Vol 1 June 15, 2011
EINC BullEtIN
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news Are Newborn Care Practices Done Appropriately within the First Hour o Lie?: A Survey on 51 o the Largest Hospitals in the Philippinesa Feature: HE QUIRINO MEMORIAL MEMORIAL MEDICAL CENER EXPERIENCE: Accepting the challenge o change EBM Notes: •
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Documenting Docume nting Essent Essential ial Intrapartu Intrapartum m Newborn Newborn Care (EINC (EINC)) Practices Practices or or Sae & Quality Quality Maternal Maternal & Newborn Newborn Care Care
Te JPMNH JPMNH Scale Scale Up Project Project
Drop in Maerna and Newborn Deahs Marks 8h week of EINC in Genera Sanos
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r. Orlando Marius Oco Jr, Chairperson o the Local Health Board o General Santos City said they were encouraged by the eedback that there has been a dramatic drop in the NICU admissions, decreasing rates o preterm and sepsis deaths and an overall decrease in maternal and newborn deaths ater 8 weeks o implementation o the EINC Scale Up Project. Dr. Oco said this as he welcomed the participants, project sta, conveners and resource speakers o the orientation workshop on Essential Intrapartum and Newborn Care last May 25, 2011. Dr. Oco cited the recent world health report which seeks to make every mother and child count. Te United Nation says that almost 11 million children under 5 years o age will die rom causes that are largely preventable. Among them are 4 million babies who will not survive the rst month o lie. At the same time, more than hal a million women will die during pregnancy or childbirth. Te report says that reducing this toll in line with the Millennium Development Goals depends largely on every mother and every child having the right access to healthcare rom pregnancy through childbirth,
the neonatal period and childhood. Te Health Board Chair said the City o General Santos was grateul that General Santos City Hospital had been identied by the Department o Health as the collaborating institution in the SOCCSKARGEN Region to implement the Essential Intrapartum and Newborn Care protocol in the area.
ABOVE: Health professionals in General Santos city attending the second round of EINC Orientation Workshop held last May.
over 3 days at the Lagao Auditorium in General Santos City.
He ended his welcome by reminding the health proessions that “we do not rest on our laurels or wallow in deeat, we will take honor in this opportunity More than 500 health proessionals to learn and serve and in this privilege rom General Santos City, Kidapawan, to host this workshop”. And with the Sultan Kudarat, acurong, acurong, Polomolok warm salutation “ You are in the home etc braved the rains to attend the o the Generals!!! Generals!!! Good day to all and EINC orientation workshop held “Magandang Gensan”!
Vol 1 June 15, 2011
MNCHN EINC BullEtIN News
unang Yakap Embraces
8,962
Heahcare Professionas!
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r. Mianne Silvestre, EINC eam Convenor and WHO Consultant, reports that at least 8,962 healthcare proessionals are now aware or knowledgea knowledgeable ble in essential intrapartum and newborn care (EINC) practices. We believe this means that mothers and newborns will benet rom saer, quality care rom these health acilities.
Participants follow Dra Izza Flores lead in proper hand hygiene technique at EINC Training in General Santos City
EINC Scale Up, Oct to May 2011
n=8,962
“ We believe this means that mothers and newborns will beneft rom saer, quality care rom these health acilities” “From October to May 2011, we tripled our goals when requests or the EINC training course, spontaneously came rom private hospitals (12%) and public hospitals in provinces outside NCR (6%). Te biggest chunk o awareness still comes rom those who attended lectures o our EINC team or talks provided at special orum (53%). But this number appears understated. Dr. Silvestre pointed out that it does not capture the number o readers or listeners who have heard heard the DOH National Center or Disease Prevention and Control Director Dr. Ed Janairo or Family Health Oce’s Dr. Anthony Calibo on radio and television talk about the benets o adopting the EINC practices.
Vol 1 June 15, 2011
MNCHN EINC BullEtIN Policy Brief Are Newborn Care Pracices Done Propery Propery wihin he Firs Hor of life?
A Survey on 51 of the Largest Hospitals in the Philippines
by Louell L. Sala, MD
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he Philippines is one o 42 countries accounting or 90 percent o all global deaths in children under 5 years o age with 82,000 Filipinos die beore reaching their 5th birthday birthday.. Tere are also over 40,000 newborns who die annually annuall y. And i newborn mortality is not reduced by hal, the goal o reducing childhood mortality by two thirds, which is part o the Millennium Development De velopment Goals, will not be met. In a study o consecutive deliveries in 51 o the largest hospitals in 9 regions in the Philippines, an assessment tool developed by the World Health Organization (WHO) as a standard in Newborn Care which included the evidence-based intervention, was used to evaluate the perormance, timing o procedures and attendant capabilities in immediate newborn care. Te Intrapartum/Newborn Practices assessment tools were developed through a collaboration between the Philippine General Hospital and World Health Organization (WHO) with Department o Health (DOH) inputs. In this cross – sectional study in 2009 using a brie questionnaire and annual reports such as hospital births, deaths and sepsis cases, approximately 10 babies were consecutively included rom each o the randomly selected 51 hospitals. Tese evidence-based interventions include immediate drying, skin-toskin contact ollowed by clamping o the cord and non-separation, and breasteeding initiation. Necessary interventions like immunizations, eye care, vitamin K administration was also timed. Unnecessary procedures such as “routine” suctioning, “routine” separation o newborns or “observation”, giving o glucose water or ormula and ootprinting
Metacards activity determine the level of knowledge and awareness on newborn care practices among health profes professionals sionals
(increasing risk o contamination rom ink pads) was also identied. A total o 481 mother-newborn dyads were directly observed. obser ved. Te percentages and median times to the ollowing included cord clamping (12 sec), drying (93.8% at 1 min), skin-to-skin contact (9.6% at 4 min) and any early contact with mother (61.1% at 5 min), washing (84.2% at 8 min), breasteeding initiation (61.3% at 10 min), separation rom mother (93.2% at 12 min), weighing (100% at 13 min), examination (75.7% at 17 min), transer to a nursery (52.4% at 20 min), eye prophylaxis (99.8% at 20 min), injections o vitamin K/vaccines (95.6% at 22 min) and rooming-in (83.4% at 138 min). Only 1 o 26 apneic or gasping newborns was dried prior to other actions. It was ound rom the study that among the randomly selected 51 hospitals in the Philippines, perormance and timing o evidence-based interventions
in immediate newborn care were below WHO essential newborn care standards. In these hospitals, their practices prevented Philippine newborns rom beneting rom their mothers’ natural protection in the rst hour o lie and almost none in the study newborns beneted rom the natural transusion rom delayed cord clamping. It should be known that any unnecessary delay and restriction on immediate thorough drying, early and sustained skin-to-skin contact, early latching, rooming in and ull breasteeding, compromised the newborns’ chance or maintenance o warmth and survival beyond the newborn period. Further, Further, these interventions can be integral to hospital inection control practices as they directly reduce risk o neonatal sepsis. Note. Te Acta Paediatrica article can be downloaded or ree via this link: http:// onlinelibrary.wiley.com/doi/10.1111/ j.1651-2227.2011.02215.x/pd
Vol 1 June 15, 2011
MNCHN EINC BullEtIN
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QuIRINO MEMORIAl
MEDICAl
CENtER EXPERIENCE
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Feature
ccepting the chal ch alle leng ngee of ch chan ange ge by Monica Feria
Barely one year after adopting the new Essential Newborn Care protocols, QMMC cut newborn deaths by half and achieved a 70% reduction in neonatal sepsis. Doing away with unnecessary procedures in the delivery room also saved the hospital a minimum of P3 million.
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he Quirino Memorial Medical Center (QMMC), ormerly known as the “labor “ hospital in Quezon City, was among 51 government-run government-run hospitals included in a comprehensive study on prevailing newborn care practices in the Philippines starting November November,, 2008.
Even beore researchers backed by he Department o Health and the World Health Organization began setting up monitoring stations at the hospital, Vitangcol and her medical colleagues knew something had to change. QMMC, which grew steadily rom a 75-bed acility when it rst opened in 1953 to the 350-bed center today, was sagging with maternity patients twoIn hindsight, Dr. Belle Vitangcol, head to-a-bed. A tertiary reerral center or o QMMC’s pediatrics department and high risk pregnancies, average deliveries lead ENC trainor, remembers this as had jumped rom an average o 500-600 the starting point o a whirlwind that in a month in 2008 to about 800 in 2009, barely one year’s time would sweep away among the largest number o deliveries many traditional practices and attitudes in any single hospital that year (9,605). in the delivery room, and usher in a Te DOH-WHO study noted that radically dierent regimen on essential QMMC, like many other hospitals, newborn care. refected the country’s country ’s high incidence
o neonatal deaths. Overall, 82,000 Filipino children die annually (2008) beore the age o ve, 45 % o them neonates. Almost hal o newborn deaths occur in the rst 28 days, a quarter o them in the rst two days o lie. Te three major causes are complications o prematurity (41%), sepsis and pneumonia (16%), asphyxia (15%)1. Te study conrmed that current practices in Philippine hospitals ell below recommended WHO standards and robbed newborns o the natural protection oered by our recommended basic interventions: immediate and thorough drying, skin to skin contact, properly timed cord clamping and early initiation o breasteeding. Cords were immediately clamped at a median o 12 seconds, ar too soon. Less than 1 in 10 babies was placed in direct skin-to-skin contact with the mother.. Many newborns were exposed mother to cold by not being dried immediately and thoroughly, and being put on cold suraces. All were washed early and 80% were suctioned unnecessarily, according to the study. >>
Vol 1 June 15, 2011
MNCHN EINC BullEtIN
FEATURE
>> Neonatal death rates in the Philippines had changed ime and motion studies conducted during the pilot minimally in the past 15 years. Health authorities noted that i implementation period, however, showed that old practices the country was to meet its Millennium Development Goal o were not that easily shed. reducing child deaths by two-thirds, drastic changes needed to be made in neonatal care—and ast. Te new interventions inter ventions required longer waiting periods—more meticulous drying o the newborn; more supervision during QMMC medical and sta executives involved in maternal skin-to-skin contact; delayed cord clamping and cutting, and child care were invited to seminars seminars to review the evidence and a waiting time o 20 minutes to up to two hours or or the WHO recommended interventions and other new breasteeding initiation. practices incorporated in the DOH’s Basic Emergency Obstetric and Newborn care (BEmONC) (BEmONC) program. program. Monitors noted that some staers did not continuously check the position o mother and baby or wait long enough or some babies to begin begin breasteeding. Some monitors even HOSPItAl POlICY caught nurses handling babies without thoroughly washing their hands. r. Vitangcol said she and many o her colleagues needed little convincing. “I anything, (the workshops) Many complained o lack o time given the many patients provided the conrmation and ramework or some piecemeal in the labor and delivery deliver y rooms. Everybody complained o improvements we had been slowly trying to put into place,” overwork. she said. Te hospital sta was already ollowing guidelines on delayed bathing, early “I there is one lesson we can breasteeding protocols and They collected more baseline immediately share, it is that rooming-in. information to show the training is not enough,” said Dr. Vitangcol. Ater the initial study on hospital staff how the Some interventions were more current practices, the WHO interventions ventions were inadequately easily implemented: delayed maternal and child health team inter cord clamping, the no bathing had approached QMMC to applied and the consequences rule and brie skin-to-skin allow them to conduct a pilot of their current practices contact. study and urther test the eectiveness o the new timeHarder to implement were the protocols on not interrupting bound Essential Newborn Care (ENC) interventions. skin-to-skin contact and breasteeding support up to 90 minutes. Surprisingly, Surprisingly, adherence to strict hand washing In the rst quarter o 2009, the QMMC’s QMMC’s Hospital Ethics immediately beore and ater handling o patients was a Review Committee approved the pilot proposal. It included tough one. a study on “Te Eect o a Package o Newborn Care Interventions on the Incidence o Neonatal Sepsis” and a In assessment meetings in November, the ENC working randomized controlled trial on “iming “ iming and Positioning o team identied several key barriers to implementing the Cord Clamping.” Nationwide, the introduction o the WHO WHO protocols. Tese included physical arrangement o the the Essential Newborn Care Course was launched. delivery room and equipment, sta resistance to change change their established practices, sta sta misperceptions o what was really “Well, the rest is history,” said Dr. Vitangcol smiling. But it happening (and its consequences) and the availability o some was not that easy, she was quick to add. essential medications (e.g., antenatal steroids, oxytocin and antibiotics).
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StAFF tRAINING AND MANPOWER CONCERNS
ith a new hospital policy in avor o the ENC shit in place, training seminars were organized. By September 2009, all pediatric, obstetric, midwiery and related nursing sta were trained in the essential newborn care protocol. Workshops Workshops were also held or deans and clinical instructors o nursing schools aliated with the QMMC.
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Tey collected more baseline inormation to show the hospital sta how the interventions were inadequately applied and an d the consequences o their current practices. Spot hand and environmental cultures were also done. Te hospital sta themselves thought o and agreed on steps to address the problems. >>
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MNCHN EINC BullEtIN
FEATURE Dr. Vitangcol recalled that at every ever y meeting they would ask themselves what other changes could be made: ‘Are Are the routine things we used to do really necessary?’ For example, the the giving o routine intravenous fuid (IVF) was abandoned. Te obstetricians agreed that it was not really necessary in normal, low-risk mothers. Routine antibiotics and the shaving o perineal areas were also stopped. Episiotomies were reduced. Letting go o practices which new evidence had shown to be unnecessary in all cases helped reduce the sta ’s workload. workload. It has also led to less stress and more comort or the mother and the newborn.
Health professionals undergoing weekly meeting with EINC Team
too, had to understand the new process and be >> Te mothers, too, convinced o the benets to their newborn.
HOSPItAl INFRAStRuCtuRE AND SuPPlIES he ENC team leaders continuously reviewed the system. Te longer time needed or skin-to-skin contact and breasteeding initiation were or the good o the mother and baby and thereore was non- negotiable. But certain renements were possible.
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A breakthrough came with a simple strategy : rearranging the urniture in the delivery room. Tey Tey took away the old steel tray where newborns used to be placed. Te nurses’ table table was moved to the recovery recover y room so there would be more supervision o mother and an d baby’s needs. It also allowed them to chart case experiences. Delivery tables were cranked up to allow mothers to birth in sitting position position i they so desired. When preerences were monitored, two-thirds o the tables were permanently placed in upright position. One room was vacated to serve ser ve as walking space or mothers in labor. Unlike beore, ood and drinks were also allowed in the labor room.
MultIDISCIPlINARY APPROACH, APPROA CH, INtERNAl AND EXtERNAl PRESSuRE y November 2009 the ollow-up meetings were scheduled weekly with representatives rom the delivery room sta, the nursing sta, NICU sta, pediatrics and obstetrics. Anesthesia sta and inection control committee members were invited as needed.
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Results o ollow up data were presented at the weekly meetings to decide i urther inormation and inter ventions were needed. Barriers were addressed in a prioritized order. For stricter hand washing, the sta made it a point to voice the question beore every delivery: ‘Have we all washed out hands?’ Sta were also provided with pocket alcohol gel or sanitizing hands when scurrying rom one patient to another. Posters reminding the sta o this requirement were increased.
POlItICAl WIll, CONStANt MONItORING While addressing the problems one by one, “we also impressed upon the sta that the administration was determined to implement the new system,” that there was no turning back, said Dr. Vitangcol.
“Actually, we discovered that we really didn’t need new and expensive equipment to implement the changes. “
She added that it helped that the team had the backing o powerul institutions like the Department o Health and the WHO. “We are being watched,” I would warn the sta.
Tey noted the positive eects o the physical changes on work habits.
“I was like a policeman,” she laughed. >>
Vol 1 June 15, 2011
MNCHN EINC BullEtIN >> “I believe one big reason we were able to comply was because someone rom the outside was looking into our set-up,” refected Dr. Vitangcol. Te DOH and WHO ocials had assigned watchers or the pilot study and were themselves oten in the hospital premises. premises. National monitoring and reporting systems were being designed. “We were all on our toes…careul,” she added. But she stressed that the internal team had long decided that they were serious about change: Tere would be no whitewashing o data, no cover-ups o weaknesses. Dr. Vitangcol also said her team could not have implemented the change without the ull support o the hospital administration. Te director and almost all related department heads had attended the ENC ENC echo seminars. Tey gave the ENC working group all-out support.
SHOWING RESul RESultS: tS: A tAStE OF SuCCESS
FEATURE Non separation of the newborn from the mother for the rst
breastfeeding resulted in higher breastfeeding breastf eeding rates on discharge at seven and 28 days highlighted. Te media attention it elicited gave the QMMC a rush.
INItIAl BENEFItS, CONtINuING DRIVE y May 2010, barely a year since the change project began, hospital director Angeles . . de Leon was condent enough en ough to report some preliminary ndings during a Maternal Neonatal and Child Health and Nutrition orum in Cebu City. Benets to mother and child were almost immediate, she reported.
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hile keeping up the pressure, the team knew that only one thing could cement the changes: Showing the sta o o their compliance with the more thorough drying dr ying technique that the new system was really working. as a rst step, De Leon attributed better thermal care and stimulation o breathing, and thereore less need or ventilator Te goal was clear: to reduce the hospital’s hospital’s neonatal mortality support to newborns; newborn s; o o early skin to skin contact, she and morbidity incidence. linked greater warmth, the prevention o hypoglycemia and heightened mother and child bonding. bonding. It also made cord Six months into the program, Dr. Vitangcol said a drop in the clamping easier to perorm. sepsis rate was palpable but too soon to call. Non separation o the newborn rom the mother or the By December 2009, it was reported in the weekly meetings rst breasteeding resulted in higher breasteeding rates on o the ENC working group that admissions to the neonatal discharge at seven and 28 days (89% and 69%, respectively). respectively). intensive care unit (NICU) were down down by a third. It was also Mothers also reported a more satisactory eeding experience. reported that all mothers were already birthing o their backs Te practice has led, she said, De Leon reported, to lower (100%), episiotomy episiotomy rates had been cut (90 %), and perineal NICU admissions and thereore a better NICU nurse to shaving, routine antibiotics and IVFs had been eliminated. patient ratio. Tere were also less sepsis cases and shorter Monitors reported dramatic improvements in hand washing hospital stays. and the non separation o mother and baby until breasteeding initiation. Changes in maternal care--or example, allowing mothers a position o choice or birthing and letting them walk, eat or Te last WHO-led assessment in February and March 2010 drink during labor-- resulted in shorter duration o labor, she noted the improved compliance compliance with the new protocols: “95% also reported. o newborns were dried immediately and placed in skinto-skin contact, about 90% had their cord clamped ater a ter 60 QMMC had stopped the practice o unnecessary unnecessar y suctioning secs and three-ourths had breasted appropriately. Similarly, Similarly, to drain secretions and induce breathing. Te baby in prone unnecessary suctioning decreased to 2.3% and none were position on the mother’s abdomen or chest did the job, while bathed early ear ly.. lowering the risk o death and sepsis, De Leon said.
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By this time too, the DOH had incorporated the WHO interventions into a mandatory protocol. At the launching o the protocol together with a public inormation campaign dubbed “Unang Yakap,” the QMMC pilot experience was
Benets to hospital administration were the added bonus, she said. Te recommendations or cord clamping (use o plastic clamp >>
Vol 1 June 15, 2011
MNCHN EINC BullEtIN >> and orceps, no milking and no antiseptics) resulted in savings on time and supplies o cotton, alcohol and iodine. Tey were also able to do away with separate cord dressing rooms and tables. Te ‘no ‘no automatic suctioning’ policy meant hospital savings on suction catheters, tubing, electricity, oxygen suction bulbs and others. Footprinting o babies was done away with. Tis eliminated the need or ink pads which increased the risk o inection. Te elimination o other ormerly routine procedures like episiotomies, enemas, shaving, IVF and prophylactic antibiotics also resulted in savings in both time and supplies. It resulted in shorter delivery room stays as well. Obstetric residents also reported less dehiscence o episiotomy wounds upon outpatient ollow-up. De Leon showed hospital administrators their calculation o the savings: more or less P465.50 on each normal delivery (just rom eliminating blades, cotton, alcohol, iodine, tubing, IVF, catheters, sutures, enemas, rubber bulbs, and other supplies). For QMMC, which handled 6,670 normal births during the study period, this added up to savings o P3.1 million.
FEATURE positive and comortable.” Summing up QMMC’s experiences, De Leon noted: “We “We were ready or the change and we were prepared to act decisively,, to accept that change was necessary despite many decisively imperect conditions and diculties.” Up to now, mothers oten still have to bunk two-to-a-bed in QMMC’s overcrowded and harried maternity wards, which service not just Quezon City residents but also those rom surrounding towns o Marikina, Antipolo, San Mateo, Montalban, Caloocan, Novaliches and even nearby provinces o Laguna, Bulacan and Cavite. “But we decreased the maternal mortality rate and we even reaped savings or QMMC, “she “she continued. What it really took, she concluded, was “the political will and a listening heart to accept the challenge o change.”
EBM REVIEWS by Louell L. Sala, MD
By August 2010, the WHO team released the ocial ndings o the pilot studies: newborn deaths had been cut by almost half and there was a 70% reduction in neonatal sepsis despite the higher total percentage o pre-terms.
lESSONS AND CHAllENGES AHEAD r. Vitangcol and the rest o the ENC working group know they cannot let down their guard. “Tere is a ast turnover o sta in the delivery room and the young nurses are still schooled in the old methods. Kailangan tutok talaga (you really have to keep close watch). Tere is always the danger o backsliding.” But it’s it ’s much easier now to keep going. “I think it’s it ’s because we get more ‘thank you’s’ s’ rom the mothers, “she “she added.
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“I make my rounds in the morning and ask the mother’s about their birthing experience. Tey seem less stressed, more more
We were ready for the change and we were prepared to act decisively, to accept that change was necessary despite many imperfect conditions and difculties
Dr. Jessamine Sareno giving our GenSan audience a crash course in evidencebased medicine
Wha is Evidence Based Medicine?
In a world where inormation can be achieved with a click o a button and yet can be disorganized and unvalidated, Dr. David Sackett in 1996 introduced the concept o conscientious, ious, Evidence Based Medicine . Dened as a conscient explicit, judicious use o current best evidence in making decisions about the care o individual patient, Dr. Sackett described it as a means o integrating individual clinical expertise with the best available external clinical c linical evidence rom systemat systematic ic research. It was created so that as physicians, we can be up to date with the latest modalities, modalities, whether diagnostic, treatment treatment or clinical practice guidelines, but more importantly or better quality o care and utilization o resources. >>
Vol 1 June 15, 2011
MNCHN EINC BullEtIN >> In their book “Painless Evidence-Based Medicine”, Drs. Antonio Dans, Leonila Dans and Maria Asuncion Silvestre set orth this denition "EBM is a systematic approach to the acquisition, appraisal and application o research evidence to guide healthcare decisions." 2
Te EINC Bulletin will look at the respective studies behind the EINC practices, dissect them and provide a short assessment that are sound and evidence - based. But in the end we should always emphasize that you are still the attending physician. Ater all it is the triad o individual clinical expertise, best external evidence and patient values and expectations that orms the backbone o evidence based medicine. EVIDENCE-BASED PRACtICES FOR INtRAPARtuM AND NEWBORN CARE Enemas Dring labor
Te use o enemas during labor is common practice among attending physicians. However, enemas can also cause discomort or women and increase the cost o deliver deliveryy. Te Systematic Review, which made use o the Cochrane Pregnancy and Childbirth Group trials register, Database o Abstracts o Reviews o Eectiveness, and Medline dated rom 1966 to December 2006, by by Cuervo et. al in the Clinical Epidemiology unit o the Universidad de Javeriana in Columbia, showed that there were no signicant dierences in the incidence o lower and respiratory tract tract inections among those who used enema during labor ater one month o ollow up (2 RCs; 594 women; relative risk (RR) 0.66, 95% CI 0.42 to 1.04) or newborn children (1 RC; 370 newborns; RR 1.12, 95% CI 0.76 to 1.67). Te authors urther concluded that there is not enough evidence to evaluate the use o routine enemas during the rst stage o labor. Enemas thereore should only be on a per request basis and not routine. Perinea Per inea Shaving
It is common practice to perorm pubic or perineal shaving beore birth in order to lessen the risk o inection especially i there is a spontaneous perineal tear. However in a Systematic Review done by Calibri et al. in Centro Interaziendale in Italy, comparing perineal shaving with that o no perineal shaving, the dierences were not signicant (odds ratio (OR) 1.26, 95% condence interval (CI) 0.75, 2.12) with regards to post partum maternal ebrile morbidity and perineal wound inection. However in one study rom the same review, they ound that ewer women who had not been shaved had gram negative bacterial colonization compared with women who had been shaved (OR 0.43, 95% CI 0.20, 0.92). How then can we reconcile this single study rom the conclusion o the authors? Surrogate outcomes are those that come rom laboratory tests while clinical outcomes are those that are well, clinical. So in eect although the gram negative bacterial colonization is indeed signicant, there there is still no sucient Clinical Evidence that it can cause perineal wound inection or post partum ebrile morbidity.
REVIEWS EBM Reviews in Coming Isses: Ucary suctioig, Fudal Prur, Poitio of Choic, ski to ski Cotact, Bratfdig, Compaio of Choic ad AMTsL.
MEEt tHE tEAM Editors Dr. Maria Asuncion A. Silvestre Dr. Cynthia Fernandez Fernande z an Managing Editor Marcia F. Miranda Feature Editors Donna Miranda Monica Feria Medical Editor Dr. Louell Sala Medical Contributors Dr. eresita Cadiz-Brion Dr. Donna Capili Ca pili Dr. Ma. Lourdes Imperial Imp erial Dr. Jessamine Sareno Dr. Francesca France sca atadatad -o Dr. Ernesto Uichanco Bulletin Advisors Dr. Anthony Calibo Cal ibo Dr. Ivan Escartin Dr. Mariella Castillo
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1
Sacket dl., et al. Evidence-based medicine: what is and what isn’t. BMJ 1996 January 13; (31217023): 71-2 Fr. Dans, Al, Dans LF and Silvestre MA. In Chapter 1. Introduction. Dans, AL, Dans LF and Silvestre MS. Painless Evidence Bas ed Medicine. Medicine . John D.Wiley and Sons, United Kingdom. 2008. 2
The publication does not reflect the off icial policy of the Department of Health.
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