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.

HOSPITAL FEATURE | Tondo Medical Center: Commitments that Effect Change

by Donna Miranda | photos by Bernie Cervantes

These days the staff of Tondo Medical Center (TMC) can only recall with nostalgia what was once the harried and busy atmosphere of its Neonatal Intensive Care Unit, but not without relief.

At TMC newborn babies receive warmth from their mothers through immediate skin-to-skin contact

In fact if there were anything noticeable, it was the great deal of pride, satisfaction and enthusiasm beaming from hospital director Dr.  Victor de la Cruz who together with his hospital staff has managed to successfully initiate change within a short period of time. Nowadays the nurses at the NICU jokingly lament how awfully quiet it has become since NICU admissions have begun to dramatically decrease to 10.9 % of total deliveries from January to March 2011. In fact at the time of our visit, there were only two babies. The two nurses stationed at the NICU candidly inform us, “we don’t seem to have any use for that here anymore” pointing to the warmer where a queue would usually form to warm delivered babies.

And indeed they don’t – since they’ve started implementing the EINC program in the hospital where the only warmth that babies receive mostly come from their mothers through immediate skin-to-skin contact.

EBM Reviews | Myth Busters

by Louell L. Sala, MD

How sound are current practices on maternal and child care? In this section we take a look at some of these expert practices and recommendations comparing their evidences vis a vis methods used and conclusions drawn from related research and clinical observations.

NPO

Fasting in labor is common practice among our attending physicians as we always see the word NPO (short for nil per os) among patients going through labor. But is there really evidence to suggest that if fasting is not done during labor, patients will aspirate gastric contents during induction of anesthesia?

The evidence does not support this common belief. In a systematic review done by Singata et al. at the University of Fort Hare/East London Complex, East London South Africa, and using the Cochrane Pregnancy and Childbirth Group Trials Register of 2009, the authors found that there was no benefit or harm done to these patients. Using randomized controlled trials (RCT) and quasi-RCTs, they identified 5 studies with a total population of 3130 women. All studies looked at women in active labor and at low risk of potentially requiring a general anaesthetic.

NEWS | EINC-friendly Birth center to open at EAMC

This July, East Avenue Medical Center (EAMC) is slated to complete its Birthing Center. To be headed by Dr. Elenita Veloso, the Birthing Center now has a spacious examination room, a spacious EINC area to accommodate mother-baby dyads with 30 reclining beds, and an OR for emergency CS cases.

After touring the premises, the EINC working group has expressed its satisfaction with
the Birthing Center’s steady development, forseeing further improvement in the OB Department’s already impressive statistics. Since EINC was implemented in April, performance of unnecessary practices have steadily gone down, and there has been very good compliance with performance of complete EINC, even in CS deliveries. From July 11-17, 2011, out of 123 normal deliveries, 58.5% had episiotomies and these were mostly young primigravid teenage mothers with tight perineums. 52.8% were not given IV fluids, and the remaining patients with IVs were OB complicated cases which comprise the majority of their admissions (65.7% of all admissions). The wall to wall stretchers in the DR don’t allow for patients’ mobility or having position of choice during labor, but 69.9% are able to deliver in the semi-upright position. More commendable is the 100% use of antenatal steroids, 100% EINC in CS deliveries, and performance of core steps 1-3 even in symptomatic patients. This ensures that all patients benefit from EINC even if they are eventually admitted to the NICU. 

With the new birthing center mothers can now deliver in non-supine position with these reclining beds

The Birthing Center, however, is not without room for improvement in its facilities. The EINC working group has suggested the addition of a sink in the IE room, the expansion of the labor room by way of converting the large area around the nurses’ station, the addition of handwashing stations in the delivery room, and the installation of exhaust fans. There remain many opportunities for the physical improvement of the space.

NEWS | More comfort from mommy-friendly beds in JRRMMC

June 3, 2011 – All delivery beds in Jose Reyes have been made “mommy-friendly” by fitting them with special wedges so mothers now deliver in non-supine positions. “Mothers are more comfortable, there have been no complaints, reported Dr. Francesca Tatad-To, Team EINC Co-Convener.

This was reported during a weekly review of EINC progress in May 2011. This innovation is a welcome addition to the low sepsis rates among term babies and low mortality rates, both at less than 1%. During this period, NICU admission rate was 10% of all deliveries.

The innovation of letting mothers have a “position of choice” comes as a result of the repeat delivery observations and time motion studies. Other changes have been instituted. The ER pharmacy is ensuring that dexamethasone is in stock. The OBGYN doctors are now revising their NPO orders to allow mothers to eat/drink. The partographs are going to be placed in charts in a more timely manner. Footprinting, a cause of potential infection for newborns, is going to stop with changes being done to hospital forms after reviewing the new guidelines in AO 2009-25.