EINC UPDATES • Educate Women on DANGER SIGNS &

SYMPTOMS
To Detect Diseases Which May • Vaginal bleeding
• Headache
Complicate Pregnancy
• Blurring of vision
SCREEN • Abdominal pain
• Anemia • Severe difficulty breathing
• Pre-eclampsia • Dangerous fever (T > 38, weak)
• Diabetes mellitus • Burning on urination
• Syphilis • Prepare the Woman & Her Family for
DETECT Childbirth
• PROM(Premature Rupture of COUNSEL ON
Membranes) • Proper nutrition & self-care during
• Preterm Labor pregnancy
PREVENT • Breastfeeding and family planning
• FeSO4 & folic acid BIRTH PLAN
• Tetanus toxoid immunization • Where she will deliver; transportation
• Corticosteroid for PTL • Who will assist her delivery
TREAT • What to expect during labor & delivery
• FeSO4 for anemia • What to prepare, estimated cost of
• AntiHPN meds & MgSO4 for SEVERE delivery
pre-eclampsia • Possible blood donors; where will she
• REFER be referred in case of emergency
• Antenatal Corticosteroids • Birth and Emergency Planning in the
• Administer ANTENATAL STEROIDS to all OPD
patients at risk for preterm delivery • Sample birth plan
– With PTL bw 24-34 weeks AOG • INTRAPARTUM CARE
– Or with any of the ff prior to • The Clinical Practice Guidelines
term: Development Process
• Antepartal • Evidence-based approach
hemorrhage/bleeding -Based on the results of studies with
• Hypertension acceptable quality
• (preterm) Pre-labor • Formal consensus approach
rupture of membranes – Discuss issues on generalizing
• ANTENATAL STEROIDS the evidence to the local
**Betamethasone 12 mg IM q 24hrs x 2 doses scenario, taking into account
OR DEXAMETHASONE 6mg IM q 12 x 4 doses • Harms & benefits
• Overall reduction in neonatal death • Costs
• Reduction in RDS • Preferences
• Reduction in cerebroventricular Best available evidence
hemorrhage PRACTICES RECOMMENDED DURING LABOR
• Reduction in sepsis in the 1st 48 hours 1. Admission to labor when the parturient
of life is already in the active phase
• Dexamethasone phosphate *Active Phase: 2-3 contractions in
• 2 ampules: 4 mg/ml 10mins
• 6 mg – 1.5 ml IM cervix is 4 cm dilated
• Even a single dose of 6 mg IM before • Admission to labor when the parturient
delivery is beneficial is in the active phase
• Emergency drug • No difference in APGAR Score
• Should be available at the OPD & ER • Decrease need for Cesarean section by
82%
 • No difference in need for labor
augmentation
2. Continuous maternal support
• Continuous Maternal Support
• Decrease need for pain relief by 10%
• Duration of labor SHORTER by half an
hour
• Increase in spontaneous vaginal
delivery by 8%
• Decrease in instrumental Vaginal
delivery by 10%
• 5-minute APGAS Score < 7 decreased by
30%
• Continuous Maternal Support
Having a LABOR COMPANION can result in:
• Less use of pain relief drugs →
increased alertness of baby
• Baby less stressed, uses less energy
• Early & frequent breastfeeding
– Reduced risk of infant
hypothermia
– Reduced risk of hypoglycemia
• Easier bonding with the baby
3. Upright position during the 1st Stage of labor
Freedom of movement- distracts mothers from
the discomfort of labor, release muscle tension
and give the mother a sense of control
• Upright Position During 1st Stage of
Labor
• First stage of labor shorter by about 1
hour
• Need for epidural analgesia ↓ by 17%
• No difference in rates of SVD, CS, and
APGAR Score < 7 at 5 minutes
• RESTRICTING PRACTICES
• IV Lines
• Fetal monitoring
• Labor-stimulating medications that
require monitoring of uterine activity
• Small labor rooms
• Epidural placement
• Absence of support persons to “be
with” the postpartum client
4. Routine use of WHO partograph to monitor
the progress of labor
-for early identification of abnormal
progress of labor
• PRACTICES RECOMMENDED DURING
LABOR
5. Limit total number of IE to 5 or less
• No difference in endometritis
• UTI lower by 34%
An observational study on 161,077 women
(with or w/o PROM) who had <5 exams(Ayzac,
L., et. Al., 2008)
• ↓ Chorioamnionitis by 72%
• ↓ Neonatal sepsis by 61%
Research on 5,018 women with PROM
comparing <3 exams vs 3 exams (Seaward, et.
Al., 1998)
PRACTICES NOT RECOMMENDED DURING
LABOR
1. Routine Perineal Shaving on admission for
Labor and Delivery
• No difference in rates of maternal
fever, perineal wound infection and
perineal wound dehiscence
• No neonatal infection was observed
2. Routine Enema during the 1st stage of labor
• Fecal soiling during delivery reduced by
64%
• No difference in maternal puerperal
infection, episiotomy dehiscence,
neonatal infection and neonatal
pneumonia
3. Routine vaginal douching
4. Routine Amniotomy to Shorten Spontaneous
Labor
• ↓ risk of dysfunctional labor by 25%
• No difference in duration of labor, CS
rate, cord prolapse, maternal infection
and APGAR Score < 7 at 5 minutes
5. Oxytocin Augmentation
• Should only be used to augment labor
in facilities where there is immediate
access to Caesarian section should the
need arise
• Use of any IM Oxytocin before the birth
of the infant is generally regarded as
dangerous because the dosage cannot
be adapted to the level of uterine
activity
6. Routine IVF
ADVANTAGES
• To have ready access for emergency
medications
• To maintain maternal hydration
DISADVANTAGES
• interferes with the natural birthing
process
• Restricts woman’s freedom to move
 • IVF not as effective as allowing food and
fluids in labor to the parturient
• Does not prevent ketosis and
electrolyte imbalance
• 6. Routine IVF
• No study found showing that having an
IV in place improves outcome
• Even the prophylactic insertion of an IV
line should be considered an
unnecessary intervention
• 7. Routine NPO During Labor
• Possible risk of aspirating gastric
contents with the administration of
anesthesia
• One study evaluated the probable risk
of maternal aspiration mortality, which
is approximately 7 in 10 million births
• No evidence of improved outcomes for
mother or newborn
• Use of epidural anesthesia for
intrapartum anesthesia in an otherwise
normal labor should not preclude oral
intake
7. Routine NPO During Labor
• For the normal, low-risk birth, there is
no need for restriction of food except
where interventions are anticipated.
• A diet of easy-to-digest foods and fluids
during labor is recommended.
• Isotonic, calorific drinks consumed
during labor reduce the incidence of
maternal ketosis without increasing
gastric volumes.
• CARE DURING LABOR
RECOMMENDED
 Admission to labor when in the active
phase
 Companion of choice to provide
continuous maternal support
 Mobility & upright position
 Allow food and drink
 Use of WHO partograph to monitor
progress of labor
 Limit IE to 5 or less
NOT RECOMMENDED
× Routine perineal shaving on admission
× Routine enema
× Routine NPO
× Routine IVF
× Routine vaginal douching
× Routine amniotomy
× Routine oxytocin augmentation
• PRACTICES RECOMMENDED DURING
DELIVERY
• PLEASE WASH YOUR HANDS
• DIAGNOSIS OF THE 2ND STAGE OF
LABOR
TRADITIONAL
• Defined by a “fully-dilated cervix”
• Coached to push though out-of-phase
with her own sensation
NON-TRADITIONAL
• Redefined as “complete cervical
dilatation” + “spontaneous expulsive
efforts” (Simkin, 1991)
– Pelvic phase of passive descent
– Perineal phase of active pushing
• Management of 2nd Stage of Labor
TRADITIONAL
DIRECTED PUSHING
 Valsalva pushing
• (?) venous return
 (?) Perfusion to uterus, placenta
& Fetus
• FHR changes
• Fetal hypoxia & acidosis
NON-TRADITIONAL
INVOLUNTARY BEARING DOWN
 Exhalation Pushing
 Let air out
 Parturient-directed
 Physiologic: force of bearing
down efforts increases as fetal
descent occurs
 Avoids hypoxia and acidosis
PRACTICES RECOMMENDED DURING DELIVERY
1. Upright position during delivery
• Upright Position During Delivery
• More efficient uterine contraction
• Improved fetal alignment
• Larger anterior-posterior and
transverse diameters of pelvic outlet
→enhances fetal movement through
the maternal pelvis in descent for birth
• Faster delivery
• Leads to less interventions; less
episiotomies
2. Selective (non-routine) episiotomy
• Perineal Support and Controlled
Delivery of the Head
 • Keep one hand on the head as it
advances during contractions while the
other hand supports the perineum
• During delivery of the head encourage
woman to stop pushing and breathe
rapidly with mouth open
3. Use of prophylactic oxytocin for management
of third stage of labor
OXYTOCIN 10 U IM
**Palpate abdomen to rule out second
baby
• Prophylactic Oxytocin for 3rd Stage of
Labor
• Postpartum blood loss > 500 ml
reduced by 39%
• Need for additional uterotonic reduced
by 47%
• No difference in need for maternal
blood transfusion, need for manual
removal of placenta, and duration of
third stage
• PRACTICES RECOMMENDED DURING
DELIVERY
4. Delayed cord clamping
Early clamping:
< 1 min after birth
Delayed (properly timed): 1-3 minutes
after birth or when pulsations stop
• Properly Timed Cord Clamping
• Lower infant hemoglobin at birth and at
24 hrs after birth prevented
• Fewer infants requiring phototherapy
for jaundice
• No difference in rates of polycythemia,
need for neonatal resuscitation, and
NICU admission
• PRACTICES RECOMMENDED DURING
DELIVERY
5. Controlled cord traction with counter-
traction to deliver the placenta
• Controlled Cord Traction
• ↓ Postpartum blood loss >500 ml by
7%
• ↓ Postpartum blood loss >100 ml by
24%
• No difference in rates of maternal
mortality or serious morbidity and need
for additional uterotonics
• PRACTICES RECOMMENDED DURING
DELIVERY
6. Uterine massage after placental delivery
• Lower mean blood loss
• Less need for uterotonics
• Active Management of the Third Stage
of Labor (AMSTL)
1. Administration of uterotonic within 1
minute of delivery of the baby
2. Controlled cord traction with counter
traction on the uterus
3. Uterine massage
PRACTICES NOT RECOMMENDED DURING
DELIVERY
1. Perineal massage in the 2nd stage of labor
• Based on review, there is clear benefit
(↓ 3rd-4th degree tears) and no clear
harm (no difference in 1st and 2nd
degree tears, vaginal pain and blood
loss)
• Commonly noted complications in
practice (perineal edema, perineal
wound infection, and perineal wound
dehiscence) were not evaluated
• Further studies are needed.
2. Fundal pressure during the second stage of
labor
• Fundal Pressure During 2nd Stage
• 2nd stage longer by 29 minutes
• Increased 3rd and 4th degree perineal
tears
• No difference in rates of postpartum
hemorrhage, instrumental vaginal
delivery, APGAR score <7 at 5 minutes
and NICU admission
• Uterine rupture was not evaluated
• CARE DURING DELIVERY
RECOMMENDED
 Upright position during delivery
 Selective episiotomy
 Use of prophylactic oxytocin for mgt of
3rd stage of labor
 Delayed cord clamping
 Controlled cord traction with
countertraction to deliver the placenta
 Uterine massage
NOT RECOMMENDED
× Coaching the mother to push
× Perineal massage in the 2nd stage of
labor
× Fundal pressure during the 2nd stage of
labor
POSTPARTUM CARE
RECOMMENDED
 Routinely inspect the birth canal for
lacerations
 Inspect the placenta & membranes for
completeness
 Early resumption of feeding (<6 hrs
postpartum)
 Massage the uterus- ensure uterus is
well –contracted
 Prophylactic antibiotics for women with
3rd or 4th degree perineal tear
 Early postpartum discharge
NOT RECOMMENDED
× Manual exploration of the uterus
× Routine use of icepacks over the
hypogastrium
× Routine oral methylergometrine
SUMMARY- KEY POINTS
• Maternal and neonatal mortality in the
Philippines is still unacceptably high
• Prevention of postpartum hemorrhage
through interventions like the use of
AMSTL will address the # 1 cause of
maternal mortality
• The evidence-based practices in the
EINC Protocol are lifesaving for both
mother and baby.
Additional Notes
• Millenium Development Goal(MDG) 5:
decrease maternal mortality (2015)
• Sustainable Development Goal(SDG):
(2016-2030)
• Leading causes of maternal death: 1.
hemorrhage(41%), 2. unsafe abortion
• At least 4 visits:
• To detect disease which may
complicate pregnancy
• Educate on dangers and emergency
signs and symptoms
• Prepare the woman & family for
childbirth
• Folic acid at least 5 years before
pregnancy
Antenatal steroids for all: PTL 24-34 wks AOG or
any of the ff prior to term:
• Antepartal
hemorrhage/bleeding
• Hypertension
• (preterm) Pre-labor
rupture of membranes
• ESSENTIAL NEWBORN CARE:
From Evidence to Practice
Efrelyn “Len” Amon-lellamo, RN, MAN
UP College of Nursing
• Objectives
By the end of this session, the learner should
• Be able to discuss the problem of child
mortality focusing on neonatal
mortality
• Know preventive interventions to
address the above
• Be able to discuss the immediate
newborn care practices that save lives
• Major causes of Under 5 Deaths
Western Pacific Region - 2010
• Neonatal deaths – 54%
birth asphyxia- 14%
preterm birth complications- 15%
neonatal sepsis- 3%
Pneumonia- 2%
Other conditions- 13%
• Majority of newborns die due to
stressful events of conditions during
labor, delivery and the immediate
postpartum period
• 3 out of 4 newborn deaths occur in the
1st week of life
• Prematurity is the Major cause of
neonatal deaths at 27% of all Neonatal
deaths followed by asphyxia(26%)
• What can we do to save NB lives?
BREASTFEEDING!!!!!!
• Headline: Large NCR hospital partially
closed for cleanup
WHY?
25 babies reportedly died due to
infection
• This was handled as a hospital infection
control problem
• Environmental cultures positive
How much colostrum did the cases receive?
NOT A DROP!!!!!!!
ESSENTIAL NEWBORN CARE PROTOCOL was
developed to address these issues
• What Immediate Newborn Care
Practices Save Lives?
• ANTENATAL STEROIDS
• BETAMETHASONE
– 12 mg IM q 24 hrs X 2 doses
 – May be the preferred drug- less unless the infant is both floppy/limp
PVL and apneic
• DEXAMETHASONE • Immediate Thorough Drying
_ 6 mg IM q 12 hrs x 4 doses • If baby is not breathing, stimulate by
• Have dexamethasone available in the E- DRYING!
cart • Do not slap, shake or rub the baby
• No additional benefits to using higher • Do not ventilate unless the baby is
or more frequent doses floppy/limp and not breathing
• Prednisone, methylprednisone and • Do not suction unless the mouth/nose
cortisol are unreliable are blocked by secretions
• Every Newborn Has Needs • SKIN-to-SKIN Contact
• To breathe normally • General perception is purely for
• To be warm mother-baby bonding
• To be protected • Other benefits:
• To be fed – B – breastfeeding success
• Providing Warmth: Check the – L – lymphoid tissue system
Environment stimulation
• Check temperature of the delivery – E- exposure to maternal flora
room – S- sugar(protection from
– Ideal temperature: 25-28◦C hypoglycemia)
• Check for air drafts – T- thermoregulation
• Turn off air conditioner at the time of • Early SKIN-to-SKIN Contact
delivery • If breathing or crying:
• Immediate Thorough Drying – Position prone on mother’s
Immediate drying: chest or abdomen
• Stimulates breathing – Cover the NB
• Prevents hypothermia • Dry linen for back
• Hypothermia leads to: • Bonnet for head
– Infection • Temperature Check
– Coagulation defects – Room: 25-28◦C
– Acidosis – Baby: 36.5-37.5 ◦C
– Delayed fetal to NB circulatory • When should the Cord be clamped after
adjustment birth?
– Hyaline membrane disease • When the cord pulsations stop
– Brain hemorrhage • Between 1 and 3 minutes
• Immediate Thorough Drying • Not less than 1 minute in term NB and
• Dry the NB thoroughly for at least 30 preterm NB not needing PPV
secs • ALL of the above are APPROPRIATE
– Do a quick check of breathing • Properly-timed Cord Clamping
while drying • Prevents anemia in both term and
– > 95% of NBs breathe normally preterm babies
after birth • Prevents bleeding in the brain in
• Follow an organized sequence premature babies
• Wipe gently, do not wipe off vernix • No significant impact on postpartum
• Remove the wet cloth, replace with a hemorrhage
dry one • Properly-timed Cord Clamping
Drying should be the first action, • When preparing for delivery, don 2
IMMEDIATELY pairs of gloves after thorough
for a full 30 seconds handwashing
• Remove the first set of gloves
 • Palpate the umbilical cord
• Wait 1-3 minutes or until cord
pulsations have stopped.
• Properly-timed Cord Clamping
• Clamp cord using a sterile plastic clamp
or tie at 2 cm from the umbilical base
• Clamp again at 5 cm from the base
• Cut the cord close to the plastic clamp
• Care of the Cord
• Do not milk the cord towards the baby.
• Observe for the oozing of blood. If
blood oozes place a second tie between
the skin and the clamp.
• DRY cord care is recommended.
• Do not use a binder or “bigkis”
• WASHING
• VERNIX
– Protective barrier to E. coli and
Group B Strep
• Early washing
– Hinders crawling reflex
– Can lead to hypothermia
• Infection, coagulation
defects, acidosis,
delayed fetal to NB
circulatory adjustment,
hyaline membrane
disease, brain
hemorrhage
• What is the approximate capacity of a
newborn’s stomach?
****a small CALAMANSI
• How long after birth is a newborn ready
to breastfeed?
20-60 minutes
• Non-separation of NB from Mother for
Early Breastfeeding
• Weighing, bathing, eye care,
examinations, injections should be done
AFTER the FIRST FULL BREASTFEED is
completed
• Postpone bathing until at least 6 hours
• Non-separation of NB from Mother
• Never leave the mother and baby
unattended
• Monitor mother and baby q 15 mins in
the first 1-2 hrs. Assess breathing and
warmth.
– Breathing: listen for grunting,
look for chest in-drawing and
fast breathing
– Warmth: check to see if feet are
cold to touch if no
thermometer
• Early and Appropriate Breastfeeding
Initiation
• Leave the NB between the mother’s
breasts in continuous skin-to-skin
contact
• The baby may want to rest for 20-30
mins and even up to 120 mins before
showing signs of readiness to feed
• Early and Appropriate Breastfeeding
Initiation
• Health workers should not touch the NB
unless there is a medical indication
• Do not give sugar water, formula or
other prelacteals
• Do not give bottles or pacifiers
• Do not throw away colostrum
• Let the baby feed for as long as he/she
wants on both breasts.
• Early and Appropriate Breastfeeding
Initiation
• Help the mother and baby into a
comfortable position
• Observe the NB
• Once the NB shows feeding cues, ask
the mother to encourage her NB to
move toward the breast
• Breastfeeding Cues
• Eye movement under closed lids
• Alertness, movements of arms and legs
• Tossing, turning or wiggling
• Mouthing, licking, tonguing movements
• Rooting
• Changes in facial expression
• Squeaking noises or light fussing
• ***CRYING IS A LATE SIGN!!
• THE EVIDENCE IS SOLID
The following Newborn Care Practices will save
lives:
• Immediate and Thorough Drying
• Early Skin-to-Skin Contact
• Properly-timed Cord Clamping
• Non-separation of NB from mother for
early breastfeeding