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.

Care Prior to Discharge

Q: Should alcohol be applied to the umbilical cord stump?

A: No. It is not advisable to use alcohol on the cord because studies have shown that it doesn’t have as much of a protective effect against infections over simply allowing an umbilical cord to dry on its own (dry cord care). Compared with the use of antiseptics, dry cord care also leads to earlier separation of the cord after birth, as seen in separate studies by Vural (dry care vs. human milk and povidone-iodine) and Dore (dry care vs. alcohol), and a Cochrane review by Zupan updated in 2004.  With dry cord care, however, the cord  should still be washed with soap and water when it becomes soiled, wiped with a dry cotton swab, and then allowed to air-dry. 

Q: Won’t dry cord care increase the chances of umbilical cord infection?

A:  A Cochrane review by Zupan updated in 2004, which included twenty-one studies with 8959 participants assessed the effects of topical cord care in preventing cord infection, illness and death.  There was no difference demonstrated between cords treated with antiseptics compared with dry cord care or placebo. There was a trend to reduced colonization with antibiotics compared to topical antiseptics and no treatment.  The use of antiseptics, however, reduced maternal concern about the cord. To date, there is limited research which has not shown an advantage of antibiotics or antiseptics over simply keeping the cord clean.  In all the 11 hospitals involved in the EINC scale-up project, there was no increase in the incidence of omphalitis observed with dry cord care.

Intravenous Fluid Infusion for Women in Labor

Intravenous (IV) therapy has been used routinely to hydrate women who were restricted from eating and drinking and to provide quick access in case of an emergency. However, researchers including Goer in 2007 have questioned the need for IVs in all women in labor since life-threatening emergencies are very rare in low-risk women[RA1] . One study evaluated the probable risk of maternal aspiration mortality to be in the extremely low range of  approximately 7 in 10 million births.   Starting IVF routinely confers several disadvantages because having  an IV line in place is painful and stressful, and disrupts the natural birthing process by hindering the woman’s freedom of movement in labor. There are also potential adverse effects of infusing glucose solutions to the mother will due to interference with glucose and insulin levels in both the mother and baby.  Excessive insulin production in the fetus occurs when women receive more than 25 g of glucose intravenously during labor. This can result in neonatal hypoglycemia and increase serum lactate levels which effectively lower the umbilical arterial blood pH.  Excessive use of dextrose-only salt-free IV solutions can also cause a fall in serum osmolality and result in hyponatremia in both the mother and the fetus.  Thus, the use of IV glucose and fluids to prevent or combat ketosis and dehydration in the mother may have serious unwanted effects on both mother and baby.  Regardless of solution type, intravenous therapy does not ensure a nutrient and fluid balance for the demands of labor and predisposes women to immobilization, stress, increased risk of fluid overload. . Other reported adverse effects include headache, nausea, slowing of labor and difficulty in establishment of breastfeeding. It is not likely to be beneficial, and no studies have demonstrated that routinely placing an IV in low-risk laboring women prevents poor outcomes (Enkin et al., 2000; Goer et al., 2007).  For the normal, low risk birth in any setting, there is no need for restriction of food, except in situations where intervention is anticipated. 

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Additional references:
1. Helsley L, McDonald JV, Stewart VT, Addressing in-hospital "falls" of newborn infants. Jt Comm J Qual Patient Saf. 2010 Jul;36(7):327-3

2. Monson SA, Henry E, Lambert DK, Schmutz N, Christensen RD, In-hospital falls of newborn infants: data from a multihospital health care system. Pediatr. Vol. 122 No. 2 August 1, 2008, pp. e 277 –e 280.

3. Annual Statistics, East Avenue Medical Center, 2008-2010. Unpublished data.

4. Dageville C, Pignol J, De Smet S, Very early neonatal apparent life-threatening events and sudden unexpected deaths: incidence and risk factors. Acta Paediatr. 2008 Jul; 97(7):866-9. Epub 2008 May 14.

5. Poets A, Steinfeldt R, Poets CF, Sudden deaths and severe apparent life-threatening events in term infants within 24 hours of birth. Pediatrics. 2011 Apr;127(4):e869-73. Epub 2011 Mar 28.

6. Shapiro-Mendoza CK, Kimball M, Tomashek KM, Anderson RN, Blanding S, US infant mortality trends attributable to accidental suffocation and strangulation in bed from 1984 through 2004: are rates increasing? Pediatr. Vol. 123, No. 2, February 2009: 533-539.

7. Vural G, Kisa S, Umbilical cord care: a pilot study comparing topical human milk, povidone-iodine, and dry care. J Obstet Gynecol Neonatal Nurs. 2006 Jan-Feb; 35(1):123-8.

8. Dore S, Buchan D, Coulas S, Hamber L, Stewart M, Cowan D, Jamieson L, Alcohol versus natural drying for newborn cord care. J Obstet Gynecol Neonatal Nurs. 1998 Nov-Dec; 27(6):621-7.

9. Zupan J, Garner P. Omari AA, Topical umbilical cord care at birth. Cochrane Database Syst Rev. 2004; (3):CD001057.

10. Lothian JA, Amis D, Crenshaw J, Care Practice #4: No Routine Interventions. J Perinat Educ. 2007 Summer; 16(3): 29–34. doi: 10.1624/105812407X217129.

11. Enkin M, Keirse M, Neilson J, Crowther C, Duley L, Hodnett E, A guide to effective care in pregnancy and childbirth. 2000 et al. New York: Oxford University Press, pp. 261-2.

12. Goer H, Leslie M. S, Romano A. The Coalition for Improving Maternity Services: Evidence basis for the ten steps of mother-friendly care. Step 6: Does not routinely employ practices, procedures unsupported by scientific evidence. J Perinat Educ. 2007;16 (Suppl. 1):32S–64S.

13. Sleutel M, Golden S, Fasting in labor: relic or requirement. J Obstet Gynecol Neonatal Nurs. 1999; 28: 507-512,.