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

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Implementation of EINC at QMMCNov 2008 to Feb 2010

0%

20%

40%

60%

80%

100%

120%

Immediate Drying Skin-to-skin Contact

Appropriate Cord Clamping Real Breastfeeding Initiation

Unnecessary Suctioning

Initial ENC work of Dr. Vitangcol, et al.

ENC TRAINING

Weekly team assess and improve

•

••••

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

Using the NSD Census of 2009:

6,670 x P465.50 =

P 3,104,885/yror

ITEMS COST

BLADE P 3

NGT P 7

Cotton P 2.50

Alcohol P 5

Betadine P 5

Distilled Water P 11.50

IVF (1L) P 52.50

IV Set P 14.50

IV Catheter P 11.50

Suture P 97

Flet Enema P 200

Blade for Shaving P 5

Rubber Bulb P 36

Lidocane P 15

TOTAL P 465.50

P 258,740.72 per month

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 thelast 10 years

0.10 1.0 10.0

OR’s for Mortality,Sepsis &Severe Disease

Skin-to-Skin Contact

M: 0.25 (0.08-0.77)

S: 0.40 (0.20 – 0.79)

SD: 0.39 (0.24 – 0.64)

M: 0.00

S: 0.17 (0.04 – 0.74)

SD: 0.18 (0.08 – 0.46)

Unnecessary

Suctioning

M: 8.75 (2.60 – 29.4)

S: 4.49 (2.26-8.89)

SD: 4.44 (2.72 – 7.25)

Protection Risk of HarmIntervention RR & CI

Appropriate Initiation &Duration

of Breastfeeding

Intervention Protection Risk of Harm Relative Risk

0.10 1.0 10.0

Achieving MDG 4 and 5 with EINC

Unang Yakap Training Video

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Antenatal

During Labor

Upon arrival at Facility

PerinealBulging

At least 4 antenatal visitsIron and folate supplementation

Tetanus Toxoid VaccinePrepare a BIRTH PLAN including UnangYakap

Identify mothers in PRETERM LABOR at point of entryAdminister 1st dose of Antenatal Steroid

History, Physical Exam and Vital SignsObtain Birth Plan, Determine Companion of choice

Allow Position of Choice

Discuss care in the 1st hours

Arrange all instruments in a linear fashion

Use Partograph to monitor labor

Allow mother to have oral fluids and light snacks

IV fluid and NPO only when indicated

Prior to Delivery

Check resuscitation equipment

Check room temperature

and air drafts

Perform Proper Handwashing and Put on 2 pairs of sterile gloves

NO routine episotomy, fundal pressure

Your 5 Moments of Hand Hygiene

1. Before Patient Contact

• Clean hands before approaching and touching a patient

2. Before a Clean / Aseptic Task

• Clean hands immediately before any clean / aseptic task

3. After bodily fluid exposure risk

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

4. After patient contact

• Clean hands after touching a patient and immediate surroundings

5. After contact with the patient’s surroundings

•

• Clean hands after touching a patient’s objects even if the patient wasn’t touched

WHY? TO PROTECT THE PATIENT AGAINST GERMS CARRIED ON YOUR HANDSWHEN? Ex. Shake hands, clinical examination

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

WHY? TO PROTECT THE ENVIRONMENT AND YOURSELF FROM THE PATIENT’S GERMS.WHEN? Ex. draining a catheter, internal exam, changing a soiled diaper

WHY? TO PROTECT THE ENVIRONMENT AND YOURSELF FROM THE PATIENT’S GERMS.WHEN? Ex. Shake hands, clinical examination

WHY? TO PROTECT THE ENVIRONMENT AND YOURSELF FROM THE PATIENT’S GERMS.WHEN? Ex. Fixing the patient’s bed, regulating the IV fluid rate

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

First 30 secs

1 minute to 3 minutes

15-90 minutes

> 6 hours

Mother

Support the perineum with controlled delivery of the head

Give Oxytocin IM

After excluding a 2nd baby

Do controlled traction of cord with counter-traction

Massage the uterus gently

Examine the placenta

Baby

Dry, check breathing

Feel for cord pulsation , Clamp, cut cord

Return baby to prone position

Do PE, weigh, measure, eye care, inject Vit K, Hep B, BCG

Support FIRST FULL BREASTFEED. Monitor as a DYAD q15 minutes

Put in skin-to-skin contact

Transport to room TOGETHER

Optional: BathingBREASTFEEDING SUPPORT

Call out time of birth and sex

Continue uterine massage; Monitor every 15 minutes

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.htm

• http://www.wpro.who.int/philippines/PubDocs.htm

EINC Implementation1. 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 Implementation2. 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 staffinvolved in maternal and newborn care services

• DR/OR, NICU, OB and Pedia Wards, ER staff• Institutional/ utility workers

EINC Implementation4. 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 Implementation5. 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 Implementation7. Enable the environment for EINC

• Provide ample space in the labor room –for companion, for mother’s 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

33

VIIEquipment

And SuppliesMaintenance

Checklist

IIICare Prior

To Dischargebut after the first

90 minutes

VAdditional

Care

VIEnabling

The Environment

IVCare afterDischargeTo 7 days

IIEssential

Newborn CareFrom 90 min to 6 hours

IIIImmediate

Newborn Care(The First 90 minutes)

II

IIIIV

V VI

VII

IImmediate

Newborn Care(The First 90 minutes)

IIEssential Newborn

From 90 min to 6 hours

I III

IIICare Prior

To Dischargebut after the first

90 minutes

III

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

•Discharge Instructions

IVCare afterDischargeTo 7 days

IV

•Breastfeeding•Warmth of the Baby•Danger Signs“Very severe disease”

VAdditional

Care

V

A. Newborn ResuscitationB. 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

VIEnabling

The Environment

VI

•Preparing for the shifts – workplace•After every delivery – restock•Standard precautions – general standard precautions and cleanlinessHand hygieneProcessing Instruments & Other Items:Step 1: DecontaminationStep 2: CleaningStep 3: High-Level Disinfection by

Boiling or SteamingSterilization by Steaming

(Autoclave)Step 4: Store or Use

VIIEquipment

And SuppliesMaintenance

Checklist

VII

•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

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

and Unang Yakap flyer

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