EBM Reviews | Enemas During Labor & Perineal Shaving

by Louell L. Sala, MD


What is Evidence Based Medicine?
In a world where information can be achieved with a click of a button and yet can be disorganized and unvalidated, Dr. David Sackett in 1996 introduced the concept of Evidence Based Medicine. Defined as a conscientious, explicit, judicious use of current best evidence in making decisions about the care of individual patient, Dr. Sackett described it as a means of integrating individual clinical expertise with the best available external clinical evidence from systematic research. It was created so that as physicians, we can be up to date with the latest modalities, whether diagnostic, treatment or clinical practice guidelines, but more importantly for better quality of care and utilization of resources. 

Dr. Jessamine Sareno giving our GenSan audience a crash course in evidence based medicine

In their book “Painless Evidence-Based Medicine”, Drs. Antonio Dans, Leonila Dans and Maria Asuncion Silvestre set forth this definition "EBM is a systematic approach to the acquisition, appraisal and application of research evidence to guide healthcare decisions." [1]

The EINC Bulletin will look at the respective studies behind the EINC practices, dissect them and provide a short assessment that are sound and evidence - based. But in the end we should always emphasize that you are still the attending physician. After all it is the triad of individual clinical expertise, best external evidence and patient values and expectations that forms the backbone of evidence based medicine.

Feature Story THE QUIRINO MEMORIAL MEDICAL CENTER EXPERIENCE Accepting the challenge of change

by Monica Feria

Barely one year after adopting the new Essential Newborn Care protocols, QMMC cut newborn deaths by half and achieved a 70% reduction in neonatal sepsis. Doing away with unnecessary procedures in the delivery room also saved the hospital a minimum of P3 million. 


The Quirino Memorial Medical Center (QMMC), formerly known as the “labor “ hospital in Quezon City, was among 51 government-run hospitals included in a comprehensive study on prevailing newborn care practices in the Philippines starting November, 2008. 

In hindsight, Dr. Belle Vitangcol, head of QMMC’s pediatrics department and lead ENC trainor, remembers this as the starting point of a whirlwind that in barely one year’s time would sweep away many traditional practices and attitudes in the delivery room, and usher in a radically different regimen on essential newborn care.

Even before researchers backed by he Department of Health and the World Health Organization began setting up monitoring stations at the hospital, Vitangcol and her medical colleagues knew something had to change. QMMC, which grew steadily from a 75-bed facility when it first opened in 1953 to the 350-bed center today, was sagging with maternity patients two-to-a-bed. A tertiary referral center for high risk pregnancies, average deliveries had jumped from an average of 500-600 a month in 2008 to about 800 in 2009, among the largest number of deliveries in any single hospital that year (9,605).

The DOH-WHO study noted that QMMC, like many other hospitals, reflected the country’s high incidence of neonatal deaths.

Overall, 82,000 Filipino children die annually (2008) before the age of five, 45 % of them neonates. Almost half of newborn deaths occur in the first 28 days, a quarter of them in the first two days of life. The three major causes are complications of prematurity (41%), sepsis and pneumonia (16%), asphyxia (15%).[1]

The study confirmed that current practices in Philippine hospitals fell below recommended WHO standards and robbed newborns of the natural protection offered by four recommended basic interventions: immediate and thorough drying, skin to skin contact, properly timed cord clamping and early initiation of breastfeeding.

Cords were immediately clamped at a median of 12 seconds, far too soon. Less than 1 in 10 babies was placed in direct skin-to-skin contact with the mother. Many newborns were exposed to cold by not being dried immediately and thoroughly, and being put on cold surfaces. All were washed early and 80% were suctioned unnecessarily, according to the study.

Neonatal death rates in the Philippines had changed minimally in the past 15 years. Health authorities noted that if the country was to meet its Millennium Development Goal of reducing child deaths by two-thirds, drastic changes needed to be made in neonatal care—and fast.

QMMC medical and staff executives involved in maternal and child care were invited to seminars to review the evidence for the WHO recommended interventions and other new practices incorporated in the DOH’s Basic Emergency Obstetric and Newborn care (BEmONC) program.

Policy Brief: Are Newborn Care Practices Done Properly within the First Hour of Life? A Survey on 51 of the Largest Hospitals in the Philippines

The Philippines is one of 42 countries accounting for 90 percent of all global deaths in children under 5 years of age with 82,000 Filipinos die before reaching their 5th birthday. There are also over 40,000 newborns who die annually. And if newborn mortality is not reduced by half, the goal of reducing childhood mortality by two thirds, which is part of the Millennium Development Goals, will not be met.

In a study of consecutive deliveries in 51 of the largest hospitals in 9 regions in the Philippines, an assessment tool developed by the World Health Organization (WHO) as a standard in Newborn Care which included the evidence-based intervention, was used to evaluate the performance, timing of procedures and attendant capabilities in immediate newborn care.

The Intrapartum/Newborn Practices assessment tools were developed through a collaboration between the Philippine General Hospital and World Health Organization (WHO) with Department of Health (DOH) inputs. In this cross – sectional study in 2009 using a brief questionnaire and annual reports such as hospital births, deaths and sepsis cases, approximately 10 babies were consecutively included from each of the randomly selected 51 hospitals.

NEWS | Unang Yakap Embraces 8,962 Healthcare Professionals!

Participants follow Dra Izza Flores lead in proper hand hygiene technique at EINC Training in General Santos City

Dr. Mianne Silvestre, EINC Team Convenor and WHO Consultant, reports that at least 8,962 healthcare professionals are now aware or knowledgeable in essential intrapartum and newborn care (EINC) practices. We believe this means that mothers and newborns will benefit from safer, quality care from these health facilities.

“From October to May 2011, we tripled our goals when requests for the EINC training course, spontaneously came from private hospitals (12%) and public hospitals in provinces outside NCR (6%). 




The biggest chunk of awareness still comes from those who attended lectures of our EINC team or talks provided at special forum (53%). But this number appears understated.

Dr. Silvestre pointed out that it does not capture the number of readers or listeners who have heard the DOH National Center for Disease Prevention and Control Director Dr. Ed Janairo or Family Health Office’s Dr. Anthony Calibo on radio and television talk about the benefits of adopting the EINC practices.

NEWS | Drop in Maternal and Newborn Deaths marks 8th week of EINC in General Santos City

Health professionals in General Santos city attending the second round of EINC Orientation Workshop held last May

Dr. Orlando Marius Oco Jr, Chairperson of the Local Health Board of General Santos City said they were encouraged by the feedback that there has been a dramatic drop in the NICU admissions, decreasing rates of preterm and sepsis deaths and an overall decrease in maternal and newborn deaths after 8 weeks of implementation of the EINC Scale Up Project.

Dr. Oca said this as he welcomed the participants, project staff, conveners and resource speakers of the orientation workshop on Essential Intrapartum and Newborn Care last May 25, 2011.  
     

Dr. Oca cited the recent world health report which seeks to make every mother and child count. The United Nation says that almost 11 million children under 5 years of age will die from causes that are largely preventable. Among them are 4 million babies who will not survive the first month of life. At the same time, more than half a million women will die during pregnancy or childbirth. The report says that reducing this toll in line with the Millennium Development Goals depends largely on every mother and every child having the right access to healthcare from pregnancy through childbirth, the neonatal period and childhood.

                

The Health Board Chair said the City of General Santos was grateful that General Santos City Hospital had been identified by the Department of Health as the collaborating institution in the SOCCSKARGEN Region to implement the Essential Intrapartum and Newborn Care protocol in the area. 

More than  500 health professionals from General Santos City, Kidapawan, Sultan Kudarat, Tacurong, Polomolok etc braved the rains to attend the EINC orientation workshop held over 3 days at the Lagao Auditorium in General Santos City. 

He ended his welcome by reminding the health professions that “we do not rest on our laurels or wallow in defeat, we will take honor in this opportunity to learn and serve and in this privilege to host this workshop”.  And with the warm salutation “ You are in the home of the Generals!!!  Good day to all and “ Magandang Gensan”!