EINC Don'ts and Do's

Unnecessary Intervention:
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 cross contamination 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 easily to 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 Practices:
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.

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Tondo Medical Center : Commitments that Effect Change by Donna Miranda

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.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. The staff also seemed much more satisfied now that some of the unnecessary workload such as cord care and routine bathing of the babies have been done away with. Instead more attention is being reallocated to breastfeeding support and monitoring. Not only was it reassuring to see that non-separation of mothers and babies conscientiously practiced but that it was also a relief to know that even those weighing between 1.5 to 1.8 kg who needed closer monitoring and care were kept with their mothers in the newly created EINC room right beside the NICU. Thanks to complete staffing realignment, mother-baby dyads are now closely monitored at least 9 times a day, ensuring that the sufficient support and care is given to mothers and during recovery. The mothers seemed to be pleased, as evident in the following quotations:

Nakakapanibago po, kasi yung mga narakaraan kong panganganak di naman ganito ang ginawa…Pero para sa akin, maganda po ito sapagkat nakakasiguro ako na di mapalitan ang anak ko, kasi pag sa hospital ka nanganganak masarap po ang pakiramdam, kasi nakabonding ko na kaagad ang anak ko… -- Marie Claire De Leon – 33 F, G7P3 NSD

Happy–happy ako, damang dama ko na anak ko talaga siya. Hindi siya napapalitan. -- Mrs. De Leon

Pakiramdam ko, relax ako. Masarap ang pakiramdam kasi namalayan ko nasa dibdib ko ang baby ko. -- Mary Ana Labayani – 25 F, G1P1 CS

After only four months since the EINC Orientation Workshop conducted last January 2011, TMC has already made remarkable progress in reducing sepsis, preterm and maternal deaths reporting reporting zero cases in the last week of March. As early as eleven weeks after training and weekly supportive supervision meetings its performance of the 4 core steps of EINC has been >95% in their normal deliveries and >90% in their caesarean deliveries. Moreover, the rates of allowing mother to eat and walk without routine IVF placement (83%) and delivering in semi-upright position (97%) have been equally impressive. And while these numbers have yet to reflect the true statistical impact of EINC on outcome indicators, the consistent drop in TMC’s NICU admissions and increase in directly room-in babies hint at future improvement in the statistics if the EINC program is continually implemented as standard of care in hospitals. The TMC in Manila is a tertiary public medical center established in 1971 operating under the supervision of the Philippine Department of Health (DOH). Currently, it has eight hospital departments, and a 200-authorized bed capacity, 60 of which is allotted to the OB-Gyne Department. Spontaneous vaginal deliveries is the leading cause of admission in TMC. In 2009, obstetric cases alone comprised 47% of the total admissions. Located at North Bay Boulevard, Balut, Tondo, Manila, TMC caters to the health needs of the residents of Tondo and CAMANAVA (Caloocan, Malabon, Navotas, Valenzuela) area.The early success of TMC is due to the strong leadership and openness of its medical director Dr. Victor de la Cruz. His “handson” management style – sitting in weekly implementation meetings, watching out for potentially conflicting clinical practices that may arise in carrying out the EINC -- and his fervent support for the program has been instrumental in the rapid but fine-tuned implementation of the program. As well as making sure that the necessary changes are adapted according to the hospital’s available resources, needs and capacities. Already some significant changes in the hospital’s policy, physical environment and practice have been put in place such as the complete realignment of staffing that allows frequent monitoring of mother-baby dyads; construction of wooden wedges to allow mothers a semi-upright position during delivery; use of a unique EINC wrap for babies in skin-to-skin contact; revision of admission forms and doctors’ orders reflecting EINC practices; and promoting EINC awareness among patients by continuously showing the EINC video material at the outpatients waiting. Additionally, an EINC-friendly floor plan is already underway and included in the hospital’s next renovation budget. Surely change is never easy and Dr. De la Cruz is quick to remark that the process was not one without some resistances. But not enough reason to give up. In fact he proudly shares that “my strategy was to keep close to those who were most resistant (to the changes), constantly convincing them to give it a try. At first they were hesitant but unwavering persuasion eventually won them over.” This tireless dedication and enthusiasm is something he says he has learned from the EINC Team whose supervised monitoring, committed support and guidance were crucial to TMC’s success. Dedication he said is not only infectious but inspiring, “how can you think otherwise, when the evidence is indisputable and safety of patients always prioritized over everything else.” Dr. De la Cruz receives the same kind of esteem from his staff who considers his openness to change and all-out support for the program as pivotal factors contributing to TMC’s successful and timely implementation of EINC -- attitudes that the staff now share with him. “The changes were not done abruptly, every week we do our commitments and then commit to do doing better for the following week. The staff is challenged to give our commitments weekly,” shares Dr. Sharon Macasadia, OB, on how they’ve managed to carry out EINC practice at a steady pace in the hospital. She further says that because of this they’ve learned to value these “incremental changes” and see how it affects the big picture. For instance she proudly cites how the use of intravenous fluids among delivering mothers has markedly dropped from 83.65% in February to 39.92 % in the last week of June. Adopting the EINC protocols has also made them appreciate the value of teamwork, pedia consultant Dr. Sheryl Joy Gracilla shares that “things are less departmentalized as we have learned to become more responsive in providing for the care of our patients.” Consequently, the non-departmentalization of care has resulted in better relationship between obstetricians and pediatricians, and of course, better satisfaction of its patients. Meanwhile the team is anticipating an even better working rhythm between the pediatrics and OB department as soon as the design of patients’ birth plan forms has been finalized. And as if things were not looking bright enough, TMC has not only managed to reduce infant sepsis and mortality rates but also incur savings cost since they’ve adopted EINC at the beginning of the year. The NICU charges, for instance have dropped from P145.00 to P43.50 and delivery room charges from P345.50 to P83.50. The savings are being reallocated to provide patients with EINC-friendly facilities. Moreover, a “free blood culture” service has been initiated to created provide free blood CS to indigent patients who cannot afford outside lab (because TMC’s lab has no blood cultures). Upon approval of Dr. Dela Cruz part of rebates from this outside lab has been converted to “free blood cultures” to selected newborns of indigent mothers.” The benefits reaped by simple health worker behavior change wereso impressive that TMC thought that EINC should not be confined within its walls. As a referral facility, TMC saw the need to share their experiences with other lower level facilities within their catchment area. In March 2011 TMC initiated an EINC training for 72 participants composed of nurses, pediatricians, obstetricians, administrators, clinical nurse instructors from Tondo’s catchment areas, including nearby Caloocan and Navotas, LGU-operated health units (Ospital ng Tondo, Pagamutan ng Bayan) and guests from tertiary medical centers (Gat Andres, VRPMC, Trinity, Delgado Hospital). The initiative to adopt EINC as the standard of care in all of these facilities is a manifestation of the system-wide effort to decrease the maternal and newborn mortality rates in the area. Dr. de la Cruz emphasizes, “We want to be part of the achievement of MDG 4 & 5, as I believe that focusing on MG 4 & 5 is a key step in solving the rest of the other MDGs.”

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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. 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.

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More Comfort from Mommy-friendly Beds in JRMMC

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. Foot printing, 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 2009:2

5.

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