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.

NEWS Feature | Essential Intrapartum and Newborn Care in San Juan, Batangas

by Romelyn April P. Imperio, Straight Intern in Family and Community Medicine, UP-PGH 

Dr. Beverly Lorraine C. Ho, Project Staff, Team EINC

Through the auspices of the UP CDHP-San Juan Partnership and assistance of UP College of Medicine together with San Juan’s Municipal Health Office, EINC Training was held in San Juan, Batangas on February 18, 2011. The EINC Training was organized to broker the necessary path and support for the municipality’s rural health units, its staff and midwives to improve maternal and newborn health in the area.

Dr. Nestor Alidio, Municipal Health Officer of San Juan and Nurse Len Comia set up the logistics of the training invited all midwives working in the barangays. Meanwhile, DFCM Straight Intern Romelyn Imperio then communicated the training request to University of the Philippines College of Medicine alumni Dr. Beverly Lorraine Ho and project staff of Team EINC.

FEATURE | General Santos City Hospital

The well-paved roads of General Santos City hint at its steady progress toward development. The city’s slogan, Magandang Gensan, strategically hoisted throughout various spots in the city and government buildings stand both as a constant reminder of the city’s collective desire for a good quality of life and testaments of the paths it has taken to get there. “The people of Gensan are very competitive but in a manner that is laid-back. It’s a paradox but perhaps this is why General Santos is a little bit more open to new practices,” Mayor Darlene Magnolia R. Antonino-Custodio. 

This openness to change has been key to inroads made by EINC in the city of General Santos. Also worth mentioning is the local government’s commitment to Millenium Development Goals to reduce maternal and infant mortality by the year 2015 that has made EINC the new standard of care for mothers and their newborns in the city and nearby areas. Such that some mothers giving birth even at the lying-in centers proudly remark, “na-Unang Yakap ako.” After only four months since EINC training was held in General Santos City, the infant mortality rate at the General Santos City Hospital has already dropped to 0.96% as of July. 

Upon training, the General Santos City Hospital (GSCH) immediately embraced the program. While it had to contend with the usual challenges of convincing the hospital’s private consultants, its staff and the whole hospital is eventually learning to imbibe a sense of ownership and pride in the program. Determined to set a precedent for the region, GSCH is working hard to maintain its >90% performance of complete EINC core steps in all of their deliveries. By end of July, 90.79% of all deliveries have been performed with complete EINC. 

The GSCH opened its doors in 1975 and became LGU-operated since 1991. A Level II hospital with tertiary functions, GSCH has a 100-bed authorized capacity but has 261 implementing beds. It caters to approximately 261 in-patients and 100 outpatients daily. Newborn deliveries comprise 22% of the total admissions in 2010. Being the only government hospital within “SoCCSKSaRGeN” (South Cotabato, Cotabato, Sultan Kudarat, Sarangani and General Santos) area with better facilities, it also caters to patients from other neighboring municipalities such as Sarangani Province, South Cotabato, Sultan Kudarat and Davao del Sur. Likewise, it also serves as a training facility for six affiliated nursing schools and six midwifery schools across the region. 

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.