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its effective and timely implementation across a wide constituency. Dr. Catibog is one of the instrumental forces in championing maternal and infant health, having headed the Task Force for Rapid Reduction of Maternal and Neonatal Mortality. The task force was responsible for institutionalization and strengthening the implementation of the Maternal, Neonatal and Child Health and Nutrition (MNCHN) Strategy. The MNCHN Strategy is formalized under the AO No. 2008-2009 otherwise known as Implementing Health Reforms for the Rapid Reduction of Maternal and Neonatal Mortality. This Order applies the Fourmula One for Health (F1) approach instituted by then Health Secretary Francisco Duque III for the implementation of an integrated Maternal, Neonatal and Child Health and Nutrition (MNCHN) Strategy. This overarching strategy guides the development, implementation and evaluation of various programs aimed at women, mothers and children, with the ultimate goal of rapidly reducing maternal and neonatal mortality in the country. This goal is to be achieved through the provision and use of integrated MNCHN services, which refers to a package of services for women, mothers and children that cover known appropriate clinical case management services and cost-effective public health measures which are provided by the health system to reduce the risks of and prevent direct causes of maternal and neonatal deaths. Enclosed within this strategy are provisions to guide the engagement, assistance and empowerment of LGUs and other partners in providing an integrated package of services for mothers, babies and children. This includes

MNCHN

news
Special Feature: Dr. Honorata Catibog Upcoming Technical Conference on EINC Best Practices Feature: 1st MNCHN EINC Advocacy Forum held in Manila Feature: San Lorenzo Ruiz Womens Hospital EINC Dos and Donts: Vol 3 July 15, 2011

Documenting Essential Intrapartum Newborn Care (EINC) Practices for Safe & Quality Maternal & Newborn Care

Dr. Honorata Catibog Bringing Healthcare to Grassroots level

by Donna Miranda photos by Bernie Cervantes

s Dr. Honorata Catibog, director of DOHs Family Health Office, fondly recalls the times she has spent as Municipal Health Officer and Provincial Board Member -- combing the remotest barrios of her native Western Samar -- one cant help but grasp that her advocacy is not one that is compulsory of her office but is borne out of years of experience accompanied with the tireless dedication to bring healthcare to those hardest to reach. Her tenacity is easily noticeable in the personal anecdotes she readily shared during our brief afternoon interview: looking back at this one time when she had sea ambulances custom made to service several island municipalities under her jurisdiction, then as provincial board member of Western Samar. Such that Dr. Catibogs remark about understanding the difficulties of bringing healthcare to people at grassroots level and importance of public policies in ensuring its success is certainly no lip service.

For the tenacious Dr. Catibog advocacy is no lip service

organizing training sessions and capacitybuilding workshops for community health workers enabling them to respond to the evolving needs of their clients from prenatal to intrapartum and postpartum/postnatal care and interventions. Dr. Catibog further emphasizes that this integration reflects the paradigm shift cognizant that health workers and providers should be able to address and manage complications that may arise at any of the stages in a woman's pregnancy. For instance, midwives, at the LGU level, shall be trained not only in evidence-based safe delivery practices but also trained in essential newborn care (ENC). >>

It is no secret that the success of any health reform lie not only in the merits and benefits of the program but equally relies on a sound and robust political strategy that shall guarantee

This goal is to be achieved through the provision and use of integrated MNCHN services, which refers to a package of services for women, mothers and children that cover known appropriate clinical case management services and cost-effective public health measures which are provided by the health system to reduce the risks of and prevent direct causes of maternal and neonatal deaths

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...continued from page 1
>> In continuing efforts to rapidly reduce the

number of newborn death in the Philippines, the DOH issued an administrative order to implement the ENC protocol last December 1, 2009. The AO 2009-0025, the whole hierarchy of the DOH and its attached agencies, public and private providers of health care and development partners implementing the Maternal, Newborn and Child Health and Nutrition Strategy and all health practitioners of maternal and newborn care were enjoined to adopt the policies and protocol on Essential Newborn Care. ENC was likewise incorporated into the Basic Emergency Obstetric and Newborn Care (BEmONC) Training. Unang Yakap is the social marketing campaign that was launched to spread the call to action to implement the Essential Newborn Care protocol. At advanced implementation sites, as the ENC scale-up program evolved into the Essential Intrapartum and Newborn Care protocol, Unang Yakap likewise became Unang Yakap 4&5. Asked of what else is needed to further the aims in achieving the goals of MDGs 4 & 5, Dr. Catibog responds, [I am hoping] that we can bring EINC implementation down to the barangay level with barangay health workers being equipped to carry out EINC protocol even at barangay health stations or perhaps even at home. She quickly qualifies, while the gold standard is facility-based, we should consider fallback options for areas where health facilities are not yet availablewith the EINC protocol, we ensure the life of the mother and baby even when the mothers are forced to give birth at home. In her closing remarks to the 1st MNCHN EINC Advocacy Forum held last July 13-15 at Century Park Hotel in Manila, Director Catibog underlines the crucial partnership of the public and private sectors as a significant step to achieving the countrys commitment to Millennium Development Goals 4 and 5: With the birth of this new partnership with the private sector, we can successfully prevent the needless death of mothers and newborns in the country, further adding that the private sectors involvement is the yet largely untapped area ensuring that safe and essential intrapartum and newborn care is given to as many Filipino mothers and newborns as possible.

upcoming technical Conference on EINC Best Practices

Almost a year has passed since Essential Intrapartum and Newborn Care (EINC) began Unang Yakap or First Embrace, its social marketing campaign, designed to transform hospitals with interventions aimed at the high-risk periods of labor, delivery, and immediate postpartum. Now that its practices have been established and are ready to be implemented in 11 DOH hospitals thanks to the efforts not only of the EINC team but also of these hospitals, JPMNH, WHO Philippines, and the National Center for Disease Prevention and Control/Family Health OfficeEINC is eager to share its experience with health stakeholders for adoption and replication on a national scale by way of a conference. The MNCHN EINC Scale Up Project Technical Conference, to be held on September in Metro Manila, is meant to convene such stakeholders, including DOH Centers for Health Development and more hospitals who can surely benefit from EINCs progressive methods and learnings. Heads of professional societies, key personnel from medical academies, as well as physicians, nurses, and midwives have been invited to attend. Expected presentations include a showcase of the results of the EINC Scale Up Project that mark improvements in the deployment of practices from baseline to project completion, an enumeration of the best practices carried out in model hospitals that are worth emulating, even a set of technical recommendations for the adoption of EINC in all health facilities across the entire nation in order to arrest maternal and newborn within this high-risk period.

[I am hoping] that we can bring EINC implementation down to the barangay level with barangay health workers being equipped to carry out EINC protocol even at barangay health stations or perhaps even at home.
2

uly 13 to 15 at the Century Park Hotel in Manila saw the realization of the first MNCHN (Maternal Child Health and Nutrition Policy) EINC (Essential Intrapartum and Newborn Care) Advocacy Partners Forum to meet the demand for EINC training by building up the pool of speakers for rapid scaling up efforts. The forum was carried out for the benefit of new EINC trainers who themselves require not only training but also updates on the Department of Healths ongoing efforts in the Scale-Up Project. Their motto being I commit to lifeit is the first declaration in their official Partners Pledgethe group by way of this forum also commits to keeping their advocacy alive by empowering their personnel with the expertise necessary for pursuing the quality of maternal child health they aspire for.

1st MNCHN EINC Advocacy Partners Forum held in Manila

Funded by JPMNH and WHO, EINC has either trained or oriented approximately 9000 healthcare workers in the short timespan between May and October 2011a testament to the ongoing demand for cpacity building in EINC among various key medical institutions. Requests for training come from both private and public hospitals, some even outside the National Capital Region, not to mention a handful of LGUs and private institutions. This is possibly due to the effectiveness of the EINC social marketing plan and training methodology, where administrative circulars as well as technical and professional training sessions are brought directly to facility-based healthcare workers, emphasizing the significance of a peer-to-peer system of learning. The course was was designed to build up a >>

NEWS

>> speakers bureau comprised of EINC advocates

learning about the evidence-based practices has empowered us to push for the advocacy because we are confident that the safety and wellness of both mother and baby are always prioritized over everything else

healthcare professionals who, after training, are committed to improving dominant hospital practices when it comes to caring for mothers and newbornsand dedicated to finding even more advocates given the abovementioned demand for EINC training. The demand is expected to grow further once Philhealth goes public with its new packages meant to address issues of maternal and newborn healthcarea demand to be met by the pool of advocacy Partners in collaboration with DOH and its Centers for Health Development. After receiving their official IDs after completion of training has, healthcare professionals maintain their status as EINC advocates by conducting workshops, the progress of which will be monitored via the EINC Advocacy Partners Forum website. The engagement of Advocacy Partners such as those coming from professional societies can also function as a kind of PPP mechanism of the Centers of Health Development, identifying specialists per region who can voluntarily lead orientations and trainings for the CHDs who will fund such venues for training. Besides the CHDs, the Advocacy Partners will also be working closely with DOH hospitals and their Health Education and Promotions Officer (HEPO), the DOH Family Health Office/NCDPC, the National Center for Health Promotions (NCHP), and the Local Government Unit (LGU). The feedback has been positive with participants

excited to return to their communities and impart their new learnings. Dr. Catherine Torres-Jison of Bacolod, for instance has committed to conduct EINC trainings and workshops at The Corazon Locsin Montelibano Regional Hospital, Bacolod City Lying-In Clinic, and at University of St. La Salle. She shares learning about the evidence-based practices has empowered us to push for the advocacy because we are confident that the safety and wellness of both mother and baby are always prioritized over everything else. Moreover, she is anticipating that bringing EINC to medical schools is best way to promote EINC protocol in that way [future] doctors and other health professionals will no longer be confused. The 70 graduates who have completed the training were enjoined to know by the heart the MNCHN EINC Advocacy Partners Pledge, a simple oath comprised of seven lines that capture the essence of what EINC stands for: I commit to life. / From its earliest stirrings in a mothers womb, through its intricate journey of development, until the moment of birth. / I will safeguard the mothers wellbeing, to maintain a nurturing environment for the life growing within. / I will shield this new life, and ensure it begins its existence safely nestled in a mothers warm embrace. / I will protect this new life, and allow only milk from a mothers breast for nourishment. / I will zealously preserve the bond between mother and child. / All these things I hold sacred, and will form my lifelong commitment.

lIst oF PArtICIPANts: DOH-Retained Hospitals:

Dr. Ricalyn Rivera, Dr. Ma. Conchitina Bandong, Dr. Resti M. Bautista, Dr. Cynthia Anzures, Dr. Mary Christine Tumale, Dr. Leilani Coloma, Dr. Ma. Leonora Villaruz, Dr. Patricia Malay-Kho, Dr. Grace Verzosa, Dr. Fortunato Boto, Jr., Dr. Fatima Dasalla, Dr. Ma. Isabelita Estrella, Dr. Marilou Nery, Dr. Ireene Cacas, Dr. Ma. Antonette Co Del Valle, Dr. Susana Merida, Dr. Nelita Salinas, Dr. Theresa Tenorio, Dr. Svettlana Rayhana E. Salendab, Dr. Charlie Alcaide, Dr. Consuelo Lu, Dr. Milabelle P. Estabillo Dolores Casio, RN, Grace Solamo, RN, Nimia Juanday, RN, Erlinda Pascual, RN, Gloria Almariego, RN, Esmeralda Caliso, RN, Alberto G. Capuli, Erlinda Lura, Teresa Rallos, Eligia Capito, Lorena Perdigon, Concepcion Castro, Leonora Destacamento, Ligaya Lora, Mohamad Karao, Tessie Remolana

Private Sector Partners:

Dr. Dinah Abella, Dr. Hilda Bernardino, Dr. Ellen May De Guzman, Dr. Daisy Grace Rivera, Dr. Jane Revilla, Dr. Rizalina Adalid, Dr. Sirikit Zafra. Dr. Mary Jean Rodriguez, Dr. Catherine Jison, Dr. Marilou Viray, Dr. Rachel Kong-Garcia, Dr. Wilfredo Santos, Dr. Adela Gatmaitan, Dr. Fay S. de Ocampo, Dr. Ma. Esterlita V. Uy, Dr. Kathylynne Abat-Senen, Dr. Rachelle Perez, Dr. Lieza Sahi, Dr. Jerome Wangdali, Dr. Aurora Gloria Inguillo-Libadia, Dr. Reinalissa Manaois, Dr. Honey May P. Raborar, Dr. Generosa Aguas, Dr. Ninfa Baria
ABoVE: Participants, trainors and guest speakers of the 1st MNCHN EINC Advocacy Forum

after receiving their official IDs after completion of training, healthcare professionals maintain their status as EINC advocates by conducting workshops

Vol 3 July 15, 2011

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Feature
by Donna Miranda | photos by Bernie Cervantes

san lorenzo ruiz Womens Hospital:

Providing a comforting, nurturing and safe environment for mothers and newborns in a hospital
ts discreet location, tucked at the far end of an almost unnoticeable alleyway along the national road, is certainly not comparable to the quality of care that San Lorenzo Ruiz Womens Hospital (SLWH) in Malabon lives up to. We may be a very small hospital but we have managed to maintain a good reputation in delivering quality care and service to our patients. Hopefully, we want to have the same for EINC, shares the charismatic Dr. Maria Isabelita Happy Estrella, hospital director and EINC Working Committee Chairman, that afternoon we dropped in for a visit.
Upon entering the premises, one senses that at SLWH things are done in a manner not quite typical of any government hospital. And yet its cozy atmosphere common of small town communities betrays the level of excellence that the hospital strives to achieve, for there is surely nothing small town about SLWHs commitment to achieve the goals set by MDG 4 & 5. Their passion to constantly improve

their compliance of the EINC practices while also soliciting the active involvement of their immediate community is noteworthy. Dr. Happy Estrella hopes that by involving the other health providers in Malabon and its nearby areas, the city of Malabon in their own small way can contribute to reducing the countrys maternal and infant mortality by 2015. San Lorenzo Ruiz Women's Hospital is a 10-bed capacity special First Level Referral hospital catering to the health needs of women and children residing in Malabon, parts of Valenzuela, Caloocan, Obando as well as Tanza, Navotas. It is also Philhealth accredited as a secondary hospital. Normal spontaneous deliveries and obstetric cases remain the leading cause of admission. While not solely a maternity hospital, Dr. Estrella remarks that there is that unavoidable impression that is why adopting the EINC is an advantage to us since the program will strengthen their capacity to meet the needs of both mother and baby during delivery and birth. She proudly adds that implementing EINC is, if not one of, their more important accomplishments for the year. Seven months after its implementation, EINC has now become part of the hospital with

corresponding hospital guidelines and policies supporting already issued from staff assignments all the way to the revision of forms, scope of work and doctors orders. More importantly, the staff -- from the doctors down to the midwives and nurses, even those not part of the Working Committee -- has by now internalized the program. And in fact, already learning to devise creative solutions when not so ideal situations arise. Such as the time when they asked a father to do skin-to-skin contact in place of the mother who was unable to hold her baby because she was vomiting immediately right after delivery. It was a very touching moment, narrate the nurses and midwives. Chief of Clinic, Pediatrician Dr. Marilou Nery adds, The father felt more involved in the process. Furthermore, (it) has brought out the creativity in us [as] the passion somewhat grows on you then you strive to be better each time. Change is indeed a concerted effort. That is to say that even a small hospital like SLWH, where administration and organization may deceptively seem simple, is still not exempt from a few uncoordinated practices that bigger hospitals experience. Dr. Estrella narrates how it was initially

FEATURE
challenging to convince the other midwives to carry out the program. Understandably, change is never an easy thing to do, most especially as this entails reconsidering old and tried methods and learning new ones. After much work, theyve eventually come around -- seeing the benefits of the program as well as appreciating their role in providing safe and quality healthcare to mothers and babies. You have to devise strategies that will challenge the staff to do better, says Dr. Nery. Episiotomies for instance used to be routinely done by the midwives to avoid laceration, but has since been declining after persistent guidance and monitoring with 39% out of 18 normal deliveries from June 5-18. And while consistency in recording deliveries can still improve, there has been good compliance with the performance of full EINC in both normal and CS deliveries with 92.2% for May and 100.00% for the first half of June. Likewise, unnecessary interventions, such as fundal pressure, manual exploration of the uterus, unnecessary suctioning, and NPO have impressively gone down. The routine administration of intravenous fluid has also dramatically decreased with 66.7% of normal deliveries performed without IV fluids for the month of May and >80 % for the first half of June. Equally worth mentioning is 100% compliance in Oxytocin IM administration for the Active Management of the Third Stage of Labor. It really is about creating a homely, comforting, nurturing but safe environment for the mother and the newborn. When we started implementing the program, no sooner did we come to realize that EINC practices were relatively in tune with the reason(s) why some mothers opt for home births, shares Dr. Estrella. With EINC, mothers feel more at ease and satisfied with the birthing experience as they are encouraged to assume a position of choice during labor, delivered in non-supine position, and even
Hospital director Dr. Maria Isabelle Estrella together with her staff share to us their improved maternal and infant statistics

The key to SLWHs success is constant communication between the midwives, pediatricians, obstetricians and patients
given the option to have a companion of choice during labor and delivery. Theyve since been receiving positive feedback from their patients, mostly of whom have expressed how much they enjoyed the (birthing) process compared to how it was before. Conversely, the staff and doctors equally feel satisfied. Weve learned to be more compassionate to patients. Now weve come to appreciate better what mothers are going through and know how to support and care for them during the process, says Dr. Estrella. Implementing the EINC has also made them realize how their previous preventive practices were bent more on assuaging their own fears for potential complications that may arise during delivery rather than a response to the patients needs. Dr. Nery for instance notes that performing the four core steps of newborn care have led them to more definitive diagnosis of sepsis which has partly contributed to the drop in reported cases, before as soon as a patient is admitted, the newborn is immediately considered for sepsis, hence, the routine administration of antibiotic even without the confirmation of a blood culture. True enough, the sepsis rates for May to June 2011 of 5.9 to 6.9%% went down to 0% for the last week of June and the first week of July 2011. Of course, these rates may yet change but with EINC implementation robust, the outlook is

ABoVE: With EINC practice, fathers feel more involved in the birthing experience

very optimistic. The use of drop lights among newborns has also been done away with since skin-to-skin contact with mother is enough to keep them warm. The key to SLWHs success is constant communication between the midwives, pediatricians, obstetricians and patients. Midwives, for instance, have learned to become more open to the needs of their patients. Furthermore, theyve begun to appreciate the integrated care needed by for mother and baby during delivery, inevitably requiring teamwork. I used to be afraid of handling neonates, immediately handing the baby out to the pediatrician once Im done delivering it. My thought then was Im only an OB and should have nothing to do with that. But now, I make it a point to check on the babies Ive delivered when I do my rounds, Dr. Estrella shares. And while the hospitals current floor plan has yet to truly reflect these new discoveries, plans for expansion are underway. The enriching experience brought by implementing EINC in their hospital has undoubtedly inspired SLWH to reach out to their immediate community. Believing that these marked improvements need not be confined to walls of their hospital but must also be shared to the rest of the community, at least those within their reach. Capitalizing on their existing network of Breastfeeding Coordinators in the community, theyve initiated a series of meetings to advocate and promote EINC beyond the hospital. Already, initial communications with RHU-based coordinators have been set-up to align delivery and care practices of private practitioners and home birth with EINC and other mother-baby friendly care practices. While SLWHs experience proves that more often than not it's little details such as the simple warmth of a mothers skin that matter, more importantly their experience only shows that being small is by no means an obstacle to thinking and aspiring big.

Vol 3 July 15, 2011

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EINC Donts and Dos:

DoNts unnecessary suctioning and Bathing
routine suctioning

Routine suctioning has been the norm in newborn resuscitation because it was believed to be necessary to clear the babys airway and to stimulate him 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 increased risk for infection. In a pilot implementation study of the Essential Newborn Care Protocol at a large government hospital in the National Capital Region, unnecessary suctioning of vigorous newborns increased the risk for sepsis (OR 4.49 95% CI 2.26-8.89), mortality (OR 8.75 95%CI 2.60 29.4) and severe disease (OR 4.44 95% CI 2.72 7.25). Routine suctioning of the newborn is a harmful practice that should be discontinued.
sources: Velaphi s,Vidyasagar D.The pros and cons of suctioning at the perineum (intrapartum) and post-delivery with and without meconium. semin Fetal neonatal Med 2008 Dec: 13 (6): 375-82. sobel HL, silvestre MA,Vitangcol B, Mantaring JB 3rd, nyunt-U s.The association between immediate newborn care practices and risk of neonatal mortality,sepsis and severe disease in a Philippine hospital. Unpublished

similar to that of amniotic fluid and breastmilk. Antimicrobial proteins (lysozyme, lactoferrin, human neutrophil peptides 1-3 and secretory leukocyte protease inhibitor) are present in organized granules embedded in the vernix, and these immune substances were found to be effective in inhibiting the growth of common perinatal pathogens, including group B Streptococcus, K. pneumoniae, L. monocytogenes, C. albicans, and E. coli. 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.
sources: Darmstadt GL,walker n, Lawn Je, Bhutta Z, Haws RA, Cousens s. saving newborn lives in Asia and Africa: cost and impact of phased scale-up of interventions within the continuum of care. Health Policy and Planning. 2008. 23 (2):101. Akinbi HT et al. Host defense proteins in vernix caseosa and amniotic fluid, Am J Obstet Gynecol. 191(6), 2090-2096. 2004. World Health Organization.Thermal Protection of the Newborn: A Practical Guide. Geneva, Switzerland:World Health Organization; 1997.

Dos Properly timed Cord Clamping

Immediate cord clamping has been traditionally been the standard in the country. In the observational study by Sobel et al of 481 births in 51 large government hospitals to evaluate the performance and timing of newborn care interventions, cords were clamped at a median of only 12 seconds with 476 (99.0%) within 60 seconds. Three (0.6%) with nuchal cords were cut prior to delivery. Research that has been done on delayed cord clamping has shown benefits to both full-term and preterm babies. Furthermore traditional practices such as milking the cord and using binders have only been proven to increase the risks for infection. Milking the cord towards the baby, for instance, can actually result in a bolus of blood being introduced suddenly into the babys system and may conceivably cause complications especially in preterms with fragile blood vessels in the brain. Binders on the other hand, when soiled and unchanged, may harbor germs that will cause infection. The binder can also rub against the skin and cause irritation. In lieu of avoiding the risk for infection, EINC recommends the use of plastic clamp to lessen subsequent cord handling (hence the risk of infection) and eliminate the need to replace the metal clamp with a plastic one later on with the first clamp applied 2 cm from the base of the umbilicus and second one at 5 cm from the base of the umbilicus.

Effects on Full-term Infants

There are two meta-analyses evaluating the effects of delayed cord clamping on full term infants. The meta-analysis by Hutton and Hassan included all controlled trials whether randomized or not, while McDonald and Middleton excluded quasi-randomized trials and included also maternal outcomes in their meta-analysis. Hutton and Hassan in their meta-analysis of 15 controlled trials (n=1912 newborns) found that delaying cord clamping of the umbilical cord in full term neonates for a minimum of 2 minutes following birth is beneficial to the newborn, extending into infancy. Benefits over ages 2-6 months associated with late clamping include improved hematocrit (WMD 3.7% 95% CI 2.0, 5.4%), ferritin concentration (WMD 17.89 95% CI 16.5819.21), stored iron (WMD 19.0 95% CI 7.67- 32.13) and a significant reduction in the risk of anemia (RR 0.53 95% CI 0,40-0.70). There was a trend towards an increased risk for polycythemia though asymptomatic in the 2 high quality studies (n=281 infants) RR 3.91 95%CI 1.00-15.36.

Early Bathing and Washing

Bathing the newborn immediately after birth predisposes him to developing huypothermia. When hypothermia sets in, there is an increased risk of infection, coagulation defects, acidosis, delayed fetalto-newborn circulatory adjustment, hyaline membrane disease, and intracranial hemorrhage. It also washes away the vernix caseosa, which has been shown in several studies to have antimicrobial properties

EINC DOS & DONTS

EBM reviews in Coming Issues:
Early Amniotomy and Oxytocin Augmentation Pain Relief in Labor Antenatal Steroids Giving Pre-lacteals or Artificial Milk Substitutes Initiation of Breastfeeding Active Management of the Third Stage of Labor Partograph Use

rIGHt: Research shows that delayed cord-clamping is beneficial to both full-term and preterm babies loWEr lEFt: Unnecessary suctioning may cause mucosal trauma and increased risk for infection

McDonald and Middletons review of 11 trials (2989 mother-baby dyads) revealed significant increases in newborn hemoglobin levels in the late vs the early cord clamping (WMD 2.17 g/dl 95% CI 0.28, 4.06; 3 trials of 671 infants) although the effect did not persist beyond 6 months. Infant ferritin levels remained higher in the late vs the early clamping group at 6 months. There was a significant increase in infants requiring phototherapy for jaundice (RR 0.59 95% CI 0.38, 0.92; five trials of 1762 infants) in the late vs early clamping group. There were no significant differences seen for maternal postpartum hemorrhage in any of the 5 trials (n=2236 women) which measured this outcome (RR for postpartum hemorrhage of > 500 ml 1.22 95% CI 0.96, 1.55).

MEEt tHE tEAM

Editors Dr. Maria Asuncion A. Silvestre Dr. Cynthia Fernandez Tan Managing Editor Marcia F. Miranda Feature Editors Donna Miranda Monica Feria Medical Editor Dr. Louell Sala Medical Contributors Dr. Teresita Cadiz-Brion Dr. Donna Capili Dr. Ma. Lourdes Imperial Dr. Jessamine Sareno Dr. Francesca Tatad-To Dr. Ernesto Uichanco Bulletin Advisors Dr. Anthony Calibo Dr. Ivan Escartin Dr. Mariella Castillo

Effects on Preterm Infants

Data from a meta-analysis by Rabe et al from 7 randomized controlled trials (n=297 infants) with a maximum delay of 2 minutes (120 secs) revealed that delayed clamping was associated with fewer transfusions for anemia (3 trials, n=111 infants; RR 2.01, 95% CI 1.24 to 3.27, low blood pressure (2 trials, n=58 infants; RR 2.58 95% CI 1.17, 5.67) and less intraventricular hemorrhage (IVH) (5 trials, n=225 infants; RR 1.74, 95% CI 1.08, 2.81). In another study by Van Rheenen on a population of low birth weight/small for gestational age (SGA) infants, the search for both randomized and quasi randomized trials yielded no trials specifically reporting the effects of delayed clamping in SGA infants. Three trials were included, with 190 term and 40 preterm infants, a proportion of whom were SGA. Data showed higher hemoglobin levels in the term infants at follow-up [2 trials, n=127 infants, weighted mean difference WMD 9.17 g/L, 95% CI 5.94-12.40]. In preterm infants, the proportion who required a blood transfusion in the 1st 6 weeks after birth was lower after DCC (one trial, 38 infants, RR 0.56, 95% CI 0.34-0.94). In a randomized controlled trial, Mercer and co-workers demonstrated that delayed cord clamping in very preterm neonates reduced the incidence of intraventricular hemorrhage and late-onset sepsis. Delayed cord clamping did not protect against the primary outcomes of interest, bronchopulmonary dysplasia and necrotizing enterocolitis. All these studies point to the facts that placental transfusion at birth brought about by 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 hemorrhages.
sources: Sobel HL, Silvestre MA, Mantaring JB III, Oliveros YE, Nyunt-U S. 2009. Immediate newborn care practices delay thermoregulation and breastfeeding initiation. Acta Paediatrica 2011. DOI:10.1111/j.1651-2227.2011.02215.x. [Epub ahead of print]deprive newborns of natural protections: A minute-by-minute assessment of care in the first hour of life in fifty-one large Philippine hospitals. Unpublished. Available at http://onlinelibrary.wiley.com/doi/10.1111/j.1651-2227.2011.02215.x/pdf Hutton eK, Hassan es. Late vs early clamping of the umbilical cord in full-term neonates. systematic review and meta-analysis of controlled trials. JAMA. 2007; 297:1241-1252. McDonald sJ, Middleton P. effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No. CD004074. DOI:10.1002/14651858.CD004074.pub2. Rabe H, Reynolds G and Diaz-Rossello. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No. CD003248. DOI: 10.1002/14651858.CD003248.pub2. van Rheenen PF, Gruschke s, Brabin BJ. Delayed umbilical cord clamping for reducing anaemia in low birthweight infants: implications for developing countries. Ann Trop Paediatr. 2006 Sep;26(3):157-67. Mercer JS,Vohr BR, McGrath MM, Padbury JF,Wallach M, Oh W. Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial. Pediatrics. 2006 Apr;117(4):1235-42.

FEEDBACK, Comments and Questions PlEAsE! Ask your questions and Team EINC will be pleased to respond. Write us at unangyakap@gmail.com and we will answer you quickly. Give us your feedback and comments so we can improve our Bulletin. Thank You! the Editors Go Unang Yakap 4 & 5

Unang Yakap ating tangkilikin Bagong Silang na sanggol ating mahalin Init ng Ina dapat niyang damhin Gintong buhay niyat ating pagyamanin -Tondo Medical Center 26 July 2011

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. The findings, 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.