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.