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.

BREASTFEEDING TSEK!

A public health education campaingn of the Department of Health (DOH) carrying the message BREASTFEEDINF TSEK! (Tama, Sapat at Eksklusibo) is a public health education campaign of DOH to encourage mothers to 'exclusively breastfeed' their babies and to educate them about the health benefits of breastfeeding. 

‘Exclusive breastfeeding’ means that mothers feed the baby nothing else but breast milk—no water, other liquid, infant formula, or food.

Called “Communication for Behavioral Impact (COMBI) on Exclusive Breastfeeding for six (6) months,” this comprehensive campaign was developed by DOH with the National Nutrition Council, the World Health Organization, the UNICEF, and other partner agencies. Breastfeeding from the first hour of life and exclusively until six months is one of the most effective strategies to prevent infant deaths. 

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