Essential Intrapartum and Newborn Care: A Step-by-Step Guide

The QMMC Experience

November 2008 to Present Antenatal steroids in Preterm Labor Improved hand-washing NO perineal shaving, routine antibiotics & IVF 100% women off their backs 90% episiotomy rates NICU admissions by1/3 Non-separation & initiation of a full breastfeed

Implementation of EINC at QMMC

Nov 2008 to Feb 2010
Immediate Drying
Appropriate Cord Clamping Unnecessary Suctioning

Skin-to-skin Contact
Real Breastfeeding Initiation

120%
100% 80% 60%

Initial ENC work of Dr. Vitangcol, et al.

ENC TRAINING

Weekly team assess and improve

40%
20% 0%

Significant Results at QMMC

Improvement in practices after training of the hospital staff Patient and staff satisfaction Economic benefit

Computed Hospital Savings for 1 NSD

ITEMS COST

BLADE
NGT Cotton Alcohol Betadine Distilled Water IVF (1L)

P3
P7 P 2.50 P5 P5 P 11.50 P 52.50

Using the NSD Census of 2009:

6,670 x P465.50 =

P 3,104,885/yr
or

IV Set
IV Catheter

P 14.50
P 11.50

Suture
Flet Enema

P 97
P 200

P 258,740.72
per month

Blade for Shaving

Rubber Bulb Lidocane

P5
P 36 P 15

TOTAL

P 465.50

Significant Results at QMMC

Improvement in practices after training of the hospital staff Patient and staff satisfaction Economic benefit Sepsis rates down to its lowest in the last 10 years

ORs for Mortality,Sepsis &Severe Disease

Intervention Intervention Protection Protection Risk of Harm Risk of Harm Relative Risk CI RR &

M: 0.25 (0.08-0.77)

Skin-to-Skin Contact

S: 0.40 (0.20 0.79) SD: 0.39 (0.24 0.64)

Appropriate Initiation &Duration of Breastfeeding Unnecessary

Suctioning
0.10 0.10 1.0 1.0 10.0 10.0

M: 0.00

S: 0.17 (0.04 0.74) SD: 0.18 (0.08 0.46)

M: 8.75 (2.60 29.4) S: 4.49 (2.26-8.89) SD: 4.44 (2.72 7.25)

Achieving MDG 4 and 5 with EINC

Unang Yakap Training Video

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Antenatal

At least 4 antenatal visits Iron and folate supplementation Tetanus Toxoid Vaccine Prepare a BIRTH PLAN including UnangYakap
Identify mothers in PRETERM LABOR at point of entry Administer 1st dose of Antenatal Steroid History, Physical Exam and Vital Signs Obtain Birth Plan, Determine Companion of choice Allow Position of Choice Use Partograph to monitor labor IV fluid and NPO only when indicated Arrange all instruments in a linear fashion Check resuscitation equipment

Upon arrival at Facility

During Labor

Allow mother to have oral fluids and light snacks

Check room temperature Prior to Delivery

and air drafts Discuss care in the 1st hours Perineal Bulging

Perform Proper Handwashing and Put on 2 pairs of sterile gloves

NO routine episotomy, fundal pressure

Your 5 Moments of Hand Hygiene

WHY? TO PROTECT THE PATIENT AGAINST GERMS CARRIED ON YOUR HANDS 1. Before Patient Contact WHEN? Ex. Shake hands, clinical examination

Clean hands before approaching and touching a patient

WHY? TO PROTECT THE PATIENT AGAINST GERMS, INCLUDING HIS/HER OWN, FROM 2. Before a Clean / Ex. IV insertion, internal exam, inserting a catheter , O.R. ENTERING HIS BODY. WHEN?Aseptic Task

Clean hands immediately before any clean / aseptic task

WHY? TO PROTECT THE ENVIRONMENT AND YOURSELF FROM THE PATIENTS GERMS. 3. After bodily fluid exposure risk WHEN? Ex. draining a catheter, internal exam, changing a soiled diaper

Clean hands after an exposure risk (and after glove removal)

WHY? TO PROTECT THE ENVIRONMENT AND YOURSELF FROM THE PATIENTS GERMS. 4. After patient clinical examination WHEN? Ex. Shake hands,contact

Clean hands after touching a patient and immediate surroundings

WHY? TO PROTECT withENVIRONMENTsurroundings FROM THE PATIENTS GERMS. 5. After contact THE the patients AND YOURSELF WHEN? Ex. Fixing the patients bed, regulating the IV fluid rate

Clean hands after touching a patients objects even if the patient wasnt touched

Your 5 Moments for Hand Hygiene

1. Wet hands with warm running water, apply soap and lather well. 2. Rub each area together counting 1-2-3-4-5

3. Rinse hands and dry thoroughly with a paper towel.

Time
Delivery

Mother
Support the perineum with controlled delivery of the head

Baby
Call out time of birth and sex Dry, check breathing

First 30 secs Give Oxytocin IM

After excluding a 2nd baby 1 minute to 3 minutes Do controlled traction of cord with counter-traction Massage the uterus gently Examine the placenta

Put in skin-to-skin contact

Feel for cord pulsation , Clamp, cut cord

Return baby to prone position

Support FIRST FULL BREASTFEED. Monitor as a DYAD q15 minutes 15-90 minutes Continue uterine massage; Monitor every 15 minutes Do PE, weigh, measure, eye care, inject Vit K, Hep B, BCG

Transport to room TOGETHER

> 6 hours BREASTFEEDING SUPPORT

Optional: Bathing

Linear Arrangement of Instruments

Immediate and Thorough Drying Early Skin to Skin Contact Properly-timed Clamping Non-Separation of Mother and Baby

EINC in Cesarean Section

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EINC in Meconium-stained Vigorous Baby

Normal Delivery?

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Websites
Download the Essential Newborn Care (ENC) Training Videos from:
www.doh.gov.ph ://www.wp://www.wpro.who.int/philippines/PubDocs.h tm http://www.wpro.who.int/philippines/PubDocs.htm

EINC Implementation
1. Organize a multidisciplinary EINC Working Group Clinical staff Physicians - OB, Pedia, Anesthesia, Infection Control Nurses, nursing assistants, midwives
Administrative staff Medical Director Finance/ Budget Officer PhilHealth Officer Medical Social Service Engineering CSR

EINC Implementation
2. Conduct a situational analysis of your facility
Time and motion studies of deliveries and immediate newborn care practices

May be done periodically to determine effectivity of program implementation 3. Conduct saturation training workshops for all staff involved in maternal and newborn care services
DR/OR, NICU, OB and Pedia Wards, ER staff Institutional/ utility workers

EINC Implementation
4. Revise hospital policies and procedures
Allow companion of choice Remove footprinting Revise Nursery admission/ discharge criteria - weight or gestational age limits for preterms - growers Review newborn policies on diagnosis and management e.g. potential sepsis hyperbilirubinemia

EINC Implementation
5. Realign hospital staff to do new tasks
Obstetrician to dry the baby Pediatrician to clamp and cut the cord Anesthesiologist to help in maintaining skin-to-skin contact DR/ NICU staff to monitor mother and baby dyads DR/ NICU nurse to weigh baby and to do eye prophylaxis, IM injections Utility worker to transfer mother-baby dyad together

EINC Implementation
6. Revise hospital forms and order sheets Incorporate EINC in the newborn admission forms, modify newborn admitting orders, checklist Utilize a mother-baby dyad monitoring sheet Breastfeeding and Danger Signs Checklist

EINC Implementation
7. Enable the environment for EINC
Provide ample space in the labor room for companion, for mothers mobility Provide back support for upright positioning Include bonnet/extra linen in the OB pack Designate an EINC Recovery Room or area

8. Disable the environment that hinders EINC Remove the transitional nursery provide trolley Close the Nursery!

Help us bring

to your community

III Immediate Newborn Care

(The First 90 minutes) III III Care Prior To Discharge

II II Essential Newborn Care

From 90 min to 6 hours

but after the first 90 minutes

IV IV Care after Discharge

To 7 days

V V Additional Care VII VII Equipment And Supplies Maintenance Checklist 33

VI VI Enabling The Environment

III Immediate Newborn Care

(The First 90 minutes)

II II Essential Newborn
From 90 min to 6 hours

III III Care Prior To Discharge

but after the first 90 minutes

Breastfeeding Warmth of the Baby Hygiene Sleeping Danger Signs: serious illness Signs of Jaundice and Local Infection Discharge Instructions

IV Care after Discharge

To 7 days

IV

Breastfeeding Warmth of the Baby Danger Signs Very severe disease

V V Additional Care

A. Newborn Resuscitation B. Additional Care of a Small Baby (or Twin): Warmth, feeding support, KMC, discharge planning C. Dealing with Feeding Problems: Mother-infant separation, manual expression of breastmilk, cup feeding

VI VI

Enabling The Environment

Preparing for the shifts workplace After every delivery restock Standard precautions general standard precautions and cleanliness Hand hygiene Processing Instruments & Other Items: Step 1: Decontamination Step 2: Cleaning Step 3: High-Level Disinfection by Boiling or Steaming Sterilization by Steaming (Autoclave) Step 4: Store or Use

VII VII Equipment And Supplies Maintenance Checklist

Warm and clean room Handwashing Waste Sterilization Supplies Miscellaneous For the Mother and Baby equipment, delivery instruments, drugs, supplies, forms & records, plus for CEmONCs

Download the Pocket Guide and Unang Yakap flyer

www.wpro.who.int/philippines/PubDocs.htm

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