Essential Intrapartum and Newborn Care: A Step-by-Step GuideThe QMMC Experience November 2008 to Present • Antenatal steroids in Preterm Labor • Improved hand-washing • NO perineal shaving, routine antibiotics & IVF • 100% women off their backs • 90% episiotomy rates • NICU admissions by1/3 • Non-separation & initiation of a full breastfeed Implementation of EINC at QMMC Nov 2008 to Feb 2010 Immediate Drying Appropriate Cord Clamping Unnecessary Suctioning Skin-to-skin Contact Real Breastfeeding Initiation 120% 100% 80% 60% • Initial ENC work of Dr. Vitangcol, et al. ENC TRAINING Weekly team assess and improve 40% 20% 0% • • • • 4 Significant Results at QMMC • Improvement in practices after training of the hospital staff • Patient and staff satisfaction • Economic benefit . 50 .72 per month Blade for Shaving Rubber Bulb Lidocane P5 P 36 P 15 TOTAL P 465.670 x P465.50 Suture Flet Enema P 97 P 200 P 258.740.885/yr or IV Set IV Catheter P 14.Computed Hospital Savings for 1 NSD ITEMS COST BLADE NGT Cotton Alcohol Betadine Distilled Water IVF (1L) P3 P7 P 2.104.50 = P 3.50 Using the NSD Census of 2009: 6.50 P 52.50 P 11.50 P5 P5 P 11. 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 . 0 1.Sepsis &Severe Disease Intervention Intervention Protection Protection Risk of Harm Risk of Harm Relative Risk CI RR & M: 0.4) S: 4.75 (2.49 (2.0 M: 0.72 – 7.0 10.00 S: 0.17 (0.20 – 0.18 (0.89) SD: 4.0 10.77) Skin-to-Skin Contact S: 0.25) .60 – 29.25 (0.26-8.40 (0.08 – 0.10 1.74) SD: 0.46) M: 8.24 – 0.44 (2.64) Appropriate Initiation &Duration of Breastfeeding Unnecessary Suctioning 0.04 – 0.OR’s for Mortality.10 0.08-0.79) SD: 0.39 (0. Achieving MDG 4 and 5 with EINC . Unang Yakap Training Video . 11 . fundal pressure . Physical Exam and Vital Signs Obtain Birth Plan. Determine Companion of choice Allow Position of Choice Use Partograph to monitor labor IV fluid and NPO only when indicated Arrange all instruments in a linear fashion Check resuscitation equipment Upon arrival at Facility During Labor Allow mother to have oral fluids and light snacks Check room temperature Prior to Delivery and air drafts Discuss care in the 1st hours Perineal Bulging Perform Proper Handwashing and Put on 2 pairs of sterile gloves NO routine episotomy.Antenatal 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. Shake hands. Before Patient Contact WHEN? Ex. FROM 2. After patient clinical examination WHEN? Ex. INCLUDING HIS/HER OWN. Before a Clean / Ex. Fixing the patient’s bed. IV insertion. Shake hands. clinical examination • Clean hands before approaching and touching a patient WHY? TO PROTECT THE PATIENT AGAINST GERMS. 5. regulating the IV fluid rate • • Clean hands after touching a patient’s objects even if the patient wasn’t touched . draining a catheter. internal exam. 3. inserting a catheter . After contact THE the patient’s AND YOURSELF WHEN? Ex. internal exam. O. ENTERING HIS BODY. 4. 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. WHEN?Aseptic Task • Clean hands immediately before any clean / aseptic task WHY? TO PROTECT THE ENVIRONMENT AND YOURSELF FROM THE PATIENT’S GERMS. After bodily fluid exposure risk WHEN? Ex.R.contact • Clean hands after touching a patient and immediate surroundings WHY? TO PROTECT withENVIRONMENTsurroundings FROM THE PATIENT’S GERMS.Your 5 Moments of Hand Hygiene WHY? TO PROTECT THE PATIENT AGAINST GERMS CARRIED ON YOUR HANDS 1. Your 5 Moments for Hand Hygiene . 2. apply soap and lather well. Rub each area together counting “1-2-3-4-5” 3. Wet hands with warm running water. Rinse hands and dry thoroughly with a paper towel. .1. inject Vit K. eye care. BCG Transport to room TOGETHER > 6 hours BREASTFEEDING SUPPORT Optional: Bathing . Clamp. Monitor as a DYAD q15 minutes 15-90 minutes Continue uterine massage. cut cord Return baby to prone position Support FIRST FULL BREASTFEED. measure. check breathing First 30 secs 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 Examine the placenta Put in skin-to-skin contact Feel for cord pulsation . Monitor every 15 minutes Do PE.Time Delivery Mother Support the perineum with controlled delivery of the head Baby Call out time of birth and sex Dry. weigh. Hep B. 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 . 20 . EINC in Meconium-stained Vigorous Baby . . “Normal” Delivery? . 24 . h tm • http://www.wpro.Websites Download the Essential Newborn Care (ENC) Training Videos from: • www.who.int/philippines/PubDocs.ph • ://www.wpro.htm .wp://www.gov.who.int/philippines/PubDocs.doh. Pedia. Anesthesia. nursing assistants. Organize a multidisciplinary EINC Working Group Clinical staff •Physicians .OB. Infection Control •Nurses.EINC Implementation 1. midwives Administrative staff •Medical Director •Finance/ Budget Officer •PhilHealth Officer •Medical Social Service •Engineering •CSR . OB and Pedia Wards. Conduct saturation training workshops for all staff involved in maternal and newborn care services • • DR/OR. NICU.EINC Implementation 2. Conduct a “situational analysis” of your facility • Time and motion studies of deliveries and immediate newborn care practices • May be done periodically to determine effectivity of program implementation 3. ER staff Institutional/ utility workers . g.growers Review newborn policies on diagnosis and management e.weight or gestational age limits for preterms . potential sepsis hyperbilirubinemia • . Revise hospital policies and procedures • • • Allow companion of choice Remove footprinting Revise Nursery admission/ discharge criteria .EINC Implementation 4. EINC Implementation 5. IM injections Utility worker to transfer mother-baby dyad together • . Realign hospital staff to do new tasks • • • • • 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. checklist Utilize a mother-baby dyad monitoring sheet Breastfeeding and Danger Signs Checklist .EINC Implementation 6. modify newborn admitting orders. Revise hospital forms and order sheets • • • Incorporate EINC in the newborn admission forms. 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.EINC Implementation 7. Enable the environment for EINC • Provide ample space in the labor room – for companion. 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 (The First 90 minutes) III III Care Prior To Discharge II II Essential Newborn Care From 90 min to 6 hours but after the first 90 minutes IV IV Care after Discharge To 7 days V V Additional Care VII VII Equipment And Supplies Maintenance Checklist 33 VI VI Enabling The Environment . III Immediate Newborn Care (The First 90 minutes) II II Essential Newborn 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 . IV Care after Discharge To 7 days IV •Breastfeeding •Warmth of the Baby •Danger Signs “Very severe disease” . Dealing with Feeding Problems: Mother-infant separation. discharge planning C.V V Additional Care A. Newborn Resuscitation B. feeding support. cup feeding . manual expression of breastmilk. Additional Care of a Small Baby (or Twin): Warmth. KMC. 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 . plus for CEmONCs . forms & records. delivery instruments. drugs. supplies.VII VII Equipment And Supplies Maintenance Checklist •Warm and clean room •Handwashing •Waste •Sterilization •Supplies •Miscellaneous •For the Mother and Baby – equipment. Download the Pocket Guide and Unang Yakap flyer www.wpro.htm .who.int/philippines/PubDocs. 41 .