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.

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.

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

EINC Don’ts & Do’s | Unnecessary Suctioning and Bathing & Properly Timed Cord Clamping

DON’Ts 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 baby’s 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.

EINC Don’ts & Do’s | Stop Newborn Footprinting and Keep Newborns Safe

Unnecessary Intervention:

Footprinting and Routine Separation

Footprinting of newborns is currently still a widespread practice in the Philippines as means of identification of newborns. In the first few minutes following delivery, the newborn’s feet are pressed into a common inkpad and later pressed onto an identification sheet.  Not only is this practice is usually done by untrained personnel with variable results, but more importantly also increases the risk of crosscontamination among the babies. In 1988, the American Academy of Pedicatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) stated that “individual hospitals may want to continue the practice of footprinting or fingerprinting, but universal use of this practice is no longer recommended.” In fact studies have demonstrated that the majority of infant footprints taken by hospital personnel prove inadequate for identification purposes, contending that DNA genotyping and human leukocyte antigen tests are better methods of identification. Moreover, the EINC practice of non-separation of newborn from the mother minimizes the risk of switching newborns.

Mostly importantly it has been proven that healthy newborns placed with their mother soon after birth transition more easilyto extrauterine life. They stay warm, cry less, are more likely to breastfeed and breastfeed sooner compared to babies separated from their mothers. Unnecessary separation of newborns from their mothers and the resultant postponement of latching on and rooming in and restrictions on breastfeeding seriously compromise colonization of the newborn with maternal skin flora, immunoprotection, milk production and eventual exclusive breastfeeding. Footprinting, should not interfere with the core steps that include skin-to-skin contact and non-separation of mother and baby from early initiation of breastfeeding.

Recommended Practice:

Skin-to-Skin Contact

Skin-to-skin contact (SSC) is generally perceived to be an intervention for the provision of warmth and bonding. But its contributions to immunoprotection of the newborn and to the protection against hypoglycemia are not widely known and less appreciated. Furthermore, evidence from several studies show that skin-to-skin contact between mother and birth reduces crying, improves mother-baby interaction, keeps the baby warmer, aids in stabilizing the baby and helps women breastfeed successfully.

Effects on Breastfeeding

A meta-analysis by Moore et all which included 30 randomized and quasi-randomized trials compared early SSC with usual hospital care involving 1925 mother-infant dyads. They reported statistically significant positive effects of early SSC on breastfeeding at 1-4 months post-birth (10 trials; 552 dyads; OR 1.82, 95% CI 1.08, 3.07), and breastfeeding duration (7 trials; 324 dyads; WMD 42.55, 95% CI -1.69, 86.79). Trends were found for improved summary scores for maternal attachment behavior (6 trials, 396 participants) (SMD 0.52%, 95% CI 0.072) and maternal affectionate love/touch during observed breastfeeding (4 trials; 314 dyads) (standardized mean difference (SMD) 0.52, 95% CI 0.07, 0.98) and with early SSC. SSC infants cried for a shorter length of time (one trial; 44 participants) (WMD -8.01, 95% CI -8.98, -7.04). Late preterm infants had better cardio respiratory stability with early SSC (one trial; 35 participants) (WMD 2.88, 95% CI 0.53, 5.23). No adverse effects were found.

Effects on the Infant’s Cardiorespiratory Stability

A study of Takahashi et al. compared the effects of different initiation and duration times of skin-to-skin contact on the stress port-birth in full-term infants. The first group began SSC 5 minutes or less after birth (birth SSC), while the second group began SSC after 5 minutes (ver early SSC). The birth of SSC group reached HR stability of 120-160 bpm significantly faster than very early SSC group by Kaplan-Meier analysis (p=0.001 by log-rank test). As for Spo(2) stability of 92% and 96%, no significantly between-group difference was found. Salivary cortisol levels were significantly lower between 60 and 120 minutes after birth in SSC group, continuing for more than 60 minutes compared with SSC group for 60 minutes or less after adjustment for salivary cortisol level at 1 minute besides infant stress factors (P=0.046). All these suggest that earlier SSC beginning within 5 minutes post birth and longer SSC continuing for more than 60 minutes within 120 minutes post birth are beneficial for stability of cardiopulmomary dynamics and the reduction of infant stress during the early period post birth.

Effect on Infant’s Body Temperature

In an early study, Christensson et al randomized 50 healthy, full-term, newborn infants to be kept either skin-to-skin with the mother (n=25 mother-baby pairs) or next to the mother in a cot “separated” (n=25 mother-baby pairs). The babies were studied during the first 90 minutes after birth. Axillary and skin temperatures were significantly higher in the skin-to-skin group. Babies kept in cots cried significantly more than those kept skin-to-skin with the mother.

Effect on Blood Sugar Levels

In the previously cited randomized controlled trial by Christensson et al., at 90 minutes after birth blood glucose levels were significantly higher and the return towards zero of the negative base-excess was more rapid in the skin-to-skin as compared to the “separated” group. The weighted difference WMC (fixed) was 11.07 95% CI [3.97. 18.17].

Effect on Immunoprotection

Close skin-to-skin contact between the maternal-infant dyad may also stimulate the mucosa-associated lymphoid tissue system.

a.  Moore E, Anderson G, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003519.

b.  Takahashi Y et al. Comparison of salivary cortisol, heart rate, and oxygen saturation between early skin-to-skin cointact with different initiation and duration times in healthy, full-term infants. Early Hum Dev, 2011 Mar, 87 (3):151-7.

c.  Christensson K, Siles C, Moreno L, Belaustequi A, De La Fuente P, Lagercrantz H, Puyol P, Winberg J. Temperature, metabolic adaptation and crying in healthy full-term newborns cared for skin-to-skin or in a cot. 1992. Acta Paediatr. 1992 Jun-Jul;81(6-7):488-93.

d.  Anderson GC, Moore E, Hepworth J, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev 2003;(2):CD003519.