Ness et al (2013) recommend the nappy is changed every 3–4 hours or when soiling occurs. When urine encounters faeces, the ureases in the faecal microbes create ammonia which increases the skin pH. This causes a reactivation of the digestive enzymes which degrades the lipids and pro-teins within the stratum corneum, breaking down the skin used, although the latter may be more tiring for the
woman’s back.
•
Towel: some towels have an integral hood, useful for drying the baby’s head (if using an ordinary towel, fold over about 25 cm of towel lengthways; this can then be pulled up to dry the head).•
Sponge (optional).•
Nappy-changing equipment and nappy.•
Baby clothes.•
Plastic apron (non-slip).•
Non-sterile gloves, if necessary.PROCEDURE: bathing a baby
Although this procedure is written as if the midwife is bathing the baby, it can also be used as the basis for instructing the parents on how to bath their baby:
•
Discuss the procedure and gain informed consent from the parents.•
Gather equipment and prepare room.•
Wash and dry hands and apply apron (put on gloves if contact with bodily luids is likely).•
Fill the bath using cold water irst then hot and check the water temperature.•
Undress the baby, leaving the nappy on, and wrap the baby in the towel.•
Wash the baby’s face with plain water, if using a sponge wipe over the face in a gentle patting motion avoiding the eyes.•
Dry the face with the towel, using gentle patting motions.Figure 13.2 Positioning of the hands when washing the back of the baby in the bath.
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barrier (Adam et al 2009, Lavender et al 2012, Ness et al 2013). Additionally, the presence of the excretory by-products of microbial proliferation in the skin folds act as irritants and sensitizers (Hale 2008).
The skin should be cleaned at this time with either warm water or a baby wipe/mild cleanser to minimize the risk of the skin becoming excoriated and diaper dermatitis/nappy rash occurring (Atherton 2005, Trotter 2006). Nappy rash is generally a result of irritant contact dermatitis rather than infection (Blincoe 2006). It is important that the midwife can demonstrate to the parents how to change the baby’s nappy, using whichever method the parents will use at home.
Nappies
Nappies are either reusable or disposable. Reusable nappies are usually made of towelling or cloth, in a variety of styles.
The traditional terry towelling nappy is square shaped, requiring folding prior to use. A nappy liner can be used to line the nappy to reduce the amount of urine and faeces coming into contact with the skin and reduce the risk of DDM. Manufacturers’ instructions should be followed when disposing of nappy liners; they should be used once only and not disposed of down the toilet. Waterproof over-pants may be used to prevent urine and faeces seeping onto the baby’s clothes. Alternatives are the all-in-one reus-ables (self-fastening itted cloth nappies, covered with a waterproof shell), two-piece reusables (cloth nappies that it into special waterproof pants with self-adhesive fasten-ings) and wrap-around nappies (cloth nappies with ties, used in conjunction with waterproof overpants). All reusa-bles require laundering. A thin layer of a barrier cream can be used to protect the genitalia and buttocks and reduce the risk of DDM, but may be contraindicated with some nappy liners.
There are three ways to fold a towelling nappy: the trian-gle, the kite, and the triple-fold method. The triple-fold is useful for boys as it provides extra thickness and absorb-ency at the front of the nappy where urination is likely to occur.
1. The triangle method (Fig. 13.3)
•
Place the nappy in a diamond shape (A), fold in half to make a triangle shape with the longest side at the top and the point at the bottom (B).•
Place the baby on the nappy and bring up the top layer between the baby’s legs (C).•
Wrap one side of the nappy across the baby, then the other side (C).•
Bring up the lower layer of the nappy between the baby’s legs and secure with a safety pin (D, E).2. The kite method (Fig. 13.4)
•
Place the nappy in a diamond shape (A); fold the outer two points to the centre to make a kite shape (B).•
Fold the top corner down and the bottom corner up towards the centre; the latter fold can be adjusted to suit the length of the baby (C).•
Place the baby on the nappy, bring up the nappy between the baby’s legs (D).•
Wrap one side of the nappy across the baby, then the other side and secure with two safety pins (D, E).3. The triple-fold method (Fig. 13.5)
•
Place the nappy in a square shape and fold into half lengthways from top to bottom (A).•
Fold in half again, from left to right, to make into a four-layer-thick square shape (B).•
Take hold of the bottom right hand corner of the irst layer of the nappy and open it to the left (C, D).•
Turn the nappy over carefully, keeping the layers in position so that the point lies to the left (E).•
Take hold of the next two layers forming the square shape and fold the outer third over towards the centre and then in half, creating a triangle shape with an extra thick pleat in the centre (E, F).•
Place the baby on the nappy and bring up the nappy between the baby’s legs (G).•
Wrap one side of the nappy across the baby, then the other side and secure with a safety pin (G, H).Disposable nappies
Disposables are paper nappies (made from luffed wood pulp) containing absorbent crystals that form a gel when they become wet from urine. Many use super-absorbent polymers to increase their absorbency, resulting in the nappies staying drier against the baby’s skin for longer and consequently less incidence of DDM (Hale 2007). Breath-able nappies, which allow more airlow around the baby’s skin regardless of whether the skin is wet or dry, are also available; this inhibits the growth of Candida albicans, reducing the risk of DDM (Hale 2007). Some nappies have nappy liners impregnated with a barrier cream (e.g. petro-leum) which Hale (2007) suggests is another way of reduc-ing the incidence of DDM. The barrier cream is hydrophobic and transfers from the nappy to the baby’s skin in response to the warmth of the skin and movement by the baby to serve as a protective barrier.
Disposable nappies have an outer plastic layer, itted elas-ticated leg bands and sticky tapes at the sides to fasten the nappy. Some have elasticated waists; some have a hole for the umbilical cord, to allow it to remain dry. They come in a variety of sizes, from newborn to toddler size.
preservative free and zinc oxide– or petrolatum-based. Hale (2007) supports this view and Sarkar et al (2010) recom-mend these be used when DDM is present. Ravanfar et al (2012) suggest the barrier cream should contain zinc oxide, titanium dioxide and starch or dexpanthenol to prevent contact between skin and faeces, avoid humidity and mini-mize TEWL. The barrier cream is applied thinly following Disposables are used once only and should not be disposed
of down the toilet.
Use of barrier creams
Ness et al (2013) recommend the use of a barrier cream as a preventative measure for DDM and suggest it should be Figure 13.3 Triangle method of nappy folding.
A
B
D
C E
1
2 3
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•
contain no antibiotics, steroids, perfumes or preservatives.PROCEDURE: changing a nappy
•
Gain informed consent from the parents.•
Gather equipment:■ non-sterile gloves and apron
■ changing mat or towel each nappy change and always after handwashing or use of
alcohol handrub to reduce the risk of cross-contamination (see Chapter 9). Bacterial preparations are unnecessary as DDM is not caused by infection and they may interfere with the resident skin lora.
Barrier cream used as a protective layer should:
•
allow the transfer of luid from the skin to the nappy•
prevent the transfer of luid from the nappy to the skinFigure 13.4 Kite method of nappy folding.
A
B
C
D
E 1
2 3
1 2
1
2
•
Lay the baby on a safe, lat surface (e.g. cot mattress, changing mat), with the towel under the baby if required.•
Undress the baby suficiently to gain access to the nappy.•
Remove the dirty nappy and put to one side.•
Using the non-dominant hand, hold the baby securely around the ankles enabling the legs to be straightened then slightly raise the buttocks to facilitate cleansing of the genital area.■ small bowl and cotton wool balls or dry wipes/
baby wipes
■ nappy bag or nappy bucket and disposable bag for used nappy and wipes
■ clean nappy
■ nappy liner (optional)
■ barrier cream (optional)
■ alcohol handrub
•
Wash and dry hands, put on apron and gloves.•
Put warm water into the bowl if using water.Figure 13.5 Triple-fold method of nappy folding.
A
B
G
H C
D
F E
1
3 2
R L
R L
R L
R L
R L
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■ clean container and cooled boiled/sterile water
■ paper towel/bag or disposable tray