and dry.

Swab with alcohol and dry.

Prick .
Clean bed after every procedure to
remove any accidental presence of
needles .
Record the findings in nurses
monitoring sheet.
Check the instruments that has been
allotted to each nursing staff for a
month.

CHECKLIST
OF
SOME
IMPORTANT
PRECAUTIONS TO BE TAKEN IN PATIENT
CARE:

Check the position of the tube by

pushing air down the tube and
checking the marking at the oral or
nasal orifice before any gavage feed.
Check for abdominal circumference
and suction amount before gavage
feed.
Keep a record of the infant feeding
tube marking and the nature of
gastric aspirate in the nurses note.
An assessment note should be put by
every nursing staff on the monitoring
sheet, in every shift with his or her
signature.
Never stock heparinised iv fluids and
do not use a single dextrose or normal
saline bottle for> 24hours .
Separate microdrip set for each baby
and should be changed every day.
Date and time of opening should be
marked on each bottle opened.
Do not keep files, books , X rays on
the cot.
Check the glutaraldehyde solution at
15days and date of change should be
marked.
Whenever a baby is referred to a
tertiary centre the nursing staff
allotted the baby should accompany
the baby to the ambulance.

A baby should be send to mother only

after the doctor has put a written
order of baby being send to mother or
discharged.
Nursing staff handing over the baby to
the mother should take the mothers
signature or thumb print on the
statement that she has received her
baby mentioning the sex of the baby.
Always be gentle to the newborn,
keep clean and warm, prevent
newborns eyes from strong light and
ears from loud noise, do not talk at
the bed side among each other , talk
to the newborn instead.

DUTY MANUAL FOR SISTER IN CHARGE

32

Duty hours should be from 9am to

5pm.
All attendance registers should be
kept in sister in charge office.
Ensuring that all staff are coming and
leaving on time and are performing
the tasks mentioned in their duty
manual accordingly.
Keeping record of all the instruments
and gadgets being used in the SNCU,
those in functional and non-functional
condition and get repair work done if
pending.
Disciplined and smooth running of the
SNCU work flow is sister in charges
responsibility and she should also take
disciplinary action if the duty manuals
are not followed.
She is also responsible for maintaining
the stock of medicines and other
accessories like syringes, needles,
neoflons , disinfectants etc. by weekly
indents.

She is responsible for training any

new staff appointed to the SNCU and
show him the duty manual.
She should ensure strict housekeeping
routine is followed.
She should ensure 24 hour water and
electric supply with adequate lighting
and ventilation.
She should ensure a clean and calm
environment in the SNCU.
She should ensure that there is
overcrowding in the SNCU Premises
She is responsible for solving day to
day problems in SCNU workflow and
repair any fault as soon as possible.

CHECK LIST FOR SISTER IN CHARGE

All staff have arrived in time at the

unit.
Guard is at the gate and nobody is
entering the unit without permission.
Floors , walls, windows, doors and
furniture are cleaned according to
schedule.
Dustbins are cleaned and contain
polar bleach solution.
Slippers are washed.
Wash basins are cleaned .
Toilets are cleaned and there is no
water logging.
Bed sheets in the doctors room are
clean and fres.
Adequate number of nappies and
splints are being made in each shift
maintaining proper sterile measures.
Autoclaving in every shift is being
done properly.
The beds, warmers, syringe pumps
are being cleaned regularly in
morning shift.

33

Oxygen connections have been

checked and humidifiers water
changed in morning shift.
Supervise that all beds have been
prepared in the morning shift,
resuscitation trays are ready.
Exchange transfusion drum to be
prepared and autoclaved by sister in
charge, re autoclaved if more than 72
hours have elapsed from last
autoclave.
Sheets 2
Cut sheet 1
Pairs of gloves2
Silk suture1
Iris forceps1
Toothed forceps 2
Allis forceps 2
Gauge piece 10
Cotton balls
Scalpel blade handle1
Swab holder1
Towel clips 2
Supervise that nursing staffs are filling
the monitoring sheet fully once in a
week.
Supervise whether the data entry
operator is keeping records up to date
once in a week.
All instruments and gadgets are
functioning.
Iv fluid bottles are marked with date
and time of their opening.

CHECK LIST FOR DOCTORS

Supervise the work of all above

mentioned staff.
Take regular classes of nursing staff.
Teach any newly recruited staff.
Supervise that all data is up to date.
Fill up the history sheet for all babies
during admission.
Keep daily notes in the proforma
attached along with.
Send monthly raw data to IPGMER,
Kolkata.
Follow uniform treatment protocol
Arrange seminars and present their
work in national conferences to make
their presence known in medical
fraternity.
Write detailed discharge certificates
without using any short form.

34

CHAPTER 4
Equipment list for SNCU complex

EQUIPMENT LIST FOR SNCU COMPLEX:

Calculated for SNCU 12 Beds, Step Down Unit 6 Beds, Triage - 2
War
1 Warmer bed (Servo Controlled)
10 beds attached with under-surface phototherapy unit
10 beds without phototherapy unit
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

Phototherapy unit (CFL)

Fluid Stand
Infusion Pump
Syringe Pump
Neonatal Stethoscope
Resuscitation Kit (Full)
Multi Monitor
Pulse Oxymeter
Oxygen hood
Oxygen Concentrator
electric suction machine for newborn
Foot Sucker
Nebulizer
Spot Lamp
Crash Cart Trolley
Procedure Trolley
Horizontal Laminar Flow
Flux Meter
Washing Machine, dryer (Separate) (Industrial grade)
Fogger Machine
Autoclave Drums (of different size)
Gowns
Full Set Dress (Upper & Lower)
For Doctors
For Nurses, GDA, Sweeper

25
26
27
28
29
30
31
32
33
34
35
36

Vacuum Cleaner
ETO Sterilizer
Sterilizer
Hot Air Oven
Refrigerator
Washable slippers
Bucket for waste disposal large size
Bucket (foot operated) with lid small size
Bowl (Small & Medium) for procedure
Trolley for keeping drums/fluids/articles/gowns
Torch (small)
Non stretchable measuring tape (mm scale)
35

20

10
20
20
10
22
22
6
14
20
5
12
20
2
1
3
3
1
1
1
2
15
Adequate
Adequate
different sizes
Adequate
Numbers
1
1
2
1
1
25
3 each
1 each bed
3
3
2
22

37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52

Weighing Machine (Digital)

Wall Clock
Infantometer
Manual Mercury sphygmomanometer with neonatal cuff
Mechanized cleaning device
3-Bucket Trolley
Fire extinguisher
Table for pressing linen
Portable X-ray machine
X-ray view box
Basic Surgical Instruments sets
Room Thermometer (digital in centigrade)
Digital centigrade THERMOMETER
Aqua Guard
AC for SNCU, teaching room, laboratory
generator15 KVA

3
3
2
2
1
1
2
1
1
2
7
5
20
1
needed
1

NEONATAL WARD-10 BEDED:

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
211.
222.
233.
244.
255.
266.

Bed ( Adult size)

Fluid stand
Bed side cabinet
Warmer ( servo controlled )
Phototherapy unit (CFL)
Infusion pump
Syringe pump
Foot sucker
Nebulizer
Bed side stool
Digital weighing scale
Infantometer
Pediatric stethoscope
Resuscitation Equipment set*
Digital centigrade THERMOMETER
Emergency drugs trolley( with wheels)Spot lamp
Pulse oxymeter
Oxygen hood
Oxygen concentrator ( double outlet )
Autoclave drums( different sizes)
Gowns
Washable slippers
Sterilizer
Electric heater
Safe source of drinking water

10
12
10
2
2
2
2
4
1
10
2
1
3
3 sets
4 to start with
1
1
2
5
2
Adequate
Adequate
11
2
1

36

ISOLATION WARD:
1
2
3
4
5
6
7
8

Bed ( Adult size)

Warmer ( servo controlled )
Phototherapy unit
Bed side cabinet
Fluid stand
Bed side stool
Neonatal stethoscope
Oxygen hood and concentrator

3
1
1
3
3
3
1
1

EACH NEONATAL RESUSCITATION KIT TO CONTAIN:

1. Neonatal self inflating resuscitation bag (silicon, autoclavable) with open type oxygen reservoirHalf of the sets to contain 500 ml bags and the others half will contain 250 ml bags
2. Neonatal round shaped, cushioned, face mask (silicon, autoclavable): each set to contain one
each of 00, 0, and 1/0 size
3. Oxygen Tubing-1
4. Neonatal laryngoscope (With extra bulb) with straight blade of different sizes- each set to
contain one each of 00, 0, and 1 size
NOTE: There should be adequate supply of ET tube of size 2.5, 3, 3.5, 4 (MM ID), Suction catheter of
REQUIREMENT
sizes 6, 8, 10, 12 fr and Delees
mucus trap.FOR Ancillary Rooms AND AREA

37

REQUIREMENT FOR ANCILLARY ROOMS AND AREA:

Doctors Room:

2
3

Sister Room.
Teaching Room.

2O

Bed - 1
Chairs - 2
Table
Locker (multichambered)

Lockers, chairs, Electrical Heater, Wall fitting Rack

Chairs - 15

LCD TV with audio system - 1

Breast Milk Extraction Room:

Data Entry Operator.

Table - 1
ILR - 1
Table - 1
TV with DVD with audio system(for IEC)- 1

Sitting arrangement (sofa/chair)

Computer (Desk top) - 1

Computer table - 1
Chair - 1

SLUICE ROOM : JANITORS

CLOSET.
7 STORE : WALL MOUNTED
RACK S( MULTIPLE).
8 Table & chair, SHELF for
nursing station.
9 Shoe rack s .
10 Oxygen hood.
11 Oxygen Concentrator.

22
22
6
8
20
5

SIDE LAB REQUIREMENT:

Item

Requirement for the unit

1.Microscope with Gram & Leishman staining facility.

1 (essential)

2.Microhaematocrit Centrifuge, capillary tubes & reader.

1 (essential)

3.Bilirubinometer .

1 (essential)

4.Multistix strips ( in container).

5.Glucometer with Dextrostix.

4 (essential)

6. Dry Biochemistry.

1 (desirable)

38

DATA COLLECTION:
Item

Requirement for the unit

1.Desk top computer( with color monitor, 1 (essential).

CPU, UPS, laser printer & computer
table).
2.Various types of stationeries.

Requirement as per running any other unit.

3.Various types of forms.

Various types of specialized forms for patient care 7

monitoring would be necessary for the unit on a
regular basis.

EQUIPMENT FOR TRAINING:

Item

Requirement for the unit

1.Desk top computer( with color monitor, CPU, UPS, laser printer &

1 (essential)

computer table).
2. Over head projector with OHP sheets.

1 (essential)

3. Resuscitation Training Mannequins.

1 set (essential)

4. LCD projector.

1 ( desirable)

UNIT LIBRARY:
Item

Requirement for the unit

1.Basic books on newborn care.

Essential

2. Training CDs on newborn care.

Essential

3. Protocols on neonatal care.

Adaptation of written protocols on neonatal care for

doctors and nursing personnel.

39

Emergency Newborn corner for OT/ LR:

1.
2.
3.
4.
5.
6.

Warmer.
Suction machine.
Resuscitation set.
Emergency management set.
Oxygen.
Hand washing arrangement with soap and chemical disinfectant.

LIST OF SOME OF THE ESSENTIAL EQUIPMENTS WITH CORRESPONDING

REPUTED MANUFACTURERS AND APPROXIMATE PRICES.
Clinical Care Instruments:
Sl.No. Name of the Equipment
1

Radiant Warmer.
Servo Controlled- Indian.
Servo Controlled-Imported.

Photo therapy unit.

Compact fluroscent lights(6 to 8;21w) .
Blue light (2 to 4;20w) and white (2 to
4;20w).

Neonatal Resuscitation
kit- Self inflating bag
Indian.

Infusion pump pg 11.

Drip rate pump.
Volumetric pump.
Syringe pump.

Oxygen concentrator.

6
7
8
9

Foot operated sucker.

Electronic slow sucker.
Weighing machine (0-5 Kg +-1gm).
Pulse oximeter.

Reputed Manufacturers*

Approx.
Price(INR)*

Meditrin, Zeal,Phoenix
Fischer Paykel,DatexOhmeda-GE

25,000 - 70,000
1.5- 3 Lakhs

Medela, Phoenix
Atom,Medela,Phoenix

14,000-60,000
20,000-2,00,000

Meditrin
Imported- Laerdal

1000 - 1400
4000 - 5000

Devilbliss
Airsep
Local
Atom D58
Zeal ,Meditrin
Datex,Pacetech Model 520
Series 300,Nellcor N180
40

60,000-75,000
1- 1.5 lakh
600-800
40000
14 Thousand
50-90 Thousand

10

Thermometer (electronic thermometer).

Becton Dickinson

350

Diagnostic Care Instruments.

11
12

Bilirubin analyser- twin beam.

Microcentrifuge.

Ginevry
Remi

* Reference: Ashok K. Deorari, Vinod K. Paul,Neonatal Equipment, 4th edition 2010.

41

1.6 lakh
15 Thousand

CHAPTER 5
House Keeping and Disinfection Routines
Name

Disinfection method

Frequency

Floors

5% phenol

Once in each shift

No dry sweeping
Use wet mopping only
Do not use cidex

Walls

2% Bacillocid

Once in each shift

Fans

Clean with wet clean cloth

Once a week

Window AC

Surface and filters

washed with soap and
water

Refrigerator

Defrost and clean with soap Once a week

and water

Buckets

Soap and water

Daily in the morning shift

Sinks

Vim, surf

Daily in morning shift or as

required

to

be Once a week

Name

Disinfection
method

Frequency

Bucket

Soap and water

Daily
in Dry in sunlight and store
morning shift inverted when not in use

Sinks

Scrub with soap

Daily
in morning shift
and
when
required

Mop head

Wash in soap and Daily

water.
Disinfect
with
hypochlorite(1%)
for half an hour
and As required
Baby
linen/blanket/blanket Wash
cover
autoclave
Autoclave
As required
Cotton gauze
Feeding utensils/paladai

Wash with soap Before

and water. Boil for use
10 minutes

42

Other consideration

Dry in sunlight

Use autoclaved linen

every time
Each time use autoclaved
cotton
each -

Swab
containers/injection/medicine
tray
Set for procedures

Wash with
and water.
Autoclave
Autoclave

Cheattle forceps

Autoclave

Steel drums

autoclaved

soap Daily morning Use

separate
swab
shift
containers for each baby
After
use
daily

Every
hours

each If not in use, re autoclave

every 72 hours
Put in sterile autoclave d
container containing dry
sterile cotton
48 Should
be
closed
properly after opening.
Broken ones to be
replaced

Prevention of Infection
Basic Requirements for asepsis in a baby care area include the following:

Adequate supply of running water and soap

Supply of hand hygiene disinfectants like alcoholic hand rub, chlorhexidine-alcohol

hand rub

Presence of conveniently located sinks and hand basins with foot /or elbow/or
sensor taps in adequate number

Strict attention to hand hygiene even when work pressure is increased

Maintenance of adequate space between beds,

Avoiding overcrowding and maintaining adequate nurse: patient ratio,

Good baby care protocols in place which are strictly followed

Supply of sufficient number of disposables

Rational antibiotic policy

Entry in Baby Care area

Guidelines Hand hygiene:

All rings, bangles, sacred threads, watch to be removed. All cuts and abrasions to be covered
with water proof dressing. Finger nails to be kept short (not more than one fourth of an inch.
If full sleeve is worn, rollup above elbow. wash hands with soap and water for 2 minutes,
Follow 6 steps of hand washing.

43

An effective hand washing technique involves three stages: preparation,

washing & rinsing and drying.

Preparation requires wetting hands under running water before applying

soap. Hand wash solution must come in contact with all parts of hands. It is
better to use liquid soap in a pump system than solid cake of soap.

Hand should be rinsed thoroughly prior to drying. Drying can be done with
autoclaved paper towels. Even old newspapers cut into squares and
autoclaved can be used for this purpose.

In order to maintain skin integrity despite regular hand washing, staff should
be encouraged to use hand cream/lotion when they go on breaks,

Protective Apparel/Gowning:

A few small Western studies which have been conducted do not support use of gowns or
changing of shoes. It is prudent in our country, where there is lot of exposure to dust, dirt
and fomites ,to change clothes or wear a gown and change shoes before entering the unit,

Sterile gloves need to be worn before any procedure.

Hair should be in place .If necessary hair nets may be worn.

Disposable mask may be worn if any staff member is suffering from cold/URTI and cannot be
kept away from active duty.

Patient care recommendations:

Do not use stock IV fluids.

Maintain separate bottles for individual babies.

Bottles to be labelled clearly with date and time of opening

After removing seal, clean thoroughly with spirit swab.

Change antibiotic vials after 24 hours E.g. Gentamicin/Ampicillin vial

Use separate IV line for giving injection.

Do not open the IV fluid line for giving injection.

44

Name

Indication of use

Frequency

Instructions
for
use/special issues
-

Stethoscope ,measuring tape, Clean with 70% Daily

thermometer, BP cuffs
alcohol/sterilium
Soap and water.2% Daily
in The
computerised
Syringe pumps
glutaraladehyde if morning shift display points should
blood stained only
not be in contact with
any chemical. Use only
wet mops for that.
Clean with wet Daily
Dry with autoclaved
Oxygen hood
cloth. If blood morning shift linen
stained, use soap &
when
and water
required
Resuscitation bags/reservoir, Clean with soap Daily
oxygen
tubing,bottles
& and
water.
tubings of suction machine
Immerse in Cidex
for 4 hours, rinse in
distilled
running
water, dry with
autoclaved
linen
and
wrap
in
autoclaved
linen
and put date
Wipe
with 2% Daily
in Whenever weighing a
Weighing machine
bacillocid
morning shift baby
spread
an
and SOS
autoclaved sheet or
paper (separate for
each baby). Do not lay
baby
directly
on
machine

45

Name

Indication for Use

Instructions for use/special issues

Bacillocid spray (2%)

Walls of unit
Incubators & radiant warmers
Weighing machine surface

-Prepare
solution
as
per
manufacturers instructions.
-Switch of air conditioner before
spraying

Cidex
(2% glutaraledehyde)

Oxygen/suction tubing
Clean thoroughly with soap and water
Face mask and resuscitation before immersion in Cidex
bag
Contact time: for sterilization: 4-6
hours
For disinfection -15 minutes
Once prepared, the solution is active
for 14 days, but this depends on usage.
Ideally the activity should be checked
with indicator strips available from
manufacturer

Formalin

Fumigation of SNCU

For routine fumigation: 30 ml formalin

in 90 ml water per 1000 cu ft area .Ac
is to be switched off ,and nursery is to
be sealed properly,
The required amount of formalin and
water is taken in the fumigation
machine and switched on for 30
minutes .After 6 hours, the room is to
be opened and cleaned thoroughly. If
necessary, neutralization can be done
with ammonia solution.

Sodium hypochlorite

Sharps and needles

Keep solution covered.

Change every 24 hours

Spirit(70% alcohol)

Skin preparation
Do not use for cleaning of incubators &
Cleaning of laryngoscope warmers.
blades,thermometers,tape
measures ,stethoscope

Soap & water

Oxygen
hood
,feeding After washing in soap and water,
utensils, swab containers, feeding utensils to be boiled for 10
injection tray, face mask minutes
,buckets
Cleaning floors

Phenyl
Povidoneiodine(betadine)

Skin preparations

46

CHAPTER 6
Running Cost of a Sick New Born Care Unit At The District

Cost per Bed

Qty. Per month

Unit
price
(Rs.)
135.00 15

Amount

100.00 20

2000.00

Tegaderm

42.00

15

630.00

Micropore (1)

36.00

02

72.00

Cotton roll (400gm)

205.00 30

6150.00

B.T. set

48.00

08

385.00

Syringe 1cc

5.00

150

750.00

Syringe 2cc

5.00

60

300.00

Syringe 5cc

5.00

60

300.00

Syringe 10cc

7.00

60

420.00

Syringe 20cc

13.00

15

195.00

Syringe 50cc

27.00

60

1620.00

NG tube (5/6)

14.00

15

210.00

Suction catheter

14.00

30

420.00

Detergent hand wash

55.00

30

1650.00

Antiseptic hand rub

95.00
with
Chlorhexidine
0.25%
Kenadion (vit k1 inj)
12.00

15

1425.00

04

48.00

Burette 150 cc with

Microdrip set
Neoflon or IV cannula

(Rs.)
2025.00

Connector
with 100.00 10
extension tubing
P.M. Line (100 cm)
145.00 30

1200.00

Dynaplast

112.50

450.00 112.50

Total

4350.00

24,262.50

Hence, the Cost / bed / day = Rs. 809.00 (Rupees eight hundred nine only)

47

MEDICATIONS

Cost per Bed

Item

Unit Price (Rs.)

NS (25 cc)
NS (100 cc)
25D (25 cc)
3% NaCl (100 ml)
25D (100 ml)
Isolyte P (500 ml)
Calcium Gluconate (10 ml)
MVI
KCl
Total

20.00
13.00
16.00
44.00
41.00
100.00
16.00
11.35
15.00
276.35

The above calculation is the Average fluid requirement for 48 hrs / bed.
Hence, the Total monthly cost = Rs. 277 x 15 = Rs. 4145.00 (Rupees four thousand one hundred forty
five only).
So, Cost / Bed / Day = Rs. 138.00 (Rupees one hundred thirty eight only).

Other Essentials
Item
NaHCO3
AminoPhylline
Gardenal
Phenytoin
Fosolin
Lorazepam
Midazolam (5 ml)
T-bact
MgSO4
Vit A
Adrenaline
Lasix
Heparin
Morphine
Total

Price per unit

(Rs.)
16.00
12.00
22.00
10.20
25.00
17.40
83.00
80.00
6.00
4.50
6.00
3.00
112.00
22.00

48

No. of
unit
4
4
5
5
5
5
4
4
8
10
4
4
4
2

Price (Rs.)
64.00
48.00
110.00
51.00
125.00
87.00
332.00
320.00
48.00
45.00
24.00
12.00
448.00
44.00
1,758.00

Hence, the cost / bed / month is Rs. 1758.00 (Rupees one thousand seven hundred fifty eight only)
So, the cost / bed / day = Rs. 59.00 (Rupees fifty nine only)

Antibiotics
Antibiotic

Unit Price
(Rs.)
Piperacillin- 100.00

Inj.
Tazobactum
(Pipzo 1.125 gm)
Inj. Amikacin (100mg)

Inj. Zanocin (Ofloxacin)

Inj.
Augmentin
(Co-amoxiclav)
Inj. Meropenem (Zaxter)
(125 mg)
Inj.
Vancomycin
(500mg)
Inj. Fluconazole
(200 mg/100ml)
Inj. Metrogyl (500mg)

Use/Month Total (Rs )

30

3000.00

18.00

30

540.00

110.00
70.00

8
15

880.00
1050.00

330.00

10

3300.00

370.00

740.00

150.00

600.00

16.00

15

240.00

Total

10,350.00

Hence, the cost of antibiotic / bed / month = Rs. 10,350.00 (Rupees ten thousand three hundred fifty
only)
So, the cost / bed / day = Rs. 345.00 (Rupees three hundred forty five only)

Misc. Medication
Item

Unit price (Rs.)

Qty. Per month

Amount (Rs.)

Syrup. Ostocalcium

63.00

02

126.00

Tonoferon drops

40.00

02

80.00

Multivitamin drops

30.00

02

60.00

Lactodex-HMF

12.00

50

600.00

Erythromycin drops 20.00

02

40.00

Domstal suspension

04

140.00

35.00

49

Paracetamol drops

23.00

02

46.00

Cephalexin drops

52.00

01

52.00

Normal saline nasal 18.00

drops

04

Ciprofloxacin
eye 13.00
drops
Clotrimazole mouth 54.00
paint
Dopamine
36.00

02

26.00

02

108.00

04

144.00

Dobutamine

02

900.00

72.00

450.00

TOTAL

2,394.00

Hence, the Cost / bed / day = Rs. 80.00 (Rupees eighty only)

Disposable items for 1 month (for 600 deliveries / month)

Sl. No
1
2
3

5
6
7
8
9
10

Item
Cord clamp
Delees mucus trap
E.T. tube (portex)
Chemical disinfectants
(Cidex,
Bacillocid,
Liquid
Soap,
Detergent,
Sterillium,
Savlon, Phenol,
Lysol,
Betadine,
Rectified
Spirit)

Unit
10 each
10 each
145 each
(For 12 Bedded
Unit)

Price per unit

600.00
600.00
10.00

Cost
6000.00
6000.00
1450.00
35000.00

Glucostix
Capillary tube
Multistix
Stationeries
Sterile gloves
Cap, Mask
Cap
Mask

6 units
400 units
1 unit
1 unit
50

550.00
10.00
1000.00
1000.00
5.00

3300.00
4000.00
1000.00
1000.00
250.00

50
50

5.00
5.00

250.00
250.00
62,750.00

Total

50

This cost is inclusive of all maintenance activities for the newborn (Labour room + O.T + SNCU +
Postnatal ward + Neonatal ward) for one month.

Hence per day cost could come down to Rs. 2092/Cost/ Patient/ Day/ Bed:
Item

Cost (Rs.)

For Disposables

809.00

For IV fluids etc

138.00

For

non-antibiotic

IV 59.00

Medications
For IV antibiotics

345.00

For misc. Medication

80.00

Total

1431.00

Maintenance cost for all activities including Labour Room, OT, SNCU, Postnatal ward, Neonatal Ward
for one month = Rs. 62,750.00 (Rupees sixty two thousand seven hundred fifty only).
So, cost / day = Rs. 2,092.00 (Rupees two thousand and ninety two only)
Hence, cost for a 12 bedded SNCU unit annually

= Rs. 1,431.00 x 12 x 365

= Rs. 62, 67, 780.00

Maintenance /year

= Rs.

7, 53, 000.00

___________________
Rs.70, 20, 780.00
___________________

Amount in words: Rupees Seventy Lakh Twenty Thousand Seven Hundred Eighty only.

51

CHAPTER 7
Sick Newborn Stabilizing Unit

Selection Criteria for SNSU

1. In the first phase all Rural Hospitals (upgraded BPHCs) and First Referral Units (FRUs) should
be selected for development of SNSU.
2. In the second phase all BPHCs, PHCs and Sub-centres where deliveries occur should be
included.

Services Provided in the SNSU

1. Provide prompt, safe and effective resuscitation of newborns i.e. stabilizing the newborns
before they are kept with their mothers or if required transferred to the SNCU.
2. Provide warmth and care at birth.
3. Monitoring of vital signs.
4. Promotion of breast feeding or give feeding support.
5. Referral Services.
6. Health education to mothers about newborn care.

LEVEL I:
Level I units provides a basic level of newborn care to newborns at low risk along with the healthy
newborns.
a) Basic and essential neonatal care

Skilled delivery practices

Cleanliness and prevention of infections

Temperature maintenance

Eye care

Cord care

Early initiation of Breast feeding

52

Extra care of Low birth weight

Resuscitation at site of babies who do not breathe properly at birth

Detection and referral and appropriate care-seeking for babies with danger signs.

b) Special neonatal care

Evaluation and postnatal care of healthy newborns.
Stabilization of sick newborns and those born at < 35 weeks gestation until transfer
to a facility that can provide the appropriate level of neonatal care.

Stabilization and provision of care for newborns born at 35 to 37 weeks gestation

those remain physiologically stable.

Arrangement of Phototherapy.
Initiate and maintain intravenous access for fluid and medications as and
when required.
Gavage feeding
Nasal oxygen with oxygen saturation monitoring.
Arrangement for estimation of Blood Glucose and Bilirubin.

These are the special services provided along with the basic services for newborn.

Newborns weighing 1800 can be treated at this level.

Newborns 35 weeks can be treated at this level.

Location of SNSU
Ideally should be located next to the Labour Room or within/ close proximity of the Maternity Ward.

Configuration of SNSU
Physical dimension: 10ft x 25 ft = 250sq.ft approximately (where only radiant warmers will be kept).

Provisions for elbow operated/ foot operated hand washing should be there.

At least 2 Radiant Warmers should be kept.

At least 1 window as a source of natural light should be there.

53

Aluminium sliding glass window and door should be there.

The walls should be made of washable tiles at least up to 7 ft.

Ideally the walls and the floor should be white/ off-white in colour. Yellow and Blue colour should
be avoided.

Flooring should be done with vitrified tiles.

In general the walls, floors, windows and doors should be easily washable.

There should be 24hrs. uninterrupted power supply.

There should be 6 electricity outlet wall tap two input, 10/15 amp. for the beds.

There should be 12-14 outlets (combined 5-15 amp. female plugs) divided in two boards.

There should be 24hrs. uninterrupted running water supply.

Provisions should be there for running hot water supply.

There should be 2 exhaust fans.

SKILLS TO BE LEARNT BY THE NEONATAL AIDES

Basic Skills:
1. Assessment of normal neonates.
2. Assessment of gestation, cord care and baby bath.
3. Breast feeding technique, manual expression of breast milk, spoon feeding and gavage feeding.
4. Methods of asepsis including decontamination of room, furniture, equipments etc.
5. Resuscitation technique including face mask & resuscitation bag.
6. Assessing urinary flow in a male child.
7. Assessment of Skin rashes.
8. Differentiate normal & abnormal respiration.
9. Identify jaundice and cyanosis.
10. Ability to teach mother about good and bad child rearing practices including nutrition and
immunization.
11. Identify early signs of illness.
12. Assess growth & development during follow up.

54

Special Skills:
1. Provide intravenous fluid and injection.
2. Provide resuscitation with bag & mask.
3. Use head box.
4. Use phototherapy.
5. Monitor care during transport.

55

CHAPTER 8
Admission criteria to SNCU

Summary of place of management:

SNCU

NEONATAL WARD

POST NATAL WARD

< 1.8 Kg , at least for 24 hrs

>1.8 Kg but less than 2.2 Kg

>2.2 Kg or
>1.8 Kg but stable

< 34 weeks

34-37 wks

>37 wks

<3RD percentile, weight for G.A.

3rd percentile 10th percentile,

weight for G.A.

AFD

APGAR Score
Between 4-6 at 1 min /gasping
breathing (moderate hypoxia)
Less than 3 at 1 min/ no resp at 1
min (severe hypoxia)

Slightly Delayed Cry,

But APGAR >7 AT 5 min

Normal APGAR

Complicated LFD

Uncomplicated LFD

Uncomplicated LFD

Symptomatic Hypoglycaemia

Asymptomatic Hypoglycaemia

Normoglycemia

Exchange transfusion

Phototherapy
Newborn with risk factors
Sepsis for investigation

Physiological jaundice
Routine care
Stable high risk neonates

Danger signs in newborn present

56

57