ESSENTIAL INTRAPARTUM AND NEWBORN CARE (EINC) EVIDENCE-BASED STANDARD PRACTICES The EINC practices are evidenced-based standards for safe and quality care of birthing mothers and their newborns, within the 48 hours of Intrapartum period (labor and delivery) and a week of life for the newborn. Developed and field tested by international and local experts, EINC practices reflect current knowledge. EINC distinguishes the necessary practices in the delivery and care for the newborn and the mother, from the unnecessary. In December 2009, the Secretary of the Department of Health Francisco Duque signed Administrative Order 2009-0025, which mandates implementation of the EINC Protocol in both public and private hospitals. Likewise, the Unang Yakap campaign was launched. The EINC practices during Intrapartum period 1. 2. 3. 4. 5. 6. 7. 8.
Continuous maternal support, by a companion of her choice, during labor and delivery Mobility during labor – the mother is still mobile, within reason, during this stage Position of choice during labor and delivery Non-drug pain relief, before offering labor anesthesia Spontaneous pushing in a semi-upright position Episiotomy will not be done, unless necessary Active management of third stage of labor (AMTSL) Monitoring the progress of labor with the use of pantograph
Recommended EINC practices for newborn care are time-bound interventions at the time of birth Immediate and thorough drying of the newborn 2. Early skin-to-skin contact between mother and the newborn 3. Properly-timed cord clamping and cutting 4. Unang Yakap (First Embrace) of the mother and her newborn for early breastfeeding initiation 1.
1. IMMEDIATE AND THOROUGH DRYING A. Ensure quality provision of time bound interventions. B. Within the first 30 seconds dry and provide warmth the newborn to prevent hypothermia 1. Put on gloves (double gloves) 2. Use clean and dry cloth to thoroughly dry newborn by wiping the eyes, face, head, front, back, arms and legs 3. Remove wet cloth – cover baby with another clean and dry warm cloth 4. Do not wipe off vernix caseosa if present. The vernix is a protective barrier to bacteria such as E. Coli and Group B Strep. 5. Do a quick check of the newborn’s breathing 6. Do not separate baby from the mother – if newborn must be separated from the mother put baby on a warm surface in a safe sa fe close to the mother 7. Do not put newborn on a cold or wet surface 8. Use radiant warmer or heat source if resuscitation is required 9. Do not bathe the newborn earlier than 6 hours of life. Washing expose the baby to hypothermia. Washing also removes the crawling reflex. Partial and incomplete drying gives risks to hypothermia which can lead to
Infection
Coagulation defects Acidosis
Delayed fetal to newborn circulatory adjustment
Hyaline membrane disease
Brain hemorrhage
2. EARLY SKIN TO SKIN CONTACT
A. B. C. D.
Place the newborn on prone position unto the mother’s abdomen or chest, skin to skin Cover the newborn’s back with a blanket and head with bonnet Place the identification band on the ankle Do not separate the newborn from the mother as long as the newborn does not exhibit severe chest in drawing, gasping or apnea and the mother does not need urgent stabilization. Skin to skin contact is generally perceived to be an intervention for the provision of warmth and bonding. Appreciated contributions are to the following: o Immuno-protection of the newborn
Colonization with maternal skin flora
Stimulation of the mucosa- associated with the lymphoid tissue system
o
o
Ingestion of colostrum Overall success of breastfeeding Studies show that delayed breastfeeding has a greater risk of death due to infection. Protection from hypoglycemia 90 minutes after birth, blood glucose levels are significantly higher
3. PROPERLY TIMED CORD CLAMPING 1. Remove first set of gloves prior to cord clamping 2. Clamp the cord aseptically and cut the cord after the pulsations have stopped between 1 to 3 minutes after birth to allow for transfusion of blood from the placenta to the newborn. 3. Do not milk the cord towards the newborn. a. Put the clamp tightly around the cord 2cm and 5cm from the abdomen of newborn b. Cut between the clamp with sterile instrument c. Observe for oozing of blood d. After clamping, give oxytocin to the mother. Note: Clamp and cut the cord immediately only if the baby requires help with breathing. Delayed Cord Clamping is found to: a. Increase the newborn’s iron reserves b. Reduces the incidence of Iron Deficiency Anemia (IDA) in infancy 4. NON SEPARATION OF NEWBORN AND MOTHER FOR EARLY BREASTFEEDING Within 90 minutes of age, facilitate the newborn’s early initiation to breastfeeding and transfer of colostrum. Leave the newborn on the mother’s chest in skin-to-skin contact. Health workers should not touch the newborn unless there is medical indication. Counsel mother on positioning infant and attachment to breast. If attachment is not good, reassess. Suggest mother to assist baby towards the breast. Advice mother not to throw away colostrum. Advice mother to start feeding once the newborn shows feeding cues like opening the mouth, licking and rooting. Encourage the Kangaroo Mother Care. Kangaroo mother care provides the newborn with low birth weight or preterm babies with benefits of incubator care. Once baby is stable, kangaroo mother care can begin.
1. 2. 3. 4. 5. 6.
Unnecessary interventions eliminated The unnecessary interventions during labor and delivery, which do not improve the health of mother and child, are eliminated. These are enemas and shavings, fluid and food intake restriction, and routine insertion of intravenous fluids. Fundal pressure to facilitate second stage of labor is no longer practiced, because it resulted to maternal and newborn injuries and death. Likewise, the unnecessary interventions in newborn care which include routine suctioning, early bathing, routine separation from the mother, foot printing, application of various substances to the cord, and giving pre-lacteals or artificial infant milk formula or other breast-milk substitutes.
Government and international Support Since 2010, WHO supports the DOH in changing practices for safe and quality care of mothers and newborns for all practitioners and health facilities. It was initially implemented in 11 selected government hospitals collectively representing about 70,000 annual live births (around 3% of all national live births). AusAID also provided support through the Joint Programme on Maternal and Neonatal Health (JPMNH).
