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Policy purpose and guiding intent

The Order ensures the provision of globally accepted evidence-based essential newborn care focusing on the first week of life.
The Order guides health workers and medical practitioners in providing evidence-based essential newborn care.
The Order defines the roles and responsibilities of different DOH offices and other agencies for implementing the newborn protocol.
The Order promotes systematic, prescribed implementation of interventions that address health risks leading to preventable neonatal deaths.
The Order is consistent with AO No. 2008-0029 on Implementing Health Reforms for Rapid Reduction of Maternal and Newborn Mortality and supports DOH initiatives and programs for newborn and child health.

Scope, coverage, and persons bound

The Order applies to the whole hierarchy of the DOH and its attached agencies.
The Order applies to other public and private providers of health care.
The Order applies to development partners implementing the Maternal, Newborn and Child Health and Nutrition (MNCHN) strategy.
The Order applies to all health practitioners involved in maternal and newborn care.

Definitions and core program terms

Attachment means the mode of contact between the baby’s mouth and the mother’s breast during breastfeeding.
Kangaroo Mother Care is a biologically sound method of care for all newborns, particularly premature babies, with three components: (a) skin-to-skin contact, (b) exclusive breastfeeding, and (c) support to the mother-infant dyad.
Newborn Resuscitation is a series of actions to establish normal breathing in a newborn with depressed vital signs.
Positioning means how the mother holds her baby to ensure proper attachment between them.
Positive pressure ventilation is the most important aspect of newborn resuscitation for adequate ventilation, oxygenation of vital organs, and initiation of spontaneous breathing.
Pregnancy, Childbirth, Postpartum and Newborn Care (PCPNC): A Guide for Essential practice in Philippine Setting is an essential care practice guideline adapted from the World Health Organization by the DOH.
Skin-to-skin contact is placing the naked newborn prone on the mother’s bare chest and is a critical component for successful breastfeeding initiation.
Small baby means a newborn weighing from 1,500 g to 2,499 g.

Guiding principles for implementation

Health care delivery must use evidence-based interventions through continuous policy and guideline updates aligned with recommended international standards proven effective and applicable to the country.
The Order requires integrated service delivery where the mother and newborn are seen as a unit, with varying needs addressed through functional service packages under the MNCHN framework.
The Order requires a human rights-based approach recognizing the person as a key actor in their own development and emphasizing indivisible rights inherent to human dignity, with participation of clients as a means and a goal.
The Order requires a life-cycle based intervention approach using the continuum of care framework rather than single, disease-specific interventions.
The Order requires multi-sectoral collaboration by proactively networking and sustaining contributions from government agencies, non-government organizations, private volunteer groups, religious and civic organizations, and educational institutions.

Time-bound newborn care protocol rules

The Order organizes standard essential newborn care practices by time, from the time of perineal bulging until one week of life.
The Order emphasizes interventions from birth until the first 6 hours of life and directs that care after six (6) hours until the first week of life be discussed in a DOH circular issued corollary to the AO.

Within the first 30 seconds

Providers must put on double gloves just before delivery.
Providers must use a clean, dry cloth to thoroughly dry the newborn by wiping eyes, face, head, front and back, arms and legs, then remove the wet cloth.
Providers must do a quick check of the newborn’s breathing while drying.
Providers must not place the newborn on a cold or wet surface.
Providers must not bathe the newborn earlier than 6 hours of life.
If separation from the mother is necessary, providers must place the newborn on a warm surface in a safe place close to the mother.

After thorough drying

Providers must place the newborn prone on the mother’s abdomen or chest for skin-to-skin.
Providers must cover the newborn’s back with a blanket and the head with a bonnet.
Providers must place the newborn’s identification band on the ankle.
Providers must not separate the newborn from the mother while the newborn does not show severe chest in-drawing, gasping or apnea and while the mother does not need urgent medical/surgical stabilization (e.g., emergency hysterectomy).
Providers must not wipe off the vernix if present.
Providers must check for multiple births as soon as the newborn is securely positioned on the mother by palpating the mother’s abdomen.
If there is a second baby or more, providers must get help and deliver the second newborn and manage it like the first.

While on skin-to-skin contact (up to 3 minutes post-delivery)

Providers must delay or perform non-immediate cord clamping to reduce anemia in term newborns and intraventricular hemorrhage in pre-term newborns.
Providers must remove the first set of gloves immediately prior to cord clamping.
Providers must clamp and cut the cord after cord pulsations have stopped, typically at 1 to 3 minutes, and must not milk the cord toward the newborn.
Providers must tie the cord tightly with ties placed at 2 cm and 5 cm from the newborn’s abdomen.
Providers must cut between ties with a sterile instrument and observe for oozing blood.
After cord clamping, providers must ensure 10 IU Oxytocin IM is given to the mother and must follow other PCPNC protocols.

Within 90 minutes of age

Providers must leave the newborn on the mother’s chest in skin-to-skin contact and must not touch the newborn unless there is a medical indication.
Providers must advise the mother to start feeding once feeding cues are present, including opening of mouth, tonguing, licking, rooting.
Providers must make verbal suggestions to encourage the newborn to move toward the breast (e.g., nudging).
Providers must counsel the mother on positioning and attachment and advise attaching and positioning when the newborn is ready.
Providers must advise the mother not to throw away colostrum.
Providers must retry and reassess if attachment or suckling is not good.
Providers must allow expression of a small amount of breast milk to soften the nipple area before breastfeeding when needed.

Ophthalmia neonatorum eye care after locating the breast

Providers must administer erythromycin or tetracycline ointment or 2.5% povidone-iodine drops to both eyes after the newborn has located the breast.
Providers must not wash away the eye antimicrobial.

Non-immediate interventions and clinical steps

Providers must give non-immediate interventions usually within 6 hours after birth and must never allow these to compete with time-bound interventions.

Vitamin K prophylaxis

Providers must administer a single dose of Vitamin K 1 mg IM.
If parents decline intramuscular injections, providers must offer oral vitamin K as a second line.

Immunizations

Providers must inject hepatitis B vaccine IM and administer BCG intradermally.

Examination and weight recording

Providers must examine the newborn, checking for birth injuries, malformations, or defects.
Providers must weigh the newborn and record the weight.
Providers must refer for special treatment and/or evaluation when available.
If feeding difficulties arise from an injury/malformation, providers must help the mother breastfeed; if unsuccessful, providers must teach alternative feeding methods.

Cord care

Providers must wash hands before cord care.
Providers must fold the diaper below the stump and keep the cord stump loosely covered with clean clothes.
If the stump is soiled, providers must wash it with clean water and soap and dry thoroughly with a clean cloth.
Providers must explain to the mother that she must seek care if the umbilicus is red or draining pus.
Providers must teach the mother to treat local umbilical infection three times a day.

Newborn resuscitation protocol directives

Providers must start resuscitation if the newborn is not breathing or is gasping after 30 seconds of drying, or before 30 seconds of drying if the newborn is completely floppy and not breathing.
Providers must clamp and cut the cord immediately during resuscitation.
Providers must call for help.
Providers must transfer the newborn to a dry, clean and warm surface, and keep the newborn wrapped or under a heat source if available.
Providers must inform the mother that the newborn needs help to breathe.
Providers must follow the Department Circular for the step-by-step newborn resuscitation guideline.

Care for small babies and twins

Additional care applies for a small baby or twin, including a preterm newborn delivered 1–2 months early or weighing 1,500–2,499 g, or visibly small where a scale is not available.

Referral rules

If the newborn is delivered 2 months earlier or weighs <1500 g, providers must refer to a specialized hospital.
If the newborn is visibly small or delivered more than 1 month early, providers must implement kangaroo-based warming when eligible.

Start Kangaroo Mother Care conditions

Providers must teach Kangaroo Mother Care via skin-to-skin contact and start it when:
- the newborn can breathe on its own (no apneic episodes), and
- the newborn is free of life-threatening disease or malformations.

Kangaroo Mother Care operational reminders

The newborn’s ability to coordinate sucking and swallowing is not a prerequisite to Kangaroo Mother Care; other feeding methods may be used until breastfeeding becomes possible.
Kangaroo Mother Care must last for as long as possible each day.
If the mother must interrupt Kangaroo Mother Care for a short period, the father, a relative, or friends must take over.
Providers must provide extra blankets for the mother and newborn plus a bonnet, mittens, and socks for the newborn.
If the mother cannot keep the newborn skin-to-skin because of complications, providers must wrap the newborn in a clean, dry, warm cloth and place it in a cot, cover with a blanket, and use a radiant warmer if the room is not warm or the baby is small.
Providers must give special support for breastfeeding by encouraging breastfeeding every 2–3 hours.
Providers must weigh the newborn daily.
Providers must use alternative feeding methods when the mother and newborn are separated or when the newborn is not sucking effectively.

Discharge planning and mother instructions

Providers must plan to discharge when all discharge conditions are met:
- breastfeeding is going well and weight is gaining adequately for 3 consecutive days,
- body temperature is between 36.5 and 37.5°C for 3 consecutive days, and
- the mother is able and confident in caring for the newborn.

Return immediately if danger signs appear

Providers must advise the mother to return or go to the hospital immediately if:
- jaundice of the soles or any of the following are present:
  - difficulty of feeding,
  - convulsions,
  - movement only when stimulated,
  - fast or slow or difficult breathing (e.g., severe chest-in-drawing),
  - temperature > 37.5°C or < 35.5°C.

Scheduled facility visits after birth

Providers must advise the mother to bring the newborn for routine check-up at:
- 48–72 hours of life (Postnatal visit 1),
- 7 days of life (Postnatal visit 2),
- 6 weeks of life (Immunization visit 1).

Additional follow-up for specific problems

Providers must advise additional follow-up visits appropriate to problems, including:
- Two days: breastfeeding difficulty, Low Birth Weight in the first week of life, red umbilicus, skin infection, eye infection, thrush, or other problems.
- Seven days: Low Birth Weight discharged more than a week of age and not gaining weight adequately.

Newborn screening

Providers must provide guidance for newborn screening in accordance with the discharge instruction component.

Prohibited or discouraged routine newborn procedures

The Order directs that certain commonly observed hospital practices are not recommended for all neonates, including the following.

Routine suctioning

Providers must not perform routine suctioning when amniotic fluid is clear and especially when the newborn cries or breathes immediately after birth.
Providers must suction only if the mouth/nose is blocked with secretions and other materials.

Early bathing/washing

Providers must not bathe/wash the newborn early; providers must align with bathing at least after 6 hours of life.

Footprinting

Providers must not use routine footprinting as an identification technique; providers must use better identification techniques such as DNA genotyping and human leukocyte antigen tests.

Prelacteals, sugar water, formula, bottles, pacifiers

Providers must not give sugar water, formula, or other prelacteals, and must not use bottles or pacifiers in a manner that delays initiation to breastfeeding.
Providers must avoid use of pacifiers before the newborn is offered the mother’s breast because it contributes to nipple confusion and undermines breastfeeding success.

Alcohol/medicine/substances on cord; bandaging cord stump/abdomen

Providers must not apply alcohol, medicine, or other substances on the cord stump and must not bandage the cord stump or abdomen as routine practice for newborn care.

Implementing mechanism, networks, and governance

Implementation must use the existing MNCHN service delivery network and referral system.
The LGU network must be operational through the organization of Service Delivery Teams at various levels of the health service delivery system.

Service delivery team structure

Community-level teams are Community/Women’s Health Teams (C/WHT).
Facility-level teams include BEmONC and CEmONC Teams, Itinerant Teams, and Social Hygiene Clinic Teams.

Service delivery content

The teams provide maternal and newborn care, family planning, adolescent reproductive health and STI and HIV service packages, and child survival packages such as Infant and Young Child Feeding (IYCF), Integrated Management of Childhood Illnesses (IMCI), and Expanded Program on Immunization (EPI).

Financing and accreditation linkage

PhilHealth implementation of newborn care policy as part of enhanced Normal Spontaneous Deliveries (NSD) and Maternal Care Packages (MCP) drives health facility accreditation and enables individual professionals to qualify for PhilHealth benefits.
Funds from national and local levels and private and public sectors must be mobilized for equipment and supplies and capability-building activities.

Regulation and clinical standards

Providers must follow the Standards for the physical structure, equipment and human resource manual for implementing health reforms aimed at rapid reduction of maternal and neonatal mortality.
The newborn protocol is integrated with the BEmONC training module and serves as the reference document for newborn care during BEmONC and in-to-be-developed CEmONC training programs.
Home care for the newborn must be developed and integrated with the Community/Women’s Health Teams training course.
The Communication for Behavior Impact (COMBI) strategy must be used targeting behaviors of stakeholders from mothers to health workers and policymakers.
The PHIC Benchbook must be integrated with essential newborn care protocol interventions and must enforce the standards of care described in the Order along with other auxiliary DOH issuances.
The DOH must advocate for adoption of the newborn policies and protocol by medical and paramedical societies and appropriate learning institutions.

Roles and responsibilities by office and partner

The Task Force on the Rapid Reduction of Maternal and Neonatal Mortality must ensure essential newborn care activities are included in the EmONC Investment Plan and ensure integration into BEmONC and comprehensive EmONC curricula.
The Task Force must ensure B/CEmONC facility, equipment, and human resource requirements adhere to ENC protocol requirements and ensure dissemination of the essential newborn care protocol and related materials.
The National Center for Disease Prevention and Control must update policies and guidelines, initiate an Experts Panel sub-group for maternal and newborn care, formulate the maternal and newborn care investment plan, and support capacity development through trainers and implementers.
The NCDPC must also develop prototype IEC materials, mobilize national/local/community support, ensure procurement of newborn resuscitation equipment and supplies, provide health systems strengthening, conduct performance audits, and monitor and evaluate program implementation including this protocol.
The National Center for Health Facility Development must review technical guidelines for integrated hospital information systems and PHIC accreditation guidelines for congruity and coordinate training modules with the HHRDB.
Dr. Jose Fabella Memorial Hospital must serve as lead training institution for BEmONC courses, be designated National Lactation Management Center for trainings, and promote Kangaroo Mother Care for all newborns, especially premature infants.
The National Center for Health Promotion must formulate and implement an advocacy plan with IEC materials and ensure integration with EmONC and ENC protocol in other health promotion activities and materials.
The Health Human Resource Development Bureau must develop and finalize training programs, engage CHED and PRC for curriculum integration, develop integrated training approaches for newborn needs, and ensure inclusion of competency needs in Human Resource Master Plan and Human Resource Information System updates.
The Bureau of Local Health Development must provide technical assistance for the health referral system and assist CHDs in mobilizing LGU support.
The Health Policy Development and Planning Bureau must assist in evidence-based policy development, assist in investment plan formulation, and coordinate research activities.
The Bureau of International Health Cooperation must apply sector-wide approaches, facilitate linkage of local and international initiatives, and act as clearing house for program initiatives.
The National Epidemiology Center must recommend data collection and reporting schemes using SMART criteria and facilitate updating DOH and LGU databases for newborn care data.
The Field Implementation and Management Office must develop monitoring and evaluation tools and technical assistance packages, and monitor and evaluate maternal and newborn care policies and activities.
The Bureau of Health Facilities and Services must ensure compliance with standards and technical requirements, promote DOH standards during monitoring and QA, and ensure relevant ENC needs are met.
Each Center for Health Development must incorporate targets and strategies in regional plans, advise and assist local policy formulation and execution, inventory local competency and resource needs, develop capacity of provincial/municipal workers, provide technical assistance, reproduce IEC materials, allocate drugs and IEC materials, assist procurement of resuscitation equipment and supplies, and monitor and evaluate maternal and newborn care activities including DOH retained hospitals.
DOH Retained Hospitals must adopt and implement the policy, include substantial amounts in investment plans/work and financial plans, conduct orientation for personnel and lower level facilities, and monitor and evaluate implementation.
The Local Government Unit must adopt and implement the policy, ensure budget support, conduct orientation/trainings for private and public health workers, and monitor and evaluate implementation.
Facilities with Comprehensive/Basic Emergency and Obstetric and Newborn Care capabilities must provide emergency obstetric and neonatal interventions, adopt and implement the policy, include substantial amounts in investment plans/work and financial plans, conduct orientation, and monitor and evaluate implementation.
PhilHealth must ensure congruence with PHIC policies (e.g., Benchbook Clinical Pathway), develop an MCP Plus benefit package supporting strict implementation of maternal and newborn care policies including this protocol, provide promotion/advocacy support, and monitor and evaluate implementation.
The National Drug Policy must ensure relevant maternal and newborn care drugs and supplies are included in the Philippine National Drug Formulary.
Development partners must support implementation and coordinate and collaborate with DOH and LGUs.
Professional societies/groups must act as resource persons/members in the Experts Panel, ensure policy communication to members, conduct monitoring of implementation among members, and coordinate with DOH and LGUs.

Repeal and separability; inconsistency rule

The Order provides that all other previous related issuances found inconsistent with this issuance shall be repealed.