EINC UPDATES • Emergency drug

• Should be available at the OPD & ER

• To Detect Diseases Which May • Educate Women on DANGER SIGNS &
Complicate Pregnancy SYMPTOMS
• Vaginal bleeding
SCREEN
• Headache
• Anemia
• Blurring of vision
• Pre-eclampsia
• Abdominal pain
• Diabetes mellitus
• Severe difficulty breathing
• Syphilis
• Dangerous fever (T > 38, weak)
DETECT
• Burning on urination
• PROM-Premature Rupture of
• Prepare the Woman & Her Family for
Membranes
Childbirth
• Preterm Labor
COUNSEL ON
PREVENT by:
• Proper nutrition & self-care during
• FeSO4 & folic acid Supplementation
pregnancy
• Tetanus toxoid immunization
• Breastfeeding and family planning
• Corticosteroid for PTL(Preterm labor)
BIRTH PLAN
TREAT
• Where she will deliver; transportation
• FeSO4 for anemia
• Who will assist her delivery
• AntiHPN meds & MgSO4 for SEVERE
• What to expect during labor & delivery
pre-eclampsia
• What to prepare, estimated cost of
• REFER
delivery
• Antenatal Corticosteroids
• Possible blood donors; where will she
• Administer ANTENATAL STEROIDS to all
be referred in case of emergency
patients at risk for preterm delivery
• Birth and Emergency Planning in the
– With PTL (Preterm Labor) bw
OPD
24-34 weeks AOG
• Sample birth plan
– Or with any of the ff prior to
term:
INTRAPARTUM CARE
• Antepartal • The Clinical Practice Guidelines
hemorrhage/bleeding Development Process
• Hypertension • Evidence-based approach
• (preterm) Pre-labor -Based on the results of studies with
rupture of membranes acceptable quality
• ANTENATAL STEROIDS –should be given • Formal consensus approach
by trained health provider or with the – Discuss issues on generalizing
presence of doctor 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 CerebrO Ventricular PRACTICES RECOMMENDED DURING LABOR
hemorrhage 1. Admission to labor when the parturient
• Reduction in sepsis in the 1st 48 hours is already in the active phase
of life *Active Phase: 2-3 contractions in
• Dexamethasone phosphate 10mins
• 2 ampules: 4 mg/ml cervix is 4 cm dilated
• 6 mg – 1.5 ml IM • Admission to labor when the parturient
• Even a single dose of 6 mg IM before is in the active phase
delivery is beneficial • No difference in APGAR Score
 • 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
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 patient
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
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
ü Admission to labor when in the active
phase
ü Companion of choice to provide
continuous maternal support
ü Mobility & upright position
ü Allow food and drink
ü Use of WHO partograph to monitor
progress of labor
ü 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
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
§ Avoid 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
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
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
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
ü Upright position during delivery
ü Selective episiotomy
ü Use of prophylactic oxytocin for mgt of
3rd stage of labor
ü Delayed cord clamping
ü Controlled cord traction with
countertraction to deliver the placenta
ü 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
ü Routinely inspect the birth canal for
lacerations
ü Inspect the placenta & membranes for
completeness
ü Early resumption of feeding (<6 hrs
postpartum)
ü Massage the uterus- ensure uterus is
well –contracted
 ü Prophylactic antibiotics for women with
3rd or 4th degree perineal tear
ü 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 (preterm labor)
24-34 wks AOG or any of the ff prior to term:
l Antepartal hemorrhage/bleeding
l Hypertension
l (preterm) Pre-labor rupture of membranes
ESSENTIAL NEWBORN CARE:
From Evidence to Practice
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
PVL
DEXAMETHASONE 6 mg IM q 12 hrs x 4
doses
Have dexamethasone available in the E-
cart
No additional benefits to using higher
or more frequent doses
Prednisone, methylprednisone and
cortisol are unreliable
Every Newborn Has Needs
• To breathe normally
• To be warm
 • To be protected
• To be fed
• Providing Warmth: Check the
Environment
• Check temperature of the delivery
room
– Ideal temperature: 25-28◦C
• Check for air drafts
• Turn off air conditioner at the time of
delivery
Immediate Thorough Drying
Immediate drying:
• Stimulates breathing
• Prevents hypothermia
• Hypothermia leads to:
– Infection
– Coagulation defects
Acidosis
– Delayed fetal to NB circulatory
adjustment
– Hyaline membrane disease
– Brain hemorrhage
• Immediate Thorough Drying
• Dry the NB thoroughly for at least 30
secs
– Do a quick check of breathing
while drying
– > 95% of NBs breathe normally
after birth
• Follow an organized sequence
• Wipe gently, do not wipe off vernix
• Remove the wet cloth, replace with a
dry one
Drying should be the first action,
IMMEDIATELY for a full 30 seconds
unless the infant is both floppy/limp and apneic
• Immediate Thorough Drying
• If baby is not breathing, stimulate by
DRYING!
• Do not slap, shake or rub the baby
• Do not ventilate unless the baby is
floppy/limp and not breathing
• Do not suction unless the mouth/nose
are blocked by secretions
• SKIN-to-SKIN Contact
• General perception is purely for
mother-baby bonding
• Other benefits:
– B – breastfeeding success
– L – lymphoid tissue system
stimulation
– E- exposure to maternal flora
– S- sugar (protection from
hypoglycemia)
– T- thermoregulation
• Early SKIN-to-SKIN Contact
• If breathing or crying:
– Position prone on mother’s
chest or abdomen
– Cover the NB
• Dry linen for back
• Bonnet for head
• Temperature Check
– Room: 25-28◦C
– Baby: 36.5-37.5 ◦C
• When should the Cord be clamped after
birth?
When the cord pulsations stop
Between 1 and 3 minutes
Not less than 1 minute in term NB and
preterm NB not needing PPV
ALL of the above are APPROPRIATE
Properly-timed Cord Clamping
• Prevents anemia in both term and
preterm babies
• Prevents bleeding in the brain in
premature babies
• No significant impact on postpartum
hemorrhage
Properly-timed Cord Clamping
• When preparing for delivery, don 2
pairs of gloves after thorough
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 • Do not give bottles or pacifiers
Group B Strep • Do not throw away colostrum
• Early washing • Let the baby feed for as long as he/she
– Hinders crawling reflex wants on both breasts.
– Can lead to hypothermia • Early and Appropriate Breastfeeding
• Infection, coagulation Initiation
defects, acidosis, • Help the mother and baby into a
delayed fetal to NB comfortable position
circulatory adjustment, • Observe the NB
hyaline membrane • Once the NB shows feeding cues, ask
disease, brain the mother to encourage her NB to
hemorrhage move toward the breast
• What is the approximate capacity of a • Breastfeeding Cues
newborn’s stomach? • Eye movement under closed lids
****a small CALAMANSI • Alertness, movements of arms and legs
• How long after birth is a newborn ready • Tossing, turning or wiggling
to breastfeed? • Mouthing, licking, tonguing movements
20-60 minutes • Rooting
• Non-separation of NB from Mother for • Changes in facial expression
Early Breastfeeding • Squeaking noises or light fussing
• Weighing, bathing, eye care, • ***CRYING IS A LATE SIGN!!
examinations, injections should be done • THE EVIDENCE IS SOLID
AFTER the FIRST FULL BREASTFEED is The following Newborn Care Practices will save
completed lives:
• Postpone bathing until at least 6 hours • Immediate and Thorough Drying
• Non-separation of NB from Mother • Early Skin-to-Skin Contact
• Never leave the mother and baby • Properly-timed Cord Clamping
unattended • Non-separation of NB from mother for
• Monitor mother and baby q 15 mins in early breastfeeding
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