EINC Recommended Practices in Intrapartum Care: Hand Hygiene, Partograph Use and Active Management of the Third Stage of Labor (AMTSL)

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. Despite substantial evidence that it reduces the incidence of infections, adherence to hand hygiene by health-care workers’ remains low at an average of 40 %.  Contributing factors are dryness and irritation caused by handwashing agents, inconveniently located sinks, lack of soap and paper towels, lack of time, understaffing and overcrowding, and the patient needs taking priority.  Thus, easy, timely access to both hand hygiene and skin protection is necessary for satisfactory hand hygiene behavior. Alcohol-based hand rubs may be better than traditional handwashing as they require less time, act faster, are less irritating and contribute to sustained improvement in compliance associated with decreased infection rates.  All institutions should prioritize improving hand hygiene by providing appropriate administrative support and financial resources to this end. Strategies that are both multimodal and multidisciplinary should be utilized to improve compliance.

Sources: Pittet D. Improving Adherence to hand Hygiene Practice: A Multidisciplinary Approach. Emerging Infectious Diseases, Vol. 7 No. 2, March-April 2001, pp.240. Guideline for Hand Hygiene in Health Care Settings. MMWR 2002; vol. 51 no. RR16: 1-44.

Frequently Asked Questions regarding Essential Intrapartum and Newborn Care

We’ve compiled some of your most frequently-asked questions and provided answers based on expert observations and evidence-based practices to help you in your EINC –Unang Yakap Advocacy.

Non-separation of newborn from mother for breastfeeding initiation

Q: Won’t the baby have an increased risk of falling when he is left alone with the mother who is still fatigued or sleepy after the delivery?

A: Falls may occur most especially in the period following delivery but what needs to be emphasized is that we should institute measures aimed at eliminating or monitoring the most common circumstances under which these falls occur.  In multicenter studies done in the United States, the incidence of in-hospital neonatal falls was estimated at 1.6-4.14/10,000 live births.  After studying the circumstances surrounding the incidents, preliminary recommendations made by a committee to reduce newborn falls included monitoring mothers more closely, improving equipment safety (such as reducing gaps between hospital bed railings, or between the mattress and the guard rails; integrating the bassinet into the design of the maternal bed so that it can be attached alongside it) and increasing awareness about newborn falls. Data from the East Avenue Medical Center from 2008 to 2010, a period before EINC Program implementation, showed  that the local incidence of falls ranged from 4.9-11.7/10,000 live births. The most frequent circumstance of an infant falling on the floor occurred when a mother, seated on a chair, falls asleep while breastfeeding her infant. In response to this finding, EAMC’s EINC Working Group designed a sling or salumbata so that the risk of falling will be significantly reduced and reorganized their staff for mother-infant dyad monitoring and education . Other project sites in the EINC scale-up project have innovated with their own sling designs for this purpose. Across the 11 Scale-up EINC Project sites, the incidence of falls has not increased.

Q: Does being in skin-to-skin contact with the mother put the baby at risk for suffocation ?

A:  There is no evidence that skin to skin contact alone puts a newborn at risk of sudden deterioration due to possible suffocation. A neonatal apparent life-threatening event (ALTE) or sudden unexpected death during the first 2 hours of life is rare.  A 2008 study by Dageville done in Provence, France  on 62,968 presumably healthy term neonates showed an overall rate of neonatal apparent life-threatening events and unexpected deaths of 0.032 per 1000 live births. A similar study by Poets done in Germany in 2010 on unexpected sudden infant deaths (SID) and severe apparent life-threatening events (S-ALTE) that occurred within 24 hours of birth yielded an incidence of 0.026 in 1000 live births. Another sub-group of sudden, unexpected infant deaths is caused by accidental suffocation and strangulation in bed (ASSB) which is a leading category of injury-related infant deaths. Events seem often related to a potentially asphyxiating position while the parents may be too fatigued or otherwise are not able to assess their infant's condition correctly, consistent with the potential risk factors for ALTE identified in the Dageville study, namely skin-to-skin contact, a first-time mother and mother and baby alone in the delivery room. With the introduction of EINC as a new protocol, it is very easy to fall into the trap of blaming the program for any untoward incidents that occur while it is being introduced.  Since we know that close interactions between the mother and baby during the immediate postpartum period is beneficial, these events should not lead us to reconsider skin-to-skin contact but instead make us focus on prevention efforts that include more vigilant monitoring of a skin-to-skin infant left alone with its mother during these hours, and helping parents and caregivers provide safer sleep environments.

Kuwentong Unang Yakap: Ella & Mika’s Miracle

Kuwentong Unang Yakap chronicles the first-hand experiences, inspiring testimonial and personal anecdotes of doctors, health professionals, patients and other healthcare providers narrating their “Unang Yakap” stories. 

by: Dr. Pinky Imperial [1]

My family and I came back in May 2010, and we had barely settled down when I began to have hyperacidity, nausea and eventually vomiting, which in my experience signified only one thing – that I was pregnant again!  After 3 sons, my husband and I were not really planning on adding to the family, but the 2 pregnancy tests that I took proved my suspicions to be all too true.  I knew that I was already a high-risk patient since I was now an elderly multigravid. Not wanting to leave anything to chance, I immediately consulted a perinatologist in the hospital nearest our home.  In the week following our return, the ultrasound done showed that I was pregnant with twins!  And thus began the steady uphill climb that would characterize the course of my pregnancy.           

I usually had excessive vomiting bouts during the first trimester of all my pregnancies, but this time around, the very high hCG levels in a twin pregnancy amplified my vomiting even more.  When I reached my fifth month and the vomiting had just started to abate, I had my second ultrasound which showed that we were expecting girls.  My husband and I were ecstatic at the thought of having girls this time around, but the joy dimmed considerably when my doctor told me that there was a “double bubble” sign in the first twin, accompanied by polyhydramnios, which were both signs that she had some form of gastrointestinal obstruction.  I knew that her condition could only be remedied by surgery, and I started to become fearful of the possible outcome when the twins were delivered. Another few weeks went by and my blood pressure, which hovered in the higher limits of normal, became persistently elevated and I had to be maintained on anti-hypertensive medications. By the sixth month, I had already developed edema in my legs, which was quite early compared to my previous pregnancies. Laboratory tests done also showed mild hypothyroidism.  Subsequent ultrasound tests showed persistence of the double bubble sign, progression of the polyhydramnios and beginning discordance in the weights of the twins. My perinatologist maintained a calm demeanor but by this time she was asking me to return more frequently for check-ups and by my 32^nd week she already advised me to have a course of betamethasone injected in the event that a combination of all the existing conditions would trigger premature labor.  It slowly began to sink in that the babies would, in all probability, be born early, so I informed my doctor that I had planned for EINC to be done when I gave birth.  It was still the pre-EINC period in the hospital and she acknowledged my request but replied that it would really depend on the twins’ condition upon delivery. 

A few days after I had my betamethasone injections, I came in for check-up and while my non-stress test showed that at 33 weeks age of gestation the babies were fine, I had to be confined for blood pressure control.  Soon I was being treated for pre-eclampsia, and after 3 more days my OB made the decision to do emergency cesarean section due to non-reassuring  fetal heart rate patterns.  Having previously delivered all my sons by NSD, I was terrified at the thought of undergoing surgery this time around, and I was crying as they wheeled me into the operating room. My anesthesiologist gently reminded me that crying would hinder my breathing and advised me to calm down.  I composed myself and asked her not to sedate me because I wanted to be awake when the girls were delivered and placed on skin-to-skin contact with me. When my OB came in, I again asked her if we could do properly timed cord clamping and she assured me that she would discuss this with the neonatologists attending the delivery.  She started the procedure, and a little while later the first twin came out, and after drying and cord clamping, she was placed on my chest.  I knew she was the one with the problem but was relieved to see that she looked stable and was comfortable.  Then soon enough the second twin came out and she joined her sister on my chest.  After a short while my OB gently asked me if the twins could be taken to the NICU already and I nodded, knowing that they had to be worked up and referred ASAP.  They were 35 weeks by pediatric aging, and weighed 1.49 kg and 1.62 kg.  Neither of them had any breathing difficulty.

Mika and Ella together again

After spending some time in the Recovery Room, I was finally wheeled back into my room.  It was a good thing that the NICU nurse started to bring Ella, the second twin, to my room to breastfeed, and I would do this every 3 hours or when the baby would demand to be fed.  After the first 24 hours, they could no longer bring her to the room as a matter of hospital policy, and I had to go to the NICU for the breastfeeding.  So despite still having an IV line and a urinary catheter I continued to go to the NICU regularly for feeding.  It was the following evening that the pediatric surgeon finally made rounds on Mika, the first twin. The x-ray done showed massive pneumoperitoneum, certainly one of the worst ones I have ever seen in all my years of practice.  I instantly knew the risks my baby faced, and I burst into tears as the surgeon explained to my husband and my siblings that immediate surgery was indicated. We requested for a priest to come and the baby was baptized prior to the contemplated procedure. Mika was stable and did not look distressed, which was totally incompatible with the ominous x-ray picture.  She was prepared for surgery, and our family and dear friends started storming the heavens for a miracle.

NEWS | Cotabato embraces Unang-Yakap

The Cotabato Regional and Medical Center (CRMC) completed a successful and festive EINC launch last August 18, 2011. It was attended by Mayor Japal Guiani, SOCCSKSARGEN CHD Director Dumama and ARMM DOH Secretary Dr. Sinolinding’s representatives, Medical Director Dr. Yambao, Dr.  Mansilla, Dr. Macalawan together with CRMC’s nursing staff. The walls of their dedicated EINC corner have been permanently painted with Unang Yakap colors. The Unang Yakap logo was made ubiquitous by rendering onto labels that were stuck to water bottles, hand disinfectant containers, tissue holder, ballpens, and Unang Yakap kits. To cap it off, cupcakes with the UY logo were served together with scrumptious food.  The highlight of the event was Mayor Guiani’s speech, in which he committed to issue an Executive Order implementing EINC in the barangays.

Meanwhile CRMC continues to make inspiring progress in the implementation of EINC, maintaining >95% performance of the four core steps of EINC in all deliveries as of the month of July. In addition to this, 98% of patients have already been delivering in a semi-upright position and 100% use of antenatal steroids for eligible patients is being observed. Equally impressive are the percentage of patients allowed to eat/drink and have companions of choice, from 40% in June to 95.8%. Likewise, not a single case of fundal pressure was reported for a month since a department policy has been issued to that effect.

Improvements in Pediatric practices have also been reported with the performance of EINC steps even in tachypneic but vigorous newborns as properly timed cord clamping is now being observed prior to separation for additional respiratory support. Commendable too are the breastfeeding advocacy strategies done by the team at the Outpatient Department and wards.  As result of the nursing staff ‘s effort to continue developing plans on improving sterility, asepsis and handwashing practices in critical areas of the hospital, steady decrease of sepsis rates have been observed with only 1 reported preterm death due to sepsis. Total mortality rate is very low at 2.9% and the ultimate low sepsis rate at 0.7% was achieved for the month of July.

And still, some challenges remain—such as pushing for more discriminating criteria for NICU admission as there are still cases of newborn being admitted just for “observation” without any true medical indication; improvements in timely referral system as well as increasing access to antenatal and prenatal care in CRMC’s catchment areas; and lastly intervention in the high cases of post-partum hemorrhage due to inappropriate use of methergine.

All, in all, CRMC is on its way to improving maternal and infant healthcare with the committed work it has put into making EINC the new standard of care. What with Mrs.  Nimia Juanday’s very comprehensive MNCHN EINC HPC Action Plan, activities to further strengthen EINC and MBFHI protocols have been set all the way to January 2012.

NEWS | ADPCN, APSOM to integrate EINC in nursing and midwifery curricula

Academic institutions and midwives may have already shared EINC with their students in the form of seminars and conventions, but both the Association of Deans of Philippine Colleges of Nursing (ADPCN) and Association of Phillipine Schools Of Midwifery (APSOM) are truly embracing the Unang Yakap spirit: Both academic umbrella organizations are preparing for its systematic integration in the pre-service curricula through a series of workshops to be supported by the UNICEF component of the Joint Program on Maternal and Neonatal Health (JPMNH). This crucial component of the strategy to institutionalize EINC will ensure the transfer of knowledge so that future health professionals in government and private health facilities consistently perform the evidence-based steps and avoid the harmful practices in maternal and neonatal care. 

 Commitment of APSOM and APDCN to integrate EINC in nursing and midwife curriculum cements the goal of such precedent efforts such as the implementation of DOH Administrative Orders 2008-0029 and 2009-0025

APSOM and ADPCN plan to convene department and curriculum chairpersons in all their member-schools and –colleges to stage the plan nationwide. Implementation will be overseen by DOH, UNICEF, UNFPA, and WHO. The Technical Panels on Nursing and Midwifery Education of the Commission on Higher Education are also expected to be involved, as well as representatives from the Association of Nursing Service Administrators of the Philippines (ANSAP), Maternal and Child Nurses Association of the Philippines (MCNAP), Critical Care Nurses Association of the Philippines (CCNAP), and the Operating Room Nurses Association of the Philippines (ORNAP).

Their commitment cements the goal of such precedent efforts such as the implementation of DOH Administrative Orders 2008-0029 and 2009-0025 which have to do with the transfer of knowledge on maternal and neonatal care to help curb both maternal and newborn mortality.  Optimism should not be conflated with ease, however. While green lights seem to be flashing everywhere for the integration of EINC into the curriculum, integration is not without its challenges.  The mismatch between actual environment and classroom theory is projected to be a hurdle they will need to leap over. Hospital policy reforms, for example, in line with the Mother-Baby-Friendly Hospital Initiative, Milk Code compliance, inclusion in regulatory and licensing requirements, and the scale-up of EINC implementation itself should all be happening simultaneously for optimum results. To compromise any of those is to compromise the whole of maternal and neonatal care. These projected problems do not seem to dampen their spirits, however, as the enthusiasm of the APSOM and ADPCN officers only seems to grow—they have even shown interest in followup activities they could bring to their respective nursing/midwifery chapters or base hospitals—with no indication whatsoever of waning.

NEWS Feature | Essential Intrapartum and Newborn Care in San Juan, Batangas

by Romelyn April P. Imperio, Straight Intern in Family and Community Medicine, UP-PGH 

Dr. Beverly Lorraine C. Ho, Project Staff, Team EINC

Through the auspices of the UP CDHP-San Juan Partnership and assistance of UP College of Medicine together with San Juan’s Municipal Health Office, EINC Training was held in San Juan, Batangas on February 18, 2011. The EINC Training was organized to broker the necessary path and support for the municipality’s rural health units, its staff and midwives to improve maternal and newborn health in the area.

Dr. Nestor Alidio, Municipal Health Officer of San Juan and Nurse Len Comia set up the logistics of the training invited all midwives working in the barangays. Meanwhile, DFCM Straight Intern Romelyn Imperio then communicated the training request to University of the Philippines College of Medicine alumni Dr. Beverly Lorraine Ho and project staff of Team EINC.

FEATURE | General Santos City Hospital

The well-paved roads of General Santos City hint at its steady progress toward development. The city’s slogan, Magandang Gensan, strategically hoisted throughout various spots in the city and government buildings stand both as a constant reminder of the city’s collective desire for a good quality of life and testaments of the paths it has taken to get there. “The people of Gensan are very competitive but in a manner that is laid-back. It’s a paradox but perhaps this is why General Santos is a little bit more open to new practices,” Mayor Darlene Magnolia R. Antonino-Custodio. 

This openness to change has been key to inroads made by EINC in the city of General Santos. Also worth mentioning is the local government’s commitment to Millenium Development Goals to reduce maternal and infant mortality by the year 2015 that has made EINC the new standard of care for mothers and their newborns in the city and nearby areas. Such that some mothers giving birth even at the lying-in centers proudly remark, “na-Unang Yakap ako.” After only four months since EINC training was held in General Santos City, the infant mortality rate at the General Santos City Hospital has already dropped to 0.96% as of July. 

Upon training, the General Santos City Hospital (GSCH) immediately embraced the program. While it had to contend with the usual challenges of convincing the hospital’s private consultants, its staff and the whole hospital is eventually learning to imbibe a sense of ownership and pride in the program. Determined to set a precedent for the region, GSCH is working hard to maintain its >90% performance of complete EINC core steps in all of their deliveries. By end of July, 90.79% of all deliveries have been performed with complete EINC. 

The GSCH opened its doors in 1975 and became LGU-operated since 1991. A Level II hospital with tertiary functions, GSCH has a 100-bed authorized capacity but has 261 implementing beds. It caters to approximately 261 in-patients and 100 outpatients daily. Newborn deliveries comprise 22% of the total admissions in 2010. Being the only government hospital within “SoCCSKSaRGeN” (South Cotabato, Cotabato, Sultan Kudarat, Sarangani and General Santos) area with better facilities, it also caters to patients from other neighboring municipalities such as Sarangani Province, South Cotabato, Sultan Kudarat and Davao del Sur. Likewise, it also serves as a training facility for six affiliated nursing schools and six midwifery schools across the region. 

EINC Don’ts and Do’s:

Unnecessary Intervention: 

Early Amniotomy and Oxytocin Augmentation

Dystocia or prolonged labor especially in the nulliparous woman usually results in the mother undergoing cesarean section. Early amniotomy with early oxytocin augmentation is commonly employed in these cases with the aim of preventing operative delivery. A systematic review was done by Wei et al in 2009 which included 12 trials involving 7792 women. The unstratified analysis found early intervention with amniotomy and oxytocin to be associated with a modest reduction in the risk of cesarean section; however the confidence interval crossed 1 - compatible with no effect (RR 0.89, 95% CI 0.79-1.01). Although only a small number of women have been randomized in therapy trials, a trend toward a reduction in the rate of cesarean section with early intervention was seen in this group (typical OR 0.6, 95% CI 0.2-1.4). They further identified that early augmentation does not appear to provide benefit over a more conservative form of management in the context of care of nulliparous women with mild delays in the progress of labor. In the context of established delay in labor, an active policy of augmentation may reduce the risk of cesarean section. However, only three small trials have been performed and they do not provide conclusive evidence for firm conclusions to be drawn. 

Source: Wei S, Wo BL, Xu H, Luo ZC, Roy C, Fraser WD. Early amniotomy and early oxytocin for prevention of, or therapy for, delay in first stage spontaneous labour compared with routine care. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD006794. DOI: 10.1002/14651858.CD006794.pub2

Recommended Practices: 

Pain Relief in Labor and Use of Antenatal Steriods 

Pain relief plays a crucial role during labor. Epidural anesthesia is widely used but there are concerns that it is accompanied by adverse effects on both the mother and infant. A systematic review by Anim – Somuah last updated in June 2010 looked at the effects of all modalities of epidural anesthesia (including combined spinal epidural) on the mother and the baby, compared with non-epidural or no pain relief during labor. 21 studies involving 6664 women found epidural anesthesia to be better for pain relief than non-epidural anesthesia (weighted mean difference (WMD) -2.60, 95% confidence interval (CI) -3.82 to -1.38), but was associated with an increased risk of instrumental vaginal birth (RR 1.38, 95% CI 1.24 to 1.53). There was no evidence of a significant difference in the risk of cesarean delivery (RR 1.07, 95% CI 0.93 to 1.23), long term backache (RR 1.00, 95% CI 0.89 to 1.12), low neonatal Apgar scores at 5 minutes (RR 0.70, 95% CI 0.44 to 1.10), and maternal satisfaction with pain relief (RR 1.18 95% CI 0.92 to 1.50). 

Source: Anim-Somuah M, Smyth RMD, Hoewll CJ. Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD000331. 

Use of Antenatal Steroids

Respiratory Distress Syndrome (RDS) is a serious and expensive complication among premature babies and the primary cause of early neonatal morbidity and disability. A systematic review by Roberts and Daziel done in 2006 included 21 studies involving 3885 women and 4269 infants. It was found that treatment with antenatal corticosteroids does not increase risk to the mother of death, chorioamnionitis or puerperal sepsis. 

Treatment with antenatal corticosteriods is associated with a 31% overall reduction in risk of neonatal death (RR 0.69, 95% CI 0.58 - 0.81) and a 34% reduction risk of dreaded RDS (RR 0.66, 95% CI 0.59 - 0.73). The risks of cerebroventricular hemorrhage (RR 0.54, 95% CI 0.43 - 0.69), necrotising enterocolitis (RR 0.46, 95% CI 0.29 - 0.74) and systemic in the first 48 hours of life (RR 0.56, 95% CI 0.38 to 0.85). were approximately halved. Requirement for respiratory support and intensive care admissions were likewise significantly reduced (RR 0.80, 95% CI 0.65 - 0.99). Because of these strong evidence of benefit, antenatal corticosteroid use is indicated in women with premature rupture of membranes and pregnancy related hypertension syndromes. This study 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. 

Source: Roberts D, Dalziel SR. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004454  

Continuous Support During Childbirth

In today’s hospital setting, continuous support of women during labor has become the exception rather than the rule. In a 2007 systematic review by Hodnett et.al of 21 trials involving 15061 women, the effects of continuous one-to-one intrapartum support was compared with usual care wherein women are subjected to institutional routines which may have adverse effects on the progress of labor. Women who received continuous support were more likely to have a spontaneous vaginal birth (RR 1.08, 95% CI 1.04 to 1.12) and were more satisfied (RR 0.69, 95% CI 0.59 to 0.79), and were less likely to have intrapartum analgesia (RR 0.90, 95% CI 0.84 to 0.97). In addition the duration of labor was shorter (mean difference -0.58 hours, 95% CI -0.86 to -0.30). The likelihood of delivery via cesarean section (RR 0.79, 95% CI 0.67 to 0.92) or instrumental vaginal birth (RR 0.90, 95% CI 0.84 to 0.96), use of regional analgesia (RR 0.93, 95% CI 0.88 to 0.99), or delivering a baby with a low 5-minute Apgar score (RR 0.70, 95% CI 0.50 to 0.96) were all significantly reduced. There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, or on breastfeeding. Subgroup analyses suggested that continuous support was most effective when provided by a woman who was neither part of the hospital staff nor the woman’s social network, and in settings in which epidural analgesia was not routinely available. Thus, continuous support during labor clearly has clinically meaningful benefits for women and infants and no known harm. 

Source: Hodnett ED, et al. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD003766.

BREASTFEEDING TSEK!

A public health education campaingn of the Department of Health (DOH) carrying the message BREASTFEEDINF TSEK! (Tama, Sapat at Eksklusibo) is a public health education campaign of DOH to encourage mothers to 'exclusively breastfeed' their babies and to educate them about the health benefits of breastfeeding. 

‘Exclusive breastfeeding’ means that mothers feed the baby nothing else but breast milk—no water, other liquid, infant formula, or food.

Called “Communication for Behavioral Impact (COMBI) on Exclusive Breastfeeding for six (6) months,” this comprehensive campaign was developed by DOH with the National Nutrition Council, the World Health Organization, the UNICEF, and other partner agencies. Breastfeeding from the first hour of life and exclusively until six months is one of the most effective strategies to prevent infant deaths. 

EINC Do’s and Don’ts:

Unnecessary Intervention: Giving Pre-lacteals or Artificial Milk Substitutes

It is a common practice in Philippine hospitals to give pre-lacteals like glucose water as a trial of feeding to newborns, or to give artificial milk substitutes to babies while the mother’s milk flow is not yet established.  This delays the mother’s breastmilk letdown, and the ease of feeding from the bottle decreases the newborn’s 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. This practice also exposes the newborn to different types of infectious agents and challenges an already weak premature or immature gastrointestinal system.  These were clearly evident in a study by Rashid done in rural Bangladesh, where 94.7 % of newborns were fed either honey, animal milk and sugar (non-exclusively).  In these newborns, the overall mean time of initiating breastfeeding was 35.9 hours (SD ± 28.4). Pre-lacteal feeding delayed breastfeeding by 32.1 hours (p<0.0001), and more newborns fed honey (17.2%) experienced episodes of diarrhea in the first 3 months compared to those who were not fed pre-lacteals (13.77%) (RR 1.25, p<0.01).  Giving artificial milk substitutes is a practice that has serious consequences on the baby’s health and wellbeing. 

Recommended Practice: Initiation of Breastfeeding

The benefits of breastfeeding for the health and wellbeing of 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.

A recent trial by Edmond has shown that early initiation of breastfeeding could reduce neonatal mortality by 22%.  In developing countries, early initiation of breastfeeding can reduce deaths due mainly to diarrhea and lower respiratory tract infections in children. 

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 policies and rooming in practices were implemented, exclusive breastfeeding increased and deaths among clinically infected newborns dropped by 95.3%.  In another prospective cohort study by Yoon et al, 9942 children in Cebu were followed using longitudinal data from 1988-1991. In the first six months of life, failing to initiate breastfeeding (or ceasing to breastfeed) resulted in an 8-10 fold increase in the rate of diarrheal death.

In the 51-hospital observational study, newborns were washed at a median of 8 minutes, put to the breast at a median of 10 minutes of life but removed at 12 minutes.  Thus only 2 minutes were allowed for their first colostrum feed. 272 (56.5%) were transferred to a nursery. They were weighed at a median of 13 minutes, examined at 17 minutes, taken to the nursery at 20 minutes, given eye prophylaxis at 20 minutes and Hepatitis B and vitamin K injections, the first of which at 22 minutes. They were reunited with their mothers at a median of 2 hours 35 minutes. 47 (9.8%) initiated breastfeeding after 2 hours but prior to discharge.  From these studies, it is evident that institutional routines are depriving our newborns of the benefits of early breastfeeding. 

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 and lymphocytes that may stimulate humoral or cell-mediated immune systems), and it may also prime the gastrointestinal tract and decrease intestinal permeability and translocation of infectious pathogens, including HIV. 

Edmond et al conducted an observational cohort study of 10,942 breastfed singleton neonates (born between 1 Jul 2003 and 30 Jun 2004 in rural Ghana), who survived to day 2, and whose mothers were visited in the neonatal period.  Verbal autopsies were used to ascertain the cause of death in 130 neonates who died from day 2 to day 28. Ninety three died of infection and 47 of non-infectious causes.  The risk of death as a result of infection increased with increasing delay in initiation of breastfeeding from 1 hr to day 7; overall late initiation (after day 1) was associated with a 2.6-fold risk (adjusted OR 2.61 95% CI 1.68, 4.04).  Partial breastfeeding was associated with a 5.7-fold adjusted risk of death as a result of infectious disease (adj OR 5.73 95% CI 2.75, 11.91).  

Such is the impact of early initiation of breastfeeding and healthcare providers and policy makers need to prioritize this simple preventive strategy. Factors that will promote breastfeeding initiation include: implementation of the Baby Friendly Hospital Initiative 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 on skin-to-skin contact.

Sources:

Lauer JA et al, Deaths and years of life lost due to suboptimal breastfeeding among children in the developing world: a global ecological risk assessment. Public Health Nutrition 2006; 9: 673-685.

The state of the world’s breastfeeding: report card. Initiation of breastfeeding within one hour. New Delhi: International Baby Food Action Network Asia. www.world breastfeedingtrends.org/reportcard/RC-IB.pdf/

Clavano N. Mode of feeding and its effect on infant mortality and morbidity. J Trop Pediatr. 1982;28 :287 –293.

Yoon PW, Black RE, Moulton LH, Becker S.  Effect of not breastfeeding on the risk of diarrheal and respiratory mortality un children under two years of age in Metro Cebu, the Philippines.  Am J Epidemiol.1996. 143:1142-1148.

Edmond KM, Kirkwood BR, Amenga-Etego S, Owusu-Agyei S, Hurt LS.  Effect of early infant feeding practices on infection-specific neonatal mortality: an investigation of the causal links with observational data from rural Ghana.  Am J Clin Nutr.  2007; 86:1126-31.

Brandtzaeg P. Mucosal immunity: integration between the mother and the breast fed infant. Vaccine 2003;21:3382–6.

Goldman AS. The immune system of human milk: antimicrobial, antiinflammatory and immunomodulating properties. Pediatr Infect Dis J 1993;12:664–71.

Goldman AS, Garza C, Nichols BL, Goldblum RM. Immunologic factors in human milk during the first year of lactation. J Pediatr 1982;100: 563–

Goldman AS. Modulation of the gastrointestinal tract of infants by human milk. Interfaces and interactions. An evolutionary perspective in symposium: bioactivity in milk and bacterial interactions in the developing immature intestine. J Nutr 2000;130(suppl);426S–31S.

Rollins NC, Filteau SM, Coutsoudis A, Tomkins AM. Feeding mode, intestinal permeability, and neopterin excretion: a longitudinal study in infants of HIV-infected South African women. J Acquir Immune Defic Syndr 2001;28:132–9.
Rashid M et al. Prelacteal feeding delays breastfeeding initiation in rural Bangladesh, ICDDR,B Periodical

Kuwentong Unang Yakap

Kuwentong Unang Yakap chronicles the first-hand experiences, inspiring testimonial and personal anecdotes of doctors, health professionals, patients and other healthcare providers narrating their “Unang Yakap” stories.  

by Dr. Donna Capili

Sept 13, 2010. It was almost half past one o'clock in the afternoon and my stomach grumbled its complaint. I just finished clinic and was set to see my in-patients, never mind my tummy. From a distance, I heard the siren.  I didn't think any of it.  I was on my way up to the patients' rooms on the second floor when the undeniable peal of the siren seemed very tangible...I retraced my steps downwards and saw that the ambulance was by the emergency room entrance.  What could it be now?

The ambulance driver was shouting that his patient, a pregnant woman, was about to deliver her baby.  He opened the back door and my eyes zeroed in on the crowning head. I yelled for sterile gloves, clamps and clean towels.  It seemed like magic that a pair of gloves appeared in my hand.  I told my resident doctor on duty (ROD) to put on his own pair of sterile gloves. Next thing I knew, I was doing perineal support -- my right thumb and index finger formed a C-shape, pressed inward and down – picturing Dra. Cynthia's demo in my head...I didn't do any of the massage nonsense.  It was quite quick.  Lucky me! I held out my hand to hold the baby's head down as he made his entry into the world. Baby out! I slipped him into the towel and put him on mom's tummy.  The ROD started to dry and stimulate the baby. The baby then let out a scandalous cry and I knew he was going to be alright. The baby was positioned further up on mom's chest. Meanwhile, I felt for her uterus and started to massage -- no complicated digging movements but just nice and simple circular motions. A voice quipped that ice was on its way, to which I quickly added, "No ice. Don't need it." (Dr. Howard Sobel would have been so proud.)

What was the next step? Number 3: cut the cord. It was a good 3-4 minutes when that was done. Uh-oh, I hope he doesn't get too jaundiced. Now, where was I? Hmm, exclude second baby… It didn't seem like there was anyone else in there.  I asked the mom if she was just expecting a singleton to which she replied “Yes.”  Ok, so no second baby. Confidently I ordered to give her oxytocin 10 via IM please.  (Thanks to our recent meetings, I appeared to know what I was doing)

I rolled the cord unto my clamp and applied traction and counter-traction steadily.  At first, it felt like I was going to tear the placenta out of there but it didn't!  I just needed to be patient. I examined the perineum and glad to see that there was no tear (vernacular: rat-rat)! I examined the placenta and its membranes and it was "clean", smooth. 

When I finally raised my head, I saw that the baby was latched and suckling away. Yipee! A smart boy for a change! Time: about 30 minutes post delivery. He stayed with his mother and avidly breastfed. I told mom that'll be the only way we feed her baby in this (my) hospital.

Oh, did I say, that all this happened at the back of the ambulance?

Mother and baby were brought down and into the hospital. The ROD was already instructing for IV fluids. He looked stupefied when I said, "No IV." and I added, "we'll talk about the CPG for uncomplicated vaginal births later."

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** Mother was actually en route to a provincial hospital after being asked to leave another LGU-run hospital, citing that the baby will be born preterm and they have no incubator. (certainly, they need to know about KMC).  Pediatric age was 36 weeks, birth weight 2450 grams. Both mother and baby are well and due home.**

Dr. Donna Capili completed her subspecialty training at the Hospital for Sick Children in Toronto, Canada.  She is a practicing Neonatologist in Bulacan and a Co-Convener of Team EINC.

Breastfeeding Checklist

by Dr. Francesca Tatad-To

This breastfeeding monitoring form was developed when I was in private practice and needed a way to keep track of my patients’ breastfeeding progress. I realized then that nurses would simply note on the chart that the baby was ‘breastfed’ but not how many times a feeding occurred, or whether there were any feeding problems.  Mothers were too tired to remember how many times they had breastfed in the last 24 hours, or how many times they had changed their baby’s diaper.

The mothers who did bother to write down the information were spending too much time recording too many details.  With the use of this graphic chart, mothers simply had to tick off the right image each time they breastfed, changed a wet diaper, and every time their baby passed stool.

When Team EINC realized that the monitoring of well babies is a challenge in our hospitals, mainly due to the lack of health workers and the large number of patients, we translated the form into Filipino and offered it to our various centers as a monitoring tool.  But this time, we added a column for danger signs, so that mothers themselves would be prompted to check their babies regularly for any signs that may indicate a severe illness or infection, and call the attention of their health worker.

The monitoring form was first used at the Jose Fabella Memorial Hospital’s Potentially-Septic Ward, where babies who are clinically well but have risk factors for sepsis are admitted together with their mothers.  Every mother admitted to the area is provided with a copy of the form and instructed in how to fill it up.  Initially there were concerns that the form would be too complicated for the mothers, or that it would take too much time to do, or that the forms would get lost.  As it turns out, the mothers find the form a very useful tool and have taken on the task of reminding each other to fill up their forms regularly.  Mothers are now more aware of how often they should be breastfeeding, and what signs to look for to know that breastfeeding is going well.  Monitoring mother-infant dyads has become an easier task for the nurses, and doctors going on rounds review the information in the form as part of their routine examination.  A big benefit of the tool is that infants who develop signs of illness are being referred earlier, and mothers are educated regarding the signs of severe illness in newborns, so that they can identify these even if they occur after discharge.  One pleasant surprise to the staff the mothers hold on to the forms and do not lose or misplace them.

How to properly use this form:

• Day 1 begins at the time of birth and ends 24 hours later, and so on.
• Instruct the mother to shade/check one breastfeeding image every time she breastfeeds, one wet diaper image every time her baby passes urine, and one soild diaper image every time her baby passes stool
• Heavy/darker images are mandatory - meaning a mother MUST breastfeed at least 8 times a day on day 2, for example. The lighter images are extras but within normal, meaning if a child has 8 soiled diapers istead of 2, this is still normal and should not be considered diarrhea.
• If a mother and baby are able to fulfill all the “MUST Dos” for each 24 hour period, it is likely that breastfeeding is going well. If however, one or more is insufficient, the health worker should address this by closer monitoring, properly observing a feeding, and identifying underlying problems.
• Also instruct the mother to go through the list of danger signs at least once a day (more often if possible) and to call the attention of a health worker immediately should any of the danger signs be present. 

Special Section: Ten Steps to Successful Breastfeeding

Every facility providing maternity services and care for newborn infants should:

1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within half an hour of birth.
5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.
6. Give newborn infants no food or drink other than breast milk, unless medically indicated.
7. Practice rooming-in – that is allow mothers and infants to remain together – 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Source: Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services, a joint WHO/UNICEF Statement published by the World health Organization.