Evidence-based Practices for Safe & Quality Care of Birthing Mothers & Their Newborns

Essential Intrapartum & Newborn Care (EINC)

A DOH Maternal, Newborn, Child Health and Nutrition (MNCHN) Strategy to Save Mothers & Newborns

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ESSENTIAL INTRAPARTUM AND NEWBORN CARE

A Critical Call for Action for Safe & Quality Care for Birthing Mothers & Their Newborns
The Philippines is concerned that it may not meet the Millennium Development Goal 51 or MDG 5 to reduce maternal death unless rapid action is taken or MDG 4 if the rate of newborn deaths especially in the first 48 hours of life is not arrested. Maternal deaths are estimated to be 162 per 100,000 live births or close to 5,000 mothers dying annually. The MDG 5 target is 52 maternal deaths per 100,000. Post-partum hemorrhage continues to be a major cause of maternal mortality (41%). Around 40,000 newborns die in the country each year, from causes that are mostly preventable such as complications of prematurity (41%), birth asphyxia (15%) or severe infection (16%). 2 Most of the deaths occur within the first two days of life, and conditions surrounding labor, delivery and the immediate postpartum period have been pinpointed as contributory factors. These concerns have been addressed through various policies by the Department of Health. A landmark observational assessment of 481 births in 51 hospitals documented practices in the immediate newborn period that delay life-saving thermoregulation and breastfeeding initiation. 3 In 2009, DOH began a hospital-based initiative to change practices for safe and quality care of mothers and newborns. 4 Supported by the World Health Organization and the Joint Programme on Maternal and Neonatal Health (JPMNH), the project is being piloted in 11 hospitals and referred to as the Scale Up EINC Project. It is fondly referred to as Unang Yakap 4&5. It is a call for all practitioners and health facilities to adopt and embrace the safe and quality care of EINC for our birthing mothers and their newborns.

1 Millennium Development Goals refer to a global agenda to, among other targets, reduce extreme poverty, improve childhood education and improve maternal and child health by 2015. The Philippines has committed to attaining these MDGs. 2 Child Health Epidemiology Reference Group (CHERG) Global, Regional and National Causes of Child Mortality: a systematic analysis. The Lancet May 2010; 375: 1969-1987. 3 Sobel HL, Silvestre MAA, Mantaring JBV, Oliveros YE, Nyunt-U S. Immediate newborn care practices delay thermoregulation and breastfeeding initiation. Acta Paediatrica 2011. DOI:10.1111/j.16512227.2011.02215.x. [Epub ahead of print] 4 DOH Administrative Order 2007-0026 on the Revitalization of the Mother-Baby Friendly Hospital Initiative in Health Facilities with Maternity and Newborn Care Services; AO No. 2008-2029 on Implementing Health Reforms for the Rapid Reduction of Maternal and Neonatal Mortality; and AO 20090025 on Adopting New Policies and Protocol on Essential Newborn Care

The EINC Bulletin is a publication under the Department of Health EINC Scale-Up Project with assistance from the World Health Organization and the Joint Program on Maternal Neonatal Health funded by AusAid . It popularizes and disseminates information and activities related to scale-up efforts of Essential Intrapartum Newborn Care (EINC) in DOH-retained Hospitals for safe and quality care of birthing mothers and newborns. Thefindings, interpretations and conclusions expressed in this publication are entirely those of the authors and should not be attributed in any manner whatsoever to the Department of Health, the World Health Organization or to AusAid. 02

What is Essential Intrapartum and Newborn Care?

The essential intrapartum and newborn care (EINC) practices are evidencebased standards that are recommended for adoption in Philippine hospitals with maternal and newborn care services and birthing facilities, both in the government and private sectors, by the Department of Health (DOH), Philippine Health Insurance Corporation (PhilHealth) and the World Health Organization (WHO). EINC represents the highest standard for safe and quality care for birthing mothers and healthy newborns in the 48 hours of the intrapartum period and up to a week of life of the newborn. Its adoption helps reduce maternal and newborn morbidity and deaths. It supports the national commitment to the United Nations Millennium Development Goals (MDG) 4 and 5 by the year 2015. Since 2010, selected DOH-retained hospitals have trained in and adopted the EINC Unang Yakap 4&5 set of practices as part of a program of the DOH, funded by the JPMNH and WHO. Results of the EINC Scale-up implementation program have been extremely positive, with admissions to the neonatal intensive care units (NICU s) dropping and reduced neonatal sepsis rates, decreased maternal and newborn deaths and more satisfied mothers. More and more hospitals and health professionals are embracing and providing EINC care.

What are the EINC Practices for the Care of Birthing Mothers &Newborns?
The EINC practices reflect current knowledge, 5 and were developed and field tested by international and local experts. They separate the clinical practices for normal deliveries that are necessary, or unnecessary for the safe and quality care for birthing mothers and their newborns.

As of December 2010

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Essential Intrapartum Care

Unnecessary interventions in the intrapartum period include the routine performance of enemas and shaving which have not been shown to improve maternal nor neonatal outcome. Restriction of fluid and food intake during labor and routine insertion of intravenous (IV) fluids continue with no evidence of improved outcomes for the mother or newborn. Practices such as routine early amniotomy and oxytocin augmentation have not been shown to have a clear advantage over expectant management. Fundal pressure to facilitate the second stage of labor has been found to cause maternal and newborn injuries and even death. The recommended EINC practices during the intrapartum period include continuous maternal support by having a companion of choice during labor and delivery, freedom of movement during labor, monitoring progress of labor using the partograph, non-drug pain relief before offering labor anesthesia, position of choice during labor and delivery, spontaneous pushing in a semi-upright position, non routine episiotomy, and active management of the third stage of labor (AMTSL).

Essential Newborn Care

Unnecessary interventions in newborn care include routine suctioning, early bathing, routine separation from the mother, foot printing, application of various substances to the cord, and giving pre-lacteals or artificial infant milk formula or other breast-milk substitutes. The recommended EINC practices for newborn care are a series of time-bound interventions: immediate and thorough drying of the newborn, early skin-to-skin contact between the mother and newborn, properly-timed cord clamping and cutting, non-separation of newborn and mothers for early breastfeeding initiation.

EINC CARE PRACTICES

A. Essential Intrapartum Care
1. Unnecessary Interventions a. Enema Enemas were thought to decrease the risk of infections, shorten the duration of labor and make delivery cleaner for the attending personnel. However, enemas can also cause discomfort for women and may increase pain. Scientific research evidence does not support the routine use of enemas during the first stage of labor. Enemas should not be done routinely unless the patient specifically requests for one. b. Shaving Shaving the pubic hair of women in labor was done routinely before birth as a perceived hygienic practice, to minimize infection risk if there a spontaneous perineal tear, and to facilitate easier repair of these tears. Research has found that routine perineal shaving may protect against bacterial colonization, but there is evidence for no effect on perineal wound infection. There was also no significant difference in the incidence of postpartum maternal febrile morbidity.
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Taken with the common feedback of mothers on pain, embarrassment and discomfort during hair regrowth, there is insufficient evidence to do routine perineal shaving for women on admission in labor. c. Restricted Intake of Food & Fluids Oral food and fluid intake is restricted during active labor because of the possible risk of aspirating gastric contents with the administration of anesthesia. However, restriction of food and fluid can be distressing and can increase the length of labor. Labor and birth need energy. Fasting during labor is a tradition that continues with no evidence of improved outcomes for mother or newborn, yet has increased costs, decreased patient satisfaction, and diminished the quality of the birth experience. Therefore, for the normal, low risk birth, there is no need for restriction of food, except in situations where intervention is anticipated. What is recommended is a diet of easy to digest foods and fluids during labor. d. Routine Intravenous Infusion Intravenous fluid (IVF therapy) has been used routinely to hydrate women who were restricted from eating and drinking and to provide quick access in case of an emergency. However, the need for IVs in all laboring women has been questioned since life-threatening emergencies are rare in low-risk laboring women. Starting IVF routinely confers several disadvantages because having an IV line in place is painful and stressful, and it disrupts the natural birthing process by hindering the womans freedom of movement in labor. There are also adverse effects with IVF use since infusions of glucose solutions to the mother will interfere with glucose and insulin levels in both the mother and baby. The use of IV glucose and fluids to prevent or combat ketosis and dehydration in the mother may have serious unwanted effects on the baby. Regardless of solution type, intravenous therapy predisposes women to immobilization, stress, increased risk of fluid overload, and does not ensure a nutrient and fluid balance for the demands of labor. For the normal, low risk birth in any setting, there is no need for restriction of food, except in situations where intervention is anticipated. e. Fundal Pressure It is a common belief that fundal pressure helps the mother with the expulsion of the fetus. Studies have raised the alarm that it is accompanied by maternal morbidities such as perineal tears, uterine rupture, uterus inversion, hypotension, and respiratory distress. In the newborn, it may cause injuries to the brachial plexus, spinal cord, and liver; rib, humeral and clavicular fractures, hypoxemia,
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asphyxia, increased intracranial pressure, cord compression, and subgaleal hemorrhage. All healthcare providers should resist the urge to do fundal pressure to assist the babys delivery but instead should be prepared to wait for the delivery of the baby, allowing passive fetal descent and delayed pushing. f. Early Amniotomy and Oxytocin Augmentation Amniotomy or artificial rupture of membranes and oxytocin augmentation are commonly employed to shorten the duration of labor. However, there is no conclusive evidence that early amniotomy has a clear advantage over expectant management. Amniotomy and oxytocin augmentation require other interventions which may restrict maternal movement. The increased risk for intrauterine infection after amniotomy creates a sense of urgency to deliver the fetus within a specified time-frame, usually 24 hours post-amniotomy. g. Routine episiotomy Episiotomy is performed to purportedly to protect the perineum, pelvic floor and the fetus from injuries during childbirth. It was thought to improve neonatal outcome and prevent urinary incontinence in the mother. Research findings suggest that episiotomy is associated with more pain, incontinence and sexual problems than spontaneous tearing of the perineum. 2. Recommended Intrapartum Care a. Continuous Support During Childbirth Women who receive continuous support we are more likely to have a spontaneous vaginal birth and we are more satisfied, and we are less likely to have intrapartum analgesia. In addition their labors we are shorter, they were less likely to have a cesarean or instrumental vaginal birth, regional analgesia, or a baby with a low 5-minute Apgar score. There is no apparent impact on other intrapartum interventions, maternal or neonatal complications, or on breastfeeding. Studies suggest that continuous support is most effective when provided by a woman who is neither part of the hospital staff and in settings in which epidural analgesia is not routinely available. b. Mobility during labor Women traditionally lie supine in bed during the first stage of labor. There is no evidence that lying supine offers advantages for women and babies. It appears to be more of a convenience for the staff monitoring the progress of labor and status of the baby. There is evidence that walking and upright positions in the first stage of labor reduce the length of labor. Freedom of movement during labor is an effective means to distract mothers from the pain
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of labor, thereby lessening the need for pain medication. During this time, women should therefore be encouraged to take up the position they find most comfortable. c. Pain Relief in Labor Pain relief plays a crucial role during labor. The EINC practice is to offer non-drug methods of pain relief before pain medications. Non-drug methods of pain relief include continuous maternal support during labor, walking and moving around, massage, verbal and physical reassurance, and a quiet environment. If anesthesia is required (i.e. if the mother asks for it), epidural anesthesia is widely used. However, there continue to be concerns that it is accompanied by increased risk of having an instrumental delivery. Maternal fever during labor as well as neonatal breastfeeding challenges are associated with epidural anesthesia. d. Partograph use to monitor progress of labor The partograph is a tool that can be used to assess the progress of labor and to identify when intervention is necessary. Studies have shown that using the partograph can be highly effective in reducing complications from prolonged labor for the mother (postpartum hemorrhage, sepsis, uterine rupture and its sequelae) and for the newborn (asphyxia, infection, death). Studies show that when the partograph is used with defined management protocols, the partograph can effectively monitor labor and prevent obstructed labor. e. Spontaneous pushing in semi-upright position Spontaneous pushing, rather than directed bearing down, is intuitive to a laboring mother. This spontaneous bearing down effort prevents perineal trauma and is oxygen sparing for the fetus. In contrast, directed bearing down once the cervix is fully dilated is ineffective, and may result in maternal exhaustion, and a greater need for operative intervention. Upright positions for pushing during the second stage of labor enhance descent of the fetal head because of the additional effect of gravity. f. Hand Hygiene Hand hygiene is perhaps the single most important and effective measure to prevent nosocomial infections and antimicrobial resistance in hospital settings. It is a general term that refers to either handwashing, antiseptic handwash, antiseptic handrub, or surgical hand antisepsis. There is substantial evidence that it reduces the incidence of infections, however adherence to hand hygiene by health-care workers remains low at an average of 40%. All institutions should priori07

tize improving hand hygiene by using different strategies to gain compliance. g. Active Management of the Third Stage of Labor (AMTSL) Postpartum hemorrhage is one of the leading causes of maternal mortality, and active management of the third stage of labor (AMTSL) has been promoted as an effective intervention in preventing excessive bleeding among facility-based deliveries. The usual components of AMTSL include administration of oxytocin after delivery of the baby, controlled cord traction (with counter traction) and uterine massage after delivery of the placenta. Studies prove that AMTSL is more effective than expectant management in preventing blood loss, severe postpartum hemorrhage, low maternal hemoglobin after birth and prolonged third stage of labor. h. Antenatal Steroids in Preterm Labor Respiratory Distress Syndrome (RDS) is a serious complication among premature babies and the primary cause of early neonatal morbidity, death and disability. Studies show that treatment with antenatal corticosteroids does not increase risk of the mothers death, chorioamnionitis or puerperal sepsis. Treatment with antenatal corticosteroids is associated with an overall reduction in neonatal death, cerebroventricular hemorrhage, necrotizing enterocolitis, respiratory support, neonatal intensive care (NICU) admissions and systemic infections in the first 48 hours of life. Antenatal corticosteroid use is also effective in women with premature rupture of membranes (PROM) and pregnancy related hypertension syndromes. Evidence supports the continued use of a single course of antenatal corticosteroids to accelerate fetal lung maturation in women at risk of preterm birth. A single course of antenatal corticosteroids should be considered routine for preterm delivery with few exceptions.

B. Essential Newborn Care

Unnecessary Interventions a. Routine Suctioning Routine suctioning has been the norm in newborn resuscitation because it was believed to be necessary to clear every babys airway and to stimulate him/her to breath. However in the presence of clear amniotic fluid especially in a baby who is crying and breathing at birth, routine suctioning has been associated with bradycardia, apnea, and delays in achieving normal oxygen saturations. It also causes mucosal trauma with an associated increased risk for infection. Studies show unnecessary suctioning of vigorous newborns increased the risk for sepsis and severe disease. Routine suctioning of the newborn is a harmful practice that should be discontinued.
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b. Footprinting Footprinting of newborns is currently still a widespread practice in the Philippines as means of identification of newborns. This practice increases the risk of cross-contamination among the babies. Professional societies, PhilHealth and DOH no longer encourage the universal use of footprinting. Studies have demonstrated that the majority of infant footprints taken by hospital personnel prove inadequate for identification purposes, and they also contend that DNA genotyping and human leukocyte antigen tests are better methods of identification. Moreover, the EINC practice of non-separation of newborn from the mother minimizes the risk of switching of newborns. c. Early bathing and washing Bathing the newborn immediately after birth predisposes him/her to developing hypothermia. When hypothermia sets in, there is an increased risk of infection, coagulation defects, acidosis, delayed fetal-to-newborn circulatory adjustment, hyaline membrane disease, and intracranial hemorrhage. Bathing also washes away the vernix caseosa, which has been shown in several studies to have antimicrobial properties similar to that of amniotic fluid and breast milk. Also, washing leads to the baby becoming disorganized, effectively hindering the crawling reflex which is present during the first hour of life. The WHO recommends that bathing be delayed for at least 6 hours after birth to minimize the risk of cold stress during the period of maximum physiologic transition of the newborn. d. Routine Separation Healthy newborns placed with their mother soon after birth transition more easily to extrauterine life. They stay warm, cry less, are more likely to breastfeed and breastfeed sooner compared to babies who are separated from their mothers. Unnecessary separation of newborns from their mothers and the resultant postponement of latching on and rooming in and restrictions on breastfeeding seriously compromise colonization of the newborn with maternal skin flora, immunoprotection, milk production and eventual exclusive breastfeeding. e. Giving Glucose Water or Artificial Milk Substitutes It is a common practice in our hospitals to give so-called pre-lacteals like glucose water as a trial of feeding to newborns, or to give artificial milk substitutes to babies while the mothers milk flow is not yet established. This delays the mothers breast milk letdown, and the ease of feeding from the bottle decreases the newborns urge to suckle, two factors that will create a vicious cycle that causes caregivers to continue pre-lacteal feeding, thus undermining the success of breastfeeding.
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This practice also exposes the newborn to different types of infectious agents and challenges an already weak premature or immature gastrointestinal system. Giving artificial milk substitutes is a practice that has serious consequences on the babys health and wellbeing. A. Drying Apart from protecting from cold stress and hypothermia, immediate and thorough drying stimulates breathing. It should be the immediate first action for all newborns, regardless of gestational age or birth weight. In our baseline observational assessment of 481 births in 51 hospitals all across the Philippines, 26 or 5.4% of the newborns did not spontaneously breathe at birth. 6 After implementation of immediate and thorough drying as the first action in essential newborn care in the advanced implementation site Quirino Memorial Medical Center (QMMC), only 2.5 % of newborns were documented to be apneic at birth. 7 B. Skin to skin contact Skin to skin contact is generally perceived to be an intervention for provision of warmth and bonding. Less well appreciated are its contributions to immunoprotection of the newborn and to the protection from hypoglycemia. Studies show that skin to skin contact between mother and baby at birth reduces crying, improves mother-baby interaction, keeps the baby warmer, aids in stabilizing the baby and helps women breastfeed successfully. Evidence shows that there are significant effects resulting from skin to skin contact on the infants cardiorespiratory stability, body temperature, and blood sugar levels, and on breastfeeding and immunoprotection since close skin to skin contact between the maternal-infant dyad facilitates colostrum feeding and may also stimulate the mucosa-associated lymphoid tissue system. C. Properly Timed Cord Clamping Immediate cord clamping has traditionally been the standard in the country. Research on delayed cord clamping has shown benefits to both full-term and preterm babies. Studies point to the facts that placental transfusion at birth via properly timed cord clamping increases the infants blood volume and iron reserves, and reduces the incidence of iron-deficiency anemia in infancy. In preterm infants, it reduces the need for blood transfusions and decreases the incidence of life-threatening intracranial (brain) hemorrhages. D. Initiation of Breastfeeding The benefits of breastfeeding for the health and wellbeing of
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2. Recommended Practices

the mother and baby are well documented. WHO recommends initiation of breastfeeding within an hour after birth but in many countries, the rates of early initiation of breastfeeding remain low. In the Philippines, breastfeeding is initiated within the first hour of life in only 54% of deliveries. Recent trials by Edmond et al 8 and Mullany et al 9 have shown that delaying the initiation of breastfeeding increases the risk of a newborns dying from infection. In developing countries, early initiation of breastfeeding can reduce deaths due mainly to diarrhea and lower respiratory tract infections in children. The late Dr. Natividad R. Clavano in a 1982 landmark study followed a cohort of 9886 infants born at the Baguio General Hospital to assess the relationship of neonatal deaths and diarrhea with feeding patterns. Ninety per cent of the 138 infants with diarrhea were formula fed, 6% were on mixed and 4% on exclusively breastfeeding. Ninety six per cent of the 67 infant deaths were formula fed, 1% were mixed- and 3% were exclusively breastfed. After formal breastfeeding and rooming in hospital policies and practices were implemented, exclusive breastfeeding rates increased and deaths among clinically infected newborns dropped by 95.3%! 10 In another prospective cohort study by Yoon et al, 9942 children in Cebu were followed from 1988-1991. In the first 6 months of life, failing to initiate breastfeeding (or ceasing to breastfeed) resulted in an 8-10 fold increase in the rate of diarrheal death. 11 Early initiation of breastfeeding may reduce neonatal mortality by decreasing the ingestion of infectious pathogens. Early breast milk also provides many immunocompetent factors, including immunoglobulins (antibodies) and lymphocytes (white blood cells) that may stimulate humoral or cell-mediated immune systems) to. It may also prime the gastrointestinal tract and decrease intestinal permeability and invasion by infectious agents, including HIV. Such is the impact of early initiation of breastfeeding. Health care providers and policy makers need to prioritize this cost-effective preventive strategy. Factors that will promote breastfeeding initiation include: implementation of the Mother-Baby Friendly Hospital Initiative (MBFHI) Ten Steps to Successful Breastfeeding; avoidance of the use of intramuscular narcotic analgesia, particularly near the end of the first stage of labor; not separating mothers and babies after birth for routine procedures; and routinely placing healthy newborns on their mothers chest/abdomen in skin-to-skin contact.

Sobel HL, et al. Acta Paediatrica 2011. DOI:10.1111/j.1651-2227.2011.02215.x. [Epub ahead of print] Sobel HL, Silvestre MAA, Vitangcol B, Mantaring JB III, Nyunt-U S MBBS. The association between immediate newborn care practices and neonatal mortality, sepsis and severe disease in a Philippine hospital. Forthcoming. 8 Edmond KM, et al. Am J Clin Nutr. 2007; 86:1126-31. 9 Mullany LC, et al. J Nutr, 2008; 138(3):599-603. 10 Clavano N. Mode of feeding and its effect on infant mortality and morbidity. J Trop Pediatr. 1982;28 :287 293. 11 Yoon PW, Black RE, Moulton LH, Becker S. Am J Epidemiol. 1996. 143:1142-1148.
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ESSENTIAL INTRAPARTUM AND NEWBORN CARE

For more information on how EINC Care can be adopted by your hospital or health facility, please write or call your Department of Health Center for Health Development (Regional Office). Or contact the DOH National Center for Disease Prevention and Control Family Health Office at (02) 7329956, (02) 7117846 or trunkline (02) 6517800 local 1726 or email acalibomd@yahoo.com.