Rwandan National Neonatal Protocol: Non-electric Infant Warmer
with Marthe Kubwimana.
My name is Marthe Kubwimana, I am a research nurse with Partners in Health/Inshuti Mu Buzima
in Rwanda. I'm going to teach you how to use an infant warmer
that is designed to compliment Kangaroo Mother Care, KMC. It is easy to
prepare, use and clean. It allows access to the baby for medical assessment and
treatment. It does not require electricity to work because the heat
source is hot water, which can be prepared by any means, including coal or
fire. It is inexpensive and can be reused multiple times. It's made out of wax that
turns from the liquid to solid phase at 37 degrees, which is skin temperature.
When it is at the temperature when it changes phase, it stays at that temperature
for about six hours. KMC is the ideal way to provide warmth for stable, premature,
low birth weight babies. However, there are three instances in which KMC may
need to be integrated into an additional support system by adding the option of
the infant warmer. The first situation is when KMC does not provide an adequate
source of heat for a hypothermic baby to attain and maintain a normal
temperature. This can occur when babies are at the more extreme end of
prematurity and low birth weight, typically those less than
28 weeks gestation and under 1 kilogram. In those circumstances the
infant warmer can be added to KMC to increase the heat transfer and therefore
increase the efficacy of KMC. The second situation when a complement to
KMC helps support the mother of a low birth weight, premature newborn is when it
is not feasible for their mother to perform KMC, for example, if she is ill,
delivered multiple gestations, or needs to attend to other tasks during which KMC
is not safe, such as bathing or cooking. At these times, she can
place her baby on the infant warmer, covered with a blanket and wearing a hat,
as the warmer lays on a flat surface. In this way, she can know that her baby will
remain warm and comfortable while she is temporarily unavailable.
Finally, the third circumstance when KMC may not be feasible is when the
newborn is ill and needs to be accessible for medical assessment and
treatment. In these situations, again, the baby can be placed on the warmer as it
lays on a flat surface. The baby can be uncovered, partially or fully covered
with a blanket, and wear a hat. In these last two circumstances, even if an
electric source of external heat is available, use of the infant warmer on the
mother's bed can decrease the extent to which the mother and
baby are separated. This warmer can be used the anywhere, any time, and addresses all the
situations in which KMC needs a complementary heat source. The
warmer is appropriate to use for any baby who is hypothermic, or at risk for
hypothermia and the mother is not available for KMC. It is not intended to
interfere with the KMC, but rather to support the mothers and families of
those caring for premature, low birth weight newborns, to ensure that there
is a robust integrated system to avoid hypothermia in these vulnerable
patients. Hypothermic infants are those with a temperature less than
36.5 degrees Celsius. Infants at risk of hypothermia
are those who weigh less than 1,500 grams or have a post menstrual age
of less than 32 weeks. If you identify a baby who is either hypothermic or at
risk of hypothermia and the mother is not available for KMC, consider using
the infant warmer. Pour boiling water into the thermos to the fill line. The water can be
boiled in a tea kettle if there is electricity. Otherwise you
can use any other means for heating the water. To prepare the warmer, roll the warmer up and
put it in the thermos. Leave the warmer in the thermos for about 30 minutes, until the
wax in the warmer is completely melted. It will look clear instead of white. When
all the wax is melted, take it out of the water and slip it into the
insulating pad, positioned so that the color indicator is visible.
When the color indicator is in the green zone,
it is safe to use. This will take about 15 minutes. The baby can either be
placed on the warmer and covered in a blanket, or the baby can be receiving
KMC and have the warmer in addition, wrapped around the baby's back.
Either way, the baby should be naked except for a hat in order to maximize heat transfer.
The warmer can be used until the color indicator drops down into the bottom red
"frown face" zone, indicating that it has become too cold. You will also notice
that the wax is becoming solid; it will look white and feel firm. The wax in the
middle of the warmer that is in contact with the baby will stay in the melted
phase for longer than the wax at the edges of the warmer. Once the color
indicator and the color and feel of the wax show that it is no longer warm,
the baby should be taken off, and resume KMC. The warmer should be washed with
standard cleaning wipes. Any visibly soiled area can be washed with soap and water.
The warmer should be stored in the thermos, with the top off. Having completed this
chapter, you should now be able to: identify circumstances when an infant
is useful to complement KMC in order to treat or prevent hypothermia. Prepare,
use, clean and store the infant warmer. Properly position the infant on
the warmer, naked except for a hat, and use it in addition to KMC, or laid
on a flat surface. Understand how to use the color indicator to determine when the
warmer has cooled enough to safely start using, and when it has cooled so much
that it is time to stop using.
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