One thing is for certain -- optimism never runs dry at the Dr. Jose Fabella Medical Hospital. Dubbed as one of the world’s busiest maternity hospital, seeing an average of 60-80 births a day, “Fabella” easily brings to mind images of crowded maternity wards, a cramped Neonatal Intensive Care Unit, delivering mothers coming and going like clockwork, and babies born one after another routinely depicted in local and international media channels. At one point, it has even been infamously tagged, albeit too conveniently, as “the baby-factory” owing to large portion of babies in Metro Manila being delivered there.
Its portrayal in the recent news has, to a certain extent, become the standard fare in representing the generally lamentable state of healthcare delivery and population development in the country. And yet despite this, Fabella unwaveringly maintains to be a competitive institution providing safe, quality and compassionate maternal and newborn care while promoting sound research and training practices in the field of women’s health. And while its crowded wards may somewhat tell a different story, this only proves how it has persistently weathered limited funds to provide quality service to mothers and newborns who otherwise could not afford it on their own. “We try our best to manage even though we have limited resources,” Assistant Chief Nurse Edna Solis candidly relates.
At Fabella, there is hardly any room for complacency. The hospital’s limited resources have never been an excuse to fall behind its mission. In fact, if any, it has only driven the medical and nursing staff to constantly be on their toes, innovatively “making do with what they have” while keeping the safety and welfare of their patients in mind.
Hence, it comes as no surprise that EINC has found its way to Fabella or that Fabella found its way to EINC. “EINC complements the many other programs that we have,” shares Dr. Cynthia Fernandez-Tan, head of the Training Department. Dr. Estrella Olonan, Coordinator of Fabella's Human Milk Bank, further adds, “EINC reinforces breastfeeding because skin-to-skin contact helps initiate breastfeeding as soon possible and we know that the soonest the baby is able to feed there is a higher chance that the mother will continue breastfeeding.” Nurse Teresa Rallos also shares, “some of the EINC practices we were already doing before, like skin-to-skin contact, non-separation, no foot printing, because we are a breastfeeding hospital.” Dr. Olonan adds how having lesser episiotomies with EINC translate to more mothers being in better position to breastfeed immediately right after giving birth.
“Fabella is a strong advocate of breastfeeding,” Dr. Fernandez-Tan proudly remarks, “pioneering programs that promote exclusive and continuous breastfeeding.” The Milk Bank, provides human breast milk to those in need as well as clients from private hospitals. Another innovation is the Dental Obturator Program, where babies with cleft palate are fitted with dental obturators to allow them to breastfeed. Likewise, the Kangaroo Mother Care, a biologically sound and cost efficient method in caring for preterm babies practiced worldwide, was pioneered and institutionalized at Fabella in 2000, setting a good example for other hospitals in country. Fabella is 700-bed capacity, DOH-retained hospital and Level IV tertiary medical center for obstetrics, gynecology, newborn care and pediatrics. It serves as a national referral facility for women’s and children’s needs, with the bulk of its patients coming in mainly from Manila, Quezon City, Caloocan and as far as Cavite. As lead institution for skills training in Basic Emergency Obstetric & Newborn Care (BEmONC) and training center for OB-GYN, Pediatrics and Neonatology with a School of Midwifery under its wing, implementing the EINC recommended practices was but a logical direction. “As a BEmONC training center we were already doing some of the EINC practices, the only difference was that they were not time-bound and sequenced,” Dr. Fernandez-Tan said. Unnecessary interventions such as administering enema, perineal shaving, applying fundal pressure foot printing and routine bathing, have long been done away with at the hospital. Properly timed cord clamping using a sterile plastic clamp and dry cord care were already being practiced. ID tags were placed on the baby’s ankle. Implementing EINC has enhanced their performance of the four core-steps in a properly sequenced and time bound manner. Before EINC training, immediate and thorough drying was performed less than 30 seconds after delivery in 92% of deliveries, with a median time of 7 seconds. Repeat assessment conducted by EINC project staff in May 2011, showed marked improvement in immediate & thorough drying which was performed less than 30 seconds after delivery in 100% of babies, with at median time of 2 seconds. Likewise, early skin-to-skin contact with the baby positioned prone on the mother’s chest or abdomen is already marked at mean time of 84 seconds with 100% of babies positioned at less than 5 minutes compared to pre-training time of 153 seconds and 95% at less than 5 minutes. Prior to training, 46% of babies were separated from their mothers for newborn procedures, which were done before their first breastfeed. After training, 70% of babies completed their first breastfeed before newborn procedures were performed.
Consequently, this has resulted to an improvement in breastfeeding support with 40% of babies delivered breastfeeding within an hour compared to only 4%, pre-training.
Other notable improvements in newborn care that were observed since the hospital has implemented EINC include elimination of unnecessary suctioning, revision of criteria for admission to the potentially septic unit, and the use of self monitoring tools for roomed-in newborns -- elimination of air draft in the delivery area, reduction in separation of mother from baby from 46% to 20%, revision of criteria for NICU admissions as well as 50% decreased in its admissions, and use of self-monitoring tools for roomed-in newborns-- have also been Likewise, good results have also been achieved in the OB practices , most impressive of which are delivery in non-supine position and active management of the third stage of labor. An increase in deliveries without episiotomy was also observed. Dr. Fernandez-Tan notes that implementing non-routine IVF remains a challenge as most of their patients have complications, saying that 60% of deliveries in Fabella are considered abnormal In response, recommendations for heplock among mothers at risk has been suggested. Less than 10% of mothers had no IVF , were allowed to eat and drink and assumed a non-supine position during labor. The present set-up of the LR-DR Complex does not allow mobility and a companion of choice during labor and delivery An underutilized area, the Pay Labor/Delivery Room, will soon be designated as a pilot area where the patient can move around, have a companion and assume position of choice during labor. While Fabella’s transition to EINC was not as drastic compared to other pilot sites, they still had to undergo a number of changes and adjustments. As the saying goes, ‘old habits die hard.’ Constant push and convincing had to done to ensure that the medical and nursing staff along with the consultants abide by the new protocol. Hospital memos, orientation and training of all hospital staff were done to ensure that complete implementation was achieved. “We saw to it that all attended. We had new residents who missed the sessions here at Fabella who went to Tondo Medical Center to attend the EINC trainings,” shares Dr. Fernandez-Tan. Nurse Rallos adds that “we include EINC in the orientation of our new residents, even nursing trainees, we orient them.” Students and volunteers from accredited schools were also required to attend the EINC training/orientation workshops
With regards non-routine episiotomy, Dr. Fernandez-Tan shares, “We had to demonstrate that it could be done, even in primigravids, and when the residents saw it can be done they all followed…now they’re happy because [actually] it’s less work for them.” Affiliate clinical clerks were previously required to perform 15 episiotomies during their 15-day rotation in Obstetrics. Now they are required 15 deliveries with perineal support and controlled delivery of the baby’s head. Another aspect that needs vigilance is handwashing. While a glow germ activity revealed that the staff practice new proper handwashing techniques, it wasn’t done as regularly as it should be. Opportunities for contamination, likely due to large patient load assigned to each health worker and lack of supplies, has been observed during the delivery assessment. To this effect more sinks , soap dispensers , and hand dryers were installed in the wards, delivery and labor room, in the NICU and other key areas in the hospital. Nurse Edna Solis suggested the ringing of a bell in the LR DR Complex periodically to remind everybody to wash their hands. Yet, one strength that Fabella prides itself is how despite its limited resources it has managed to custom-fit wooden wedges placed under the mattresses of their delivery beds so that mothers may deliver in semi-upright positions. Now all mothers are ensured that they will be able to deliver safely in the said position. Meanwhile further refinements in design and manufacture of the wooden wedges is currently being weighed and explored Overall, the implementation of EINC at Fabella has had positive results as indicated in the decrease in their term mortality with a reported 0.7% in June 2011 from 1.3% in December 2010. The same has been reported in term sepsis mortality going down to 4.9% in June 2011 from 20.7% in December 2010. Moreover, they’ve managed to reallocate “savings” in some supplies to address their other needs such as more supplies for gloves and disinfectants. While the challenge to lower mortality among those admitted in NICU remain, options for its temporary renovations and drafting a supplemental budget are currently being explored. “We are working on that…Dr Ruben Flores, Medical Center Chief mentioned that the NICU should be considered as a small hospital, because it’s really a critical unit. We are an end referral center, 30% of all livebirths are NICU admissions. Contractual nurses have been hired to augment the NICU nursing staff. Plans are underway to relocate the Potentially Septic Unit to a wider area in Ward 4. The Supplemental Budget for additional NICU supplies and equipment has been approved.
With such encouraging outcomes, combined with Fabella’s commendable tenacity in providing competitive and compassionate health care to mothers and newborn, the path towards achieving the country’s commitment to reduce infant and child mortality by 2015 is without doubt attainable. Their experience shows that even with such limited resources and challenging circumstances changes and improvements are always possible – it just takes a little bit more of creativity and lots of optimism.
by Donna Miranda & photos by Bernie Cervantes
I actually have taken up my medical office assistant training because I cannot do the work that doctors and nurses do like in this hospital. 60 to 80 births a day can really be a handful. Kudos to all the medical professionals in that hospital.
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