Essen Essentia tiall Intr Intrap apart artum um and Newborn Care: A Step-by-Step Guide
The QMMC Experience November 2008 to Present •
Antenatal steroids in Preterm Labor
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Improved hand-washing NO perine perineal al shaving, shaving, routin routine e antibiotics & IVF
100% women off their backs 90% episiotomy rates NICU admissions by 1/3 Non-separation Non-separation & initiation of a full breastfeed
Implementation Implementation of EINC at QMMC Nov 2008 to Feb 2010 Immediate Drying
Skin-to-skin Contact
Appropriate Cord Clamping
Real Breastfeeding Initiation
Unnecessary Suctioning 120%
Initial ENC work of Dr. Vitangcol, et al.
ENC TRAINING
Weekly team assess and improve
100% 80%
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60% 40% 20% 0%
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4
Significant Results at QMMC •
Improvement in practices after training of the hospital staff
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Patient and staff satisfaction
•
Economic benefit
Computed Hospital Savings for 1 NSD ITEMS
COST
BLADE
P3
NGT
P7
Cotton
P 2.50
Alcohol
P5
Betadine
P5
Distilled Water
P 11.50
P 3,104,885/yr
IVF (1L)
P 52.50
or
IV Set
P 14.50
IV Catheter
P 11.50
Suture
P 97
Flet Enema
P 200
Blade for Shaving
P5
Rubber Bulb
P 36
Lidocane
P 15
TOTAL
P 465.50
Using the NSD Census of 2009:
6,670 x P465.50 =
P 258,740.72 per month
Significant Results at QMMC •
Improvement in practices after training of the hospital staff
•
Patient and staff satisfaction
•
Economic benefit
•
Sepsis rates down to its lowest in the last 10 years
OR’s for Mortality,Sepsis &Severe Disease Intervention Intervention
Protection Protection
Risk Riskof ofHarm Harm
Relative RRRisk &
CI
M: 0.25 (0.08-0.77)
Skin-to-Skin Contact
S: 0.40 (0.20 – 0.79) SD: 0.39 (0.24 – 0.64)
Appropriate Initiation &Duration of Breastfeeding
M: 0.00
S: 0.17 (0.04 – 0.74) SD: 0.18 (0.08 – 0.46)
M: 8.75 (2.60 – 29.4)
Unnecessary
S: 4.49 (2.26-8.89)
Suctioning
SD: 4.44 (2.72 – 7.25) 0.10 0.10
1.0 1.0
10.0 10.0
Achieving MDG 4 and 5 with EINC
Unang Yakap Training Video
11
Antenatal
Upon arrival at Facility
During Labor
Prior to Delivery
Perineal Bulging
At least 4 antenatal visits Iron and folate supplementation Tetanus Toxoid Vaccine Prepare a BIRTH PLAN including UnangYakap Identify mothers in PRETERM LABOR at point of entry Administer 1st dose of Antenatal Steroid History, Physical Exam and Vital Signs Obtain Birth Plan, Determine Companion of choice Allow Position of Choice
Use Partograph to monitor labor
Allow mother to have oral fluids and light snacks
IV fluid and NPO only when indicated
Check room temperature and air drafts
Arrange all instruments in a linear fashion
Discuss care in the 1 st hours
Check resuscitation equipment
Perform Proper Handwashing and Put on 2 pairs of sterile gloves NO routine episotomy, fundal pressure
Your 5 Moments of Hand Hygiene WHY? TO PROTECT THE PATIENT AGAINST GERMS CARRIED ON YOUR HANDS 1. Before Patient Contact WHEN? Ex. Shake hands, clinical examination
• Clean hands before approaching and touching a patient WHY? TO PROTECT THE PATIENT AGAINST GERMS, INCLUDING HIS/HER OWN, FROM 2. Before a Clean / Aseptic Task ENTERING HIS BODY. WHEN? Ex. IV insertion, internal exam, inserting a catheter , O.R.
• Clean hands immediately before any clean / aseptic task WHY? TO PROTECT THE ENVIRONMENT AND YOURSELF FROM THE PATIENT’S GERMS.
3. After bodilya catheter, fluid exposure risk WHEN? Ex. draining internal exam, changing a soiled diaper
• Clean hands after an exposure risk (and after glove removal) WHY? TO PROTECT THE ENVIRONMENT AND YOURSELF FROM THE PATIENT’S GERMS. 4. After patient contact WHEN? Ex. Shake hands, clinical examination
• Clean hands after touching a patient and immediate surroundings WHY? TO PROTECT THE ENVIRONMENT AND YOURSELF FROM THE PATIENT’S GERMS. 5. After contact with the patient’s surroundings WHEN? Ex. Fixing the patient’s bed, regulating the IV fluid rate •
• Clean hands after touching a patient’s objects even if the patient wasn’t touched
Your 5 Moments for Hand Hygiene
1. Wet hands with warm running water, apply soap and lather well. 2. Rub each area together counting “1-2-3-4-5”
3. Rinse hands and dry thoroughly with a paper towel.
Time Delivery
Mother Support the perineum with controlled delivery of the head
Baby Call out time of birth and sex
Dry, check breathing First 30 secs
Put in skin-to-skin contact Give Oxytocin IM After excluding a 2nd baby
1 minute to 3 minutes
Do controlled traction of cord with counter-traction Massage the uterus gently
Feel for cord pulsation , Clamp, cut cord Return baby to prone position
Examine the placenta Support FIRST FULL BREASTFEED. Monitor as a DYAD q15 minutes 15-90 minutes
Continue uterine massage; Monitor every 15 minutes
Do PE, weigh, measure, eye care, inject Vit K, Hep B, BCG
Transport to room TOGETHER > 6 hours
BREASTFEEDING SUPPORT
Optional: Bathing
Linear Arrangement of Instruments
Immediate and Thorough Drying Early Skin to Skin Contact Properly-timed Clamping Non-Separation of Mother and Baby
EINC in Cesarean Section
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EINC in Meconium-stained Vigorous Baby
“Normal” Delivery?
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Websites Download the Essential Newborn Care (ENC) Training Videos from: •
www.doh.gov.ph
•
://www.wp://www.wpro.who.int/philippines/PubDocs.h
tm •
http://www.wpro.who.int/philippines/PubDocs.htm
EINC Implementation 1. Organize a multidisciplinary EINC Working Group Clinical staff Physicians - OB, Pedia, Anesthesia, Infection Control Nurses, nursing assistants, midwives • •
Administrative staff Medical Director Finance/ Budget Officer PhilHealth Officer Medical Social Service Engineering CSR
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EINC Implementation 2. Conduct a “situational analysis” of your facility •
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Time and motion studies of deliveries and immediate newborn care practices May be done periodically to determine effectivity of program implementation
3. Conduct saturation training workshops for all staff involved in maternal and newborn care services • •
DR/OR, NICU, OB and Pedia Wards, ER staff Institutional/ utility workers
EINC Implementation 4. Revise hospital policies and procedures • • •
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Allow companion of choice Remove footprinting Revise Nursery admission/ discharge criteria - weight or gestational age limits for preterms - growers Review newborn policies on diagnosis and management e.g. potential sepsis hyperbilirubinemia
EINC Implementation 5. Realign hospital staff to do new tasks • • •
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Obstetrician to dry the baby Pediatrician to clamp and cut the cord Anesthesiologist to help in maintaining skin-to-skin contact DR/ NICU staff to monitor mother and baby dyads DR/ NICU nurse to weigh baby and to do eye prophylaxis, IM injections Utility worker to transfer mother-baby dyad together
EINC Implementation 6. Revise hospital forms and order sheets •
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Incorporate EINC in the newborn admission forms, modify newborn admitting orders, checklist Utilize a mother-baby dyad monitoring sheet Breastfeeding and Danger Signs Checklist
EINC Implementation 7. Enable the environment for EINC •
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Provide ample space in the labor room – for companion, for mother’s mobility Provide back support for upright positioning Include bonnet/extra linen in the OB pack Designate an EINC Recovery Room or area
8. Disable the environment that hinders EINC • •
Remove the transitional nursery – provide trolley Close the Nursery!
Help us bring
to your community
III Immediate Newborn Care
II II Essential Newborn Care
(The First 90 minutes)
From 90 min to 6 hours
III III Care Prior To Discharge
but after the first 90 minutes
IV IV Care after Discharge
To 7 days
VI VI Enabling The Environment
V V Additional Care
VII VII Equipment And Supplies Maintenance Checklist 33
III Immediate Newborn Care
II II Essential Newborn
(The First 90 minutes)
From 90 min to 6 hours
III III Care Prior To Discharge
but after the first 90 minutes
Breastfeeding Warmth of the Baby Hygiene Sleeping Danger Signs: serious illness Signs of Jaundice and Local Infection Discharge Instructions
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IV
IV Care after Discharge To 7 days
Breastfeeding Warmth of the Baby Danger Signs “Very severe disease”
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V V Additional Care
A. Newborn Resuscitation B. Additional Care of a Small Baby (or Twin): Warmth, feeding support, KMC, discharge planning C. Dealing with Feeding Problems: Mother-infant separation, manual expression of breastmilk, cup feeding
VI
VI Enabling The Environment
Preparing for the shifts – workplace After every delivery – restock Standard precautions – general standard precautions and cleanliness Hand hygiene Processing Instruments & Other Items: Step 1: Decontamination Step 2: Cleaning Step 3: High-Level Disinfection by Boiling or Steaming Sterilization by Steaming (Autoclave) Step 4: Store or Use • • •
VII VII Equipment And Supplies Maintenance Checklist
Warm and clean room Handwashing Waste Sterilization Supplies Miscellaneous For the Mother and Baby – equipment, delivery instruments, drugs, supplies, forms & records, plus for CEmONCs • • • • • • •
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www.wpro.who.int/philippines/PubDocs.htm
