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EINC Recommended Practices in Intrapartum Care EINC FAQs News: Jose Reyes Memorial Medical Center Drafts EINC Action Plan Feature: Mothers Testimonials Kuwentong Unang Yakap

Documenting Essential Intrapartum Newborn Care (EINC) Practices for Safe & Quality Maternal & Newborn Care

Vol 6 August 30, 2011

Mothers say Yes to unang-Yakap in tondo Medical Center

atient satisfaction surveys were undertaken by the EINC Team of Tondo Medical Center as part of their process of monitoring the adoption of the EINC set of practices. Mrs. Erlinda T. Pascual, EINC-Nurse Coordinator reports that from July 1 to August 31, 2011, 435 patients were asked about their satisfaction with having a companion of choice during labor and delivery and having their baby placed skinto-skin on their breast after delivery. Close to 100% of the mothers said they wanted to be with companions of their choosing during labor and delivery, with 426 of 435 responding with a yes! All of the mothers said they were satisfied with having their babies placed on their breasts after birth.

EINC Scale up, Oct-Aug 2011 n=11,680

JRRMMC drafts EINC action plan

s early as August 2011, Jose R. Reyes Memorial Medical Center ( JRRMMC) had a six-objective action plan for EINC until 2012. As the objective shifts, so does the target audience, making for a well-rounded series of goals.

JPMNH Scale Up Hospitals

26%

EINC Lectures

48%

Spontaneous Scale UpPublic Spontaneous Scale UpPrivate

12%

14%

The beginning of August alone saw the dissemination of information about EINC policies among hospital staff, geared toward increasing awareness among all hospital employees. This is carried out by way of lectures, held twice every month from hereon. Just as often, the EINC team will coordinate with the Head of Medical and Nursing Training for the inclusion of an EINC lecture during the general orientation program of nursing affiliates, medical interns, clerks, even paramedical affiliates and trainees. August also saw the start of increasing awareness about EINC among expectant

mothers seeking consultation at the OB section of the outpatient department by way of lecturettes, video presentations, and leaflets. Come end of month, the efforts is expected to reach out of the hospital and into the adopted barangay by coordinating with officials so their expectant constituents with their spouses can also undergo Health Education activities regarding EINC, exclusive breastfeeding and the barangays various nutrition programs. On a daily basis, from August till December, lectures and demonstrations will be conducted at OB Gyne-Outpatient Department (OBOPD), Obstetric and Pediatric Wards for the benefit of postpartum mothers so their knowledge of EINC can be ensured. By the end of the first week of December, random monitoring or spot checks will commence in strategic areas where EINC is expected to be practiced. EINC is expected to be going strong even into 2012 and beyond.

ABOVE: As of August 31, 2011, the EINC Scale Up Project has reached out and trained 11,680 health professionals.

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tONDO MEDICAl CENtER

PAtIENtS SAtISFACtION SuRVEY July 1 to August 31, 2011 = 435 patients
UNANG YAKAP EXPERIENCE (Tanong para sa mga bagong panganak dito sa Ospital) (Survey Questions from the Patients Satisfaction Survey Form) Do you prefer being with a companion of choice during labor and delivery? Mas gusto mo ba na ikaw ay may kasamang kamag-anak, o kaibigan habang ikaw ay nanganganak? Feedback = 9/435 answered - NO = 426/435 OB patient answered - YES with comments: Para di ako matakot Kasi dagdag pampalakas ng loob Para lumakas ang aking loob habang nanganganak Para may kaagapay ako habang nangananak Feedback

ABOVE: A satisfying birth experience is a right of every mother.

tONDO MEDICAl CENtER

Did you feel satisfied when you were able to embrace and breastfeed your newborn immediately? Nasiyahan ka ba nang ipinayakap at hinayaang sumuso kaagad sa iyo ang iyong sanggol?

Mothers Feedback on Unang Yakap (July to August 2011)

1 Masayang-masaya po, super happy nang makayakap ko agad baby ko. 2 Wala po akong pagsidlan ng saya, habang dumedede sa akin ang baby lalo na ngayon ang hirap ng buhay, hindi na ako bibili ng gatas. 3 Feel na feel, bonding agad kami ng baby ko. 4 Sarap sa pakiramdam, nakakawala ng pagod at hirap. 5 Okey lang, mas maganda kaysa dati. 6 Masaya, kasi akap-akap ko siya (baby). 7 Ay siempre masaya, yakap ko agad baby ko. 8 Naramdaman agad namin ang init sa isat-isa. 9 Naiyak ako ng makita ko kayakap ko ang baby ko. 10 Malakas agad dumede baby ko, nakakatuwa. 11 Mainit pakiramdam ko, magkadikit ang aming katawan. 12 Kulang pa gatas na nakukuha ng baby ko. EINC Nurse: Advised continuous breastfeeding and proper attachment. 13 Masarap ang pakiramdam di ko gaano nararamdaman ang pagtahi sa sugat (pwerta). 14 Tanggal ang hirap nung naipatong siya sa dibdib ko. 15 Ok lang, sigurado akong anak ko siya. 16 Mahirap nakapatong siya sa dibdib ko, hindi ako makakilos ng maayos. 17 Mahirap para sa nanay pagsabay na kirot ng sugat at galaw ng bata. 18 Lubog ang utong ko di pa nakadede baby ko. EINC Nurse: Assisted the mother for proper breastfeeding. 19 Nawala ang pagod ko sa pag-ire ng mayakap ko agad ang baby ko. 20 Masarap pakiramdam kasi nakayakap siya sa akin.

= 435 patient answered - YES with comments: Magaan sa pakiramdam Feels good Nasiyahan talaga Nakita at nayakap ko agad baby ko Masaya dahil nakita at kasama ko agad ang aking anak; habang tinatahi ako masakit pero kapag nakikita ko yung anak ko parang lahat kaya ko tiisin Of course that is the best for my baby

Mothers Speak: Make Birthing a Rights-based Satisfying Experience

hree hundred mothers shared their thoughts on how birthing can be a satisfying and respectful experience at public hospitals. The survey was commissioned by the DOH National Center for Health Promotion (DOH-NCHP) with support from the JPMNH WHO component. It was conducted by Marcia F. Miranda in December 2010 to help identify the perceptions and information needs of mothers on birthing practices.
Mothers Satisfaction. The survey found that satisfaction of mothers with the birthing experience, while intrinsically difficult and painful, varied throughout the four stages of birth: on admission, labor, delivery and after birth. More than half of the mothers said they were satisfied with how they were admitted into the hospitals with 57.4% being satisfied. The level of satisfaction dipped during labor but increased with the delivery and birth and once the birth was over during the stage of recovery. The average level of a mothers satisfaction ranged from 78.3% to 50%. But if they were to recommend the birthing facility, many mothers stepped back and became critical as only 46.7% to 49.3% said they would recommend the facility to their family or friends. Overall, mothers who are satisfied with one stage of the birthing experience tended to be satisfied with the other stages and with the whole birthing process.

FEATURE
Positive Practices and Indicators for Mothers Satisfaction. The study found that there were a number of birthing practices that were associated with a mothers satisfaction. These included information on the different processes, professionalism and respectfulness of the staff, the skin to skin contact that is done after birth and the initiation of breastfeeding. The physical environment of the hospital, adequacy of beds and electric fans and cleanliness were other attributes that were important to patient satisfaction. These indicators can serve as basis for the development of a rights code, especially for birthing mothers. Mothers Rights. The study painfully reveals the presence of human rights abuses and discrimination in the hospitals. These violations range from verbal abuse, physical and psychosocial abuse that nevertheless become normalized and tolerated, both by mothers, health professionals and hospital administrators. The survey findings underline the need to arrest many of the practices that are considered harmful to mothers and to adopt evidence-based practices that not only ensure safe and quality care at birth but result in satisfied and happier mothers.

EINC Recommended Practices in Intrapartum Care

Hand Hygiene, Partograph Use and Active Management of the Third Stage of Labor (AMTSL)
Hand Hygiene Hand hygiene is perhaps the single most important and effective measure to prevent nosocomial infections and antimicrobial resistance in hospital settings. It is a general term that refers to either handwashing, antiseptic handwash, antiseptic handrub, or surgical hand antisepsis. Despite substantial evidence that it reduces the incidence of infections, adherence to hand hygiene by health-care workers remains low at an average of 40 %. Contributing factors are dryness and irritation caused by handwashing agents, inconveniently located sinks, lack of soap and paper towels, lack of time, understaffing and overcrowding, and the patient needs taking priority. Thus, easy, timely access to both hand hygiene and skin protection is necessary for satisfactory hand hygiene behavior. Alcoholbased hand rubs may be better than traditional handwashing as they require less time, act faster, are less irritating and contribute to sustained improvement in compliance associated with decreased infection rates. All institutions should prioritize improving hand hygiene by providing appropriate administrative support and financial resources to this end. Strategies that are both multimodal and multidisciplinary should be utilized to improve compliance.
Sources: Pittet D. Improving Adherence to hand Hygiene Practice: A Multidisciplinary Approach. Emerging Infectious Diseases,Vol. 7 No. 2, March-April 2001, pp.240. Guideline for Hand Hygiene in Health Care Settings. MMWR 2002; vol. 51 no. RR16: 1-44.

A Framework towards Right-based Birthing in Health Facilities

A Guide for Health Professionals
MY RIGHTS IN GIVING BIRTH1 On Checking into the Hospital As a patient, I have the right to participate in decisions involving my well-being and that of my unborn child. I want to immediately be attended to when I arrive in a hospital

I would like to be asked if I have a birth plan for the birth of my baby I would like to know what the doctors and nurses will do for me I would like to be asked who is my companion of choice Labor

I would prefer to be vaginally examined only when absolutely necessary. I want to remain as mobile as possible during my labor. I would prefer only to have an IV drip if I become dehydrated or need IV medications. I would like to be allowed to drink fluids at will during the first stage of my Labor. I would like (companion of choice) present during my labor.

If needed, I would like my pain to be relieved in a way that will not interfere with my plan to breastfeed my baby within one hour after delivery. C-Section Unless necessary, I would like to avoid a C-section.

If a C-section is unavoidable, I would like to be kept informed about the reasons as to why this is the case. I would like to remain conscious during my C-section, if possible. If my baby is not distressed, please place him or her skin-to skin on my chest immediately after being dried and after the umbilical cord is cut. Perineal Care I wish to avoid having an episiotomy (surgical cut) unless it is believed necessary for the safe delivery of my baby. I wish to avoid having my perineum shaved. I wish to avoid having an enema. Delivery

I would like to be allowed to choose my preferred birthing position.

I want my baby dried on my stomach/ chest for at least 30 seconds immediately after delivery. I want my baby placed skin-to-skin on my stomach/ chest immediately after drying. After the Delivery

I would like to wait until the umbilical cord has stopped pulsating before allowing it cut.

If possible, I wish to hold my baby while I deliver the placenta and while any tears are being seen to.

I plan to keep my baby with me after his/ her birth and would prefer if any examinations were carried out with the baby on my abdomen or beside me. If my baby needs to be taken away for medical treatment, (birth partner) will accompany him/ her. I do not wish to be separated from my baby unless absolutely unavoidable.
1 Adapted by Dr. Mariella Castillo and Dr. Mianne Silvestre for Philippine mothers based on a sample birth plan posted by Sinead Hoben at http://www.breastfeedingmums.com/sample-birth-plan.htm

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Partograph use The partograph is a tool that can be used to assess the progress of labor and to identify when intervention is necessary. Studies have shown that using the partograph can be highly effective in reducing complications from prolonged labor for the mother (postpartum hemorrhage, sepsis, uterine rupture and its sequelae) and for the newborn (asphyxia, infection, death). As part of the safe motherhood initiative, the World Health Organization (WHO) promoted and produced a partograph with a view to improving labor management and reducing maternal and fetal morbidity and mortality. Partograph use was recommended by Wall as one of the simple, affordable and effective approaches to reduce intrapartum-related neonatal deaths in lowresource settings. Mathai in 2009 stated that when used with defined management protocols, the partograph can effectively monitor labor and prevent obstructed labor.
Sources: Wall SN et al. Reducing intrapartum-related neonatal deaths in low- and middle-income countries what works? Semin Perinatol 2010 Dec: 34(6): 397-407. Review. Mathai M. The partograph for the prevention of obstructed labor. Clin Obstet Gynecol 2009 Jun: 52 (2): 256-69

uterine massage after delivery of the placenta. In a 2010 Cochrane systematic review by Begley et al, AMTSL was more effective than expectant management in preventing blood loss, severe postpartum hemorrhage (RR 0.34, 95% CI 0.14 - 0.87), low maternal hemoglobin after birth (RR 0.50, 95% CI 0.30 - 0.83) and prolonged third stage of labor. There was no identifiable difference in Apgar scores less than 7 at 5 minutes. However, there were reported adverse effects in the mother such as increases in diastolic blood pressure, after-pains, use of analgesia and more women returning to hospital with bleeding. There was also a decrease in the babys birthweight with active management, reflecting the lower blood volume from interference with placental transfusion. It is important to note that in this review, immediate cord clamping was practiced rather than the properly timed cord clamping after the cessation of cord pulsations that is part of the EINC protocol. It is now recommended that use of ergots be avoided and immediate cord clamping be deferred to prevent hypertension and decrease in the babys blood volume. The Bristol and Hinchingbrooke trials concluded that with physiologic management there is an increased risk of PPH and an increased need of blood transfusion; with active management there was no increase in the entrapment of the placenta, with oxytocin as the drug of choice.
Sources: Prendiville et al, The Bristol third stage trial: active versus physiological management of the third stage of labor. BMJ 297: 1295-1300. Begley CM et al. Active versus expectant management for women in the third stage of labor. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD007412.

Frequently Asked Questions regarding Essential Intrapartum and Newborn Care

Weve compiled some of your most frequently-asked questions and provided answers based on expert observations and evidence-based practices to help you in your EINC Unang Yakap Advocacy.
Non-separation of newborn from mother for breastfeeding initiation Q: Wont the baby have an increased risk of falling when he is left alone with the mother who is still fatigued or sleepy after the delivery? A: Falls may occur most especially in the period following delivery but what needs to be emphasized is that we should institute measures aimed at eliminating or monitoring the most common circumstances under which these falls occur. In multicenter studies done in the United States, the incidence of in-hospital neonatal falls was estimated at 1.6-4.14/10,000 live births. After studying the circumstances surrounding the incidents, preliminary recommendations made by a committee to reduce newborn falls included monitoring mothers more closely, improving equipment safety (such as reducing gaps between hospital bed railings, or between the mattress and the guard rails; integrating the bassinet into the design of the maternal bed so that it can be attached alongside it) and increasing awareness about newborn falls. Data from the East Avenue Medical Center from 2008 to 2010, a period before EINC Program implementation, showed that the local incidence of falls ranged from 4.9-11.7/10,000 live births. The most frequent circumstance of an infant falling on the floor occurred when a mother, seated on a chair, falls asleep while breastfeeding her infant. In response to this finding, EAMCs EINC Working Group designed a sling or salumbata so that the risk of falling will be significantly reduced and reorganized their staff for mother-infant dyad monitoring and education . Other project sites in the EINC scale-up project have innovated with their own sling designs for this purpose. Across the 11 Scale-up EINC Project sites, the incidence of falls has not increased. Q: Does being in skin-to-skin contact with the mother put the baby at risk for suffocation ? A: There is no evidence that skin to skin contact alone puts a newborn at risk of sudden deterioration due to possible suffocation. A neonatal apparent life-threatening event (ALTE) or sudden unexpected death during the first 2 hours of life is rare. A 2008 study by Dageville done in Provence, France on 62,968 presumably healthy term neonates showed an overall rate of neonatal apparent life-threatening events and >>

Active Management of the third Stage of labor (AMtSl) Postpartum hemorrhage is one of the leading causes of maternal mortality, and active management of the third stage of labor (AMTSL) has been promoted as an effective intervention in preventing excessive bleeding among facility-based deliveries. The usual components of AMTSL include administration of uterotonic agents, controlled cord traction and

BElOW: AMSTL or active management of the third stage of labor is best way to prevent postpartum complications

HOSPITAL FEATURE
lEFt: Using a sling helps keep the baby secure while mother is still recovering from fatigue of delivery

unexpected deaths of 0.032 per 1000 live births. A similar study by Poets done in Germany in 2010 on unexpected sudden infant deaths (SID) and severe apparent life-threatening events (S-ALTE) that occurred within 24 hours of birth yielded an incidence of 0.026 in 1000 live births. Another sub-group of sudden, unexpected infant deaths is caused by accidental suffocation and strangulation in bed (ASSB) which is a leading category of injury-related infant deaths. Events seem often related to a potentially asphyxiating position while the parents may be too fatigued or otherwise are not able to assess their infants condition correctly, consistent with the potential risk factors for ALTE identified in the Dageville study, namely skin-to-skin contact, a first-time mother and mother and baby alone in the delivery room. With the introduction of EINC as a new protocol, it is very easy to fall into the trap of blaming the program for any untoward incidents that occur while it is being introduced. Since we know that close interactions between the mother and baby during the immediate postpartum period is beneficial, these events should not lead us to reconsider skin-to-skin contact but instead make us focus on prevention efforts that include more vigilant monitoring of a skin-to-skin infant left alone with its mother during these hours, and helping parents and caregivers provide safer sleep environments. Care Prior to Discharge Q: Should alcohol be applied to the umbilical cord stump? A: No. It is not advisable to use alcohol on the cord because studies have shown that it doesnt have as much of a protective effect against infections over simply allowing an umbilical cord to dry on its own (dry cord care). Compared with the use of antiseptics, dry cord care also leads to earlier separation of the cord after birth, as seen in separate studies by Vural (dry care vs. human

milk and povidone-iodine) and Dore (dry care vs. alcohol), and a Cochrane review by Zupan updated in 2004. With dry cord care, however, the cord should still be washed with soap and water when it becomes soiled, wiped with a dry cotton swab, and then allowed to air-dry. Q: Wont dry cord care increase the chances of umbilical cord infection? A: A Cochrane review by Zupan updated in 2004, which included twenty-one studies with 8959 participants assessed the effects of topical cord care in preventing cord infection, illness and death. There was no difference demonstrated between cords treated with antiseptics compared with dry cord care or placebo. There was a trend to reduced colonization with antibiotics compared to topical antiseptics and no treatment. The use of antiseptics, however, reduced maternal concern about the cord. To date, there is limited research which has not shown an advantage of antibiotics or antiseptics over simply keeping the cord clean. In all the 11 hospitals involved in the EINC scale-up project, there was no increase in the incidence of omphalitis observed with dry cord care. Intravenous Fluid Infusion for Women in labor Intravenous (IV ) therapy has been used routinely to hydrate women who were restricted from eating and drinking and to provide quick access in case of an emergency. However, researchers including Goer in 2007 have questioned the need for IVs in all women in labor since lifethreatening emergencies are very rare in low-risk women. One study evaluated the probable risk of maternal aspiration mortality to be in the extremely low range of approximately 7 in 10 million births. Starting IVF routinely confers several disadvantages because having an IV line in place is painful and stressful,

and disrupts the natural birthing process by hindering the womans freedom of movement in labor. There are also potential adverse effects of infusing glucose solutions to the mother due to interference with glucose and insulin levels in both the mother and baby. Excessive insulin production in the fetus occurs when women receive more than 25 g of glucose intravenously during labor. This can result in neonatal hypoglycemia and increase serum lactate levels which effectively lower the umbilical arterial blood pH. Excessive use of dextrose-only salt-free IV solutions can also cause a fall in serum osmolality and result in hyponatremia in both the mother and the fetus. Thus, the use of IV glucose and fluids to prevent or combat ketosis and dehydration in the mother may have serious unwanted effects on both mother and baby. Regardless of solution type, intravenous therapy does not ensure a nutrient and fluid balance for the demands of labor and predisposes women to immobilization, stress, increased risk of fluid overload. . Other reported adverse effects include headache, nausea, slowing of labor and difficulty in establishment of breastfeeding. It is not likely to be beneficial, and no studies have demonstrated that routinely placing an IV in low-risk laboring women prevents poor outcomes (Enkin et al., 2000; Goer et al., 2007). For the normal, low risk birth in any setting, there is no need for restriction of food, except in situations where intervention is anticipated.
Additional references: 1. Helsley L, McDonald JV, Stewart VT, Addressing in-hospital falls of newborn infants. Jt Comm J Qual Patient Saf. 2010 Jul;36(7):327-33. 2. Monson SA, Henry E, Lambert DK, Schmutz N, Christensen RD, Inhospital falls of newborn infants: data from a multihospital health care system. Pediatr.Vol. 122 No. 2 August 1, 2008, pp. e 277 e 280. 3.Annual Statistics, East Avenue Medical Center, 2008-2010. Unpublished data. 4. Dageville C, Pignol J, De Smet S, Very early neonatal apparent lifethreatening events and sudden unexpected deaths: incidence and risk factors. Acta Paediatr. 2008 Jul; 97(7):866-9. Epub 2008 May 14. 5. Poets A, Steinfeldt R, Poets CF, Sudden deaths and severe apparent lifethreatening events in term infants within 24 hours of birth. Pediatrics. 2011 Apr;127(4):e869-73. Epub 2011 Mar 28. 6. Shapiro-Mendoza CK, Kimball M, Tomashek KM, Anderson RN, Blanding S, US infant mortality trends attributable to accidental suffocation and strangulation in bed from 1984 through 2004: are rates increasing? Pediatr.Vol. 123, No. 2, February 2009: 533-539. 7. Vural G, Kisa S, Umbilical cord care: a pilot study comparing topical human milk, povidone-iodine, and dry care. J Obstet Gynecol Neonatal Nurs. 2006 Jan-Feb; 35(1):123-8. 8. Dore S, Buchan D, Coulas S, Hamber L, Stewart M, Cowan D, Jamieson L, Alcohol versus natural drying for newborn cord care. J Obstet Gynecol Neonatal Nurs. 1998 Nov-Dec; 27(6):621-7. 9. Zupan J, Garner P. Omari AA, Topical umbilical cord care at birth. Cochrane Database Syst Rev. 2004; (3):CD001057. 10. Lothian JA, Amis D, Crenshaw J, Care Practice #4: No Routine Interventions. J Perinat Educ. 2007 Summer; 16(3): 2934. doi: 10.1624/105812407X217129. 11. Enkin M, Keirse M, Neilson J, Crowther C, Duley L, Hodnett E, A guide to effective care in pregnancy and childbirth. 2000 et al. New York: Oxford University Press, pp. 261-2. 12. Goer H, Leslie M. S, Romano A.The Coalition for Improving Maternity Services: Evidence basis for the ten steps of mother-friendly care. Step 6: Does not routinely employ practices, procedures unsupported by scientific evidence. J Perinat Educ. 2007;16(Suppl. 1):32S64S. 13. Sleutel M, Golden S, Fasting in labor: relic or requirement. J Obstet Gynecol Neonatal Nurs. 1999; 28: 507-512,.

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Kuwentong
Ella & Mikas Miracle
by: Dr. Pinky Imperial2

Kuwentong Unang Yakap chronicles the first-hand experiences, inspiring testimonials and personal anecdotes of doctors, health professionals, patients and other healthcare providers narrating their Unang Yakap stories.

Unang Yakap

wanted to be awake when the girls were delivered and placed on skin-to-skin contact with me. When my OB came in, I again asked her if we could do properly timed cord clamping and she assured me that she would discuss this with the neonatologists attending the delivery. She started the procedure, and a little while later the first twin came out, and after drying and cord clamping, she was placed on my chest. I knew she was the one with the problem but was relieved to see that she looked stable and was comfortable. Then soon enough the second twin came out and she joined her sister on my chest. After a short while my OB gently asked me if the twins could be taken to the NICU already and I nodded, knowing that they had to be worked up and referred ASAP. They were 35 weeks by pediatric aging, and weighed 1.49 kg and 1.62 kg. Neither of them had any breathing difficulty. After spending some time in the Recovery Room, I was finally wheeled back into my room. It was a good thing that the NICU nurse started to bring Ella, the second twin, to my room to breastfeed, and I would do this every 3 hours or when the baby would demand to be fed. After the first 24 hours, they could no longer bring her to the room as a matter of hospital policy, and I had to go to the NICU for the breastfeeding. So despite still having an IV line and a urinary catheter I continued to go to the NICU regularly for feeding. It was the following evening that the pediatric surgeon finally made rounds on Mika, the first twin. The x-ray done showed massive pneumoperitoneum, certainly one of the worst ones I have ever seen in all my years of practice. I instantly knew the risks my baby faced, and I burst into tears as the surgeon explained to my husband and my siblings that immediate surgery was indicated. We requested for a priest to come and the baby was baptized prior to the contemplated procedure. Mika was stable and did not look distressed, which was totally incompatible with the ominous x-ray picture. She was prepared for surgery, and our family and dear friends started storming the heavens for a miracle. After the surgery, the doctor came back into my room with good news he repaired the gastric perforation, and did not find any obstruction. We thanked God for the strength He gave Mighty Mika, and the miracle of a second chance for her. She remained stable and seemed fine every time I would sit with her when I would go into the NICU for Ellas feeding. On the 2nd hospital day, Mika developed a heart murmur, labored breathing and poor perfusion, and was referred to a pediatric cardiologist. Because of her small size, he suggested transferring Mika to another institution which had a better 2-D echocardiography machine that would yield better diagnostic results. We then prepared for the transfer, which was facilitated by midnight.

My family and I came back in May 2010, and we had barely settled down when I began to have hyperacidity, nausea and eventually vomiting, which in my experience signified only one thing that I was pregnant again! After 3 sons, my husband and I were not really planning on adding to the family, but the 2 pregnancy tests that I took proved my suspicions to be all too true. I knew that I was already a high-risk patient since I was now an elderly multigravid. Not wanting to leave anything to chance, I immediately consulted a perinatologist in the hospital nearest our home. In the week following our return, the ultrasound done showed that I was pregnant with twins! And thus began the steady uphill climb that would characterize the course of my pregnancy. I usually had excessive vomiting bouts during the first trimester of all my pregnancies, but this time around, the very high hCG levels in a twin pregnancy amplified my vomiting even more. When I reached my fifth month and the vomiting had just started to abate, I had my second ultrasound which showed that we were expecting girls. My husband and I were ecstatic at the thought of having girls this time around, but the joy dimmed considerably when my doctor told me that there was a double bubble sign in the first twin, accompanied by polyhydramnios, which were both signs that she had some form of gastrointestinal obstruction. I knew that her condition could only be remedied by surgery, and I started to become fearful of the possible outcome when the twins were delivered. Another few weeks went by and my blood pressure, which hovered in the higher limits of normal, became persistently elevated and I had to be maintained on anti-hypertensive medications. By the sixth month, I had already developed edema in my legs, which was quite early compared to my previous pregnancies. Laboratory tests done also showed mild hypothyroidism. Subsequent ultrasound tests showed persistence of the double bubble sign, progression of the polyhydramnios and beginning discordance in the weights of the twins. My perinatologist maintained a calm demeanor but by this time she was asking me to return more frequently for check-ups and by my 32nd week she already advised me to have a course of betamethasone injected in the event that a combination of all the existing conditions would trigger premature labor. It slowly began to sink in that the babies would, in all probability, be born early, so I informed my doctor that I had planned for EINC to be done when I gave birth. It was still the pre-EINC period in the hospital and she acknowledged my request but replied that it would really depend on the twins condition upon delivery. A few days after I had my betamethasone injections, I came in for checkup and while my non-stress test showed that at 33 weeks age of gestation the babies were fine, I had to be confined for blood pressure control. Soon I was being treated for pre-eclampsia, and after 3 more days my OB made the decision to do emergency cesarean section due to non-reassuring fetal heart rate patterns. Having previously delivered all my sons by NSD, I was terrified at the thought of undergoing surgery this time around, and I was crying as they wheeled me into the operating room. My anesthesiologist gently reminded me that crying would hinder my breathing and advised me to calm down. I composed myself and asked her not to sedate me because I

Early the next morning, the pediatric surgeon at the second hospital saw Mika and the repeat x-ray again showed a significant re-accumulation of free air in the abdominal cavity. He offered us two options he could insert an abdominal drain at bedside to relieve the pneumoperitoneum (air leak) or do another exploratory laparotomy to look for the obstruction which he believed was the cause of the perforations. We immediately agreed to the surgery, and true enough the exploration revealed an annular pancreas as the root cause of all the complications. The surgery went well and Mika finally seemed on her way to recovery. Back at the first hospital, 3-day old Ella was still maintained in an incubator and had an IV line for calcium supplementation. She settled into a regular feeding schedule of every 2-3 hours and I would immediately go to the NICU as soon as she showed signs of being hungry. After one particular feeding, however, the nurse called me back because the baby was crying again. It was just an hour after the feeding and I was wondering why she was agitated. I went to the NICU and as soon as I held her in my arms she

Mika was stable and did not look distressed...She was prepared for surgery, and our family and dear friends started storming the heavens for a miracle

KWENTONG UNANG-YAKAP
We continued with our prayers of thanksgiving that both girls were doing very well and asked that God grant us the continued strength to overcome all obstacles until such time that the twins were together once more
RIGHt: Mika and Ella: together again.

stopped crying and promptly went to sleep. The nurse remarked that maybe she just wanted to be held. This made me resolve to have her roomed-in right away despite all the contraindications that traditionally dictated that low birth weight premature babies should remain in the Nursery/NICU. I requested the neonatologist to already remove the IV fluids of Ella because since birth she was able to breastfeed well, and I also asked that they start weaning her from the incubator. I kept pestering the nurses on duty to remind the neonatologist about the IV and weaning, and after another day, Ellas IV line was finally removed and she was transferred to a bassinet. That night I asked that she be roomed-in because I planned to take her home the next day when I was due to be discharged. So she was brought to me and we spent the night on skin-to-skin contact to ensure that she would not become hypothermic. The next morning, the neonatologist made rounds and I assured her that I would monitor my baby very closely at home and make sure that she is always thermoregulated. She looked at me with some uncertainty because Ella was only a few days old, was still losing weight (she was now down to 1.44 kg) and had been out of the incubator for only half a day. She reluctantly agreed despite the babys weight because she was reassured by the fact that I was also a neonatologist. I heaved a sigh of relief because I couldnt bear to leave her alone in the hospital after all the time we spent together breastfeeding. When we got home, I was delighted to have Ella with me but then the realization that I brought home a tiny baby who was 1.4 kg and not quite 4 days old hit me and I began to have doubts if I made the right decision. It was one thing to absolutely refuse to leave her with strangers but caring for her at home was an entirely different thing altogether. Our first few days together revealed what a truly complicated situation I had gotten myself into. As a neonatologist, I had gotten used to just taking for granted the orders I wrote on the charts of my growers: strict thermoregulation, feeding with increments every 3 hours, supplementation of feeding and daily weighing. With Ella, I was now doing all these things myself and I developed a renewed appreciation for the NICU nurses who did these things routinely, day in and day out. Everything that was being given to Mika in the NICU, Ella was also getting at home. Aside from breastfeeding Ella I would also be pumping out my milk several times each day, then would measure out the multivitamin drops, virgin coconut oil or be adding human milk fortifier to the expressed breast milk and would feed this to her by cup or by syringe. We struggled with the supplemented feeding at first, but after some time, she got the hang of it and was able to do syringe feeding effortlessly. There was one time that the NICU nurse texted us that Mikas milk supply was running low, and

then she also asked how Ella was being fed at home. I said that aside from breastfeeding she preferred being fed by syringe and the nurse replied that Mika, too, preferred the same method of feeding. I smiled at the thought of the invisible bond between the twins being evident even that early. In the NICU, Mika was tolerating her feedings already and the volume was gradually increased. I had to pump out more milk for the two of them and when it was not enough, we had to get from the milk banks of 2 large tertiary hospitals, and were lucky if it was available. Mikas doctor also referred me to her previous patient who had established a milk bank of sorts in her home and was giving breast milk for free to those who needed it. Another pediatrician-friend referred me to the mother of her patient who was regularly storing her excess breast milk and on several occasions she gladly shared her milk with our twins. Mika continued to recover steadily, and was already tolerating full feeds for 2 weeks when she developed fecaloid vomiting due to post-operative adhesions. I slumped in my seat after hearing the news, and was worried that she might need to undergo surgery once more. Thankfully the obstruction resolved with medical management and after 2 days she was able to resume feeding again. She had a second bout of infection, and had to complete another course of antibiotics. She was also given a blood transfusion to correct anemia. Her hearing screening, cranial ultrasound and ophthalmologic evaluations were all normal, and she was gaining weight again. Ella at home was not gaining weight as rapidly, but remained in stable condition. At this time she seemed to be quite pale, but did not become symptomatic and did not require a blood transfusion. We continued with our prayers of thanksgiving that both girls were doing very well and asked that God grant us the continued strength to overcome all obstacles until such time that the twins were together once more. Finally, after 50 long days in the NICU, Mika was cleared by all her 6 doctors, and exactly a week before Christmas, she was discharged from the hospital. It was the best Christmas gift we could ever hope for, and once again we thanked the Lord for the blessing of having both girls safely home and into our warm Unang Yakap embrace.

Dr. Pinky Imperial is a neonatologist and Co-Convener of Team EINC

Our St lukes Global City Experience

Here is my birthing story:
July 13, 2011 - We left the house at 7:30 AM and got to St. Lukes Medical Center - Global City (SLMC-GC) at 9AM. The traffic was heavy at EDSA. Upon arrival at SLMC-GC and examination I was already 4 cm dilated. I was transferred to the High Risk Pregnancy Unit or HRPU (their private labor room, where hubby can stay with me). I was hooked to a fetal monitor until 12 noon and cervical dilatation did not progress. I had a light lunch of salad and coffee (decaf !). After which, I requested if I can walk around as per my OBs instruction. Since no IV line was inserted, I was free to move around. Pain began to accelerate. I was given the option of having epidural anesthesia. The anesthesiologist even did some preliminary history and evaluation in case I did ask for anesthesia. I said Im keeping my options open. Should I be unable to tolerate the pain, of course I would want some relief. At 2 pm I was already at 5 cm. The pain increased but was still bearable. I would sit then stand and walk around every time there was a contraction. This worked for me as walking made the pain tolerable. At 4 pm, I was tired from walking around and decided to lie down. During this time, I would tear up every time there was a contraction. I was seriously contemplating asking for epidural and even told hubby about it. Suddenly my OB, Dr Cynthia Fernandez-Tan, arrived and her words (and her presence) encouraged me to go on further. I was already at 6 cm by this time. I warned the OB resident that with my 2 previous deliveries, I progressed fast after 5 cm. True enough after a few minutes I felt the urge to push. IE was done and I was immediately wheeled to the delivery room, as I was already 9 cm dilated. Hubby was asked to change into a scrub suit so he can come to the delivery room with me. It was a pleasant surprise! We didnt expect it so we didnt bring the camera with us. The few pictures taken were from his Iphone. [Soon after delivering] the baby was immediately placed on top my tummy where he was wiped dry. The cord wasnt clamped immediately, they waited for the pulsation of the cord to stop before they clamped and cut it. Oxytocin was given per IM on my left arm as I didnt have an IV line. Then the placenta was delivered. My baby on the other hand was directed to my breast and latch was initiated. My baby latched and sucked immediately. Everyone was surprised as most babies would only latch for a while then fall asleep. My baby was wide-awake all throughout (from delivery room, to recovery room until we reached our room). Im proud to say that we were able to follow the Unang Yakap - Essential Intrapartum and Newborn Care (EINC) Protocol. At this point, I was overwhelmed with emotions. The baby was then weighed, measured and dressed up. After he was comfortably dry, he was again given to me to nurse at the recovery room. Since there was no anesthesia to recover from, we stayed at the recovery room for 2 hours only -- just enough time for my own and my babys chart to be updated, endorsement to be done, etc. It was also there that the eye ointment was applied to our babys eyes and Hepa B vaccine and Vitamin K were injected. Since SLMC-GC doesnt have any nursery, our baby roomed-in with us. This is to encourage continuous breastfeeding. Downside of this is I didnt get any sleep that night. I was cradling my baby the whole night. I have no regrets in choosing SLMC-GC. I had my husbands presence and support all throughout the labor and delivery process. The doctors, especially Dr. Cynthia Tan, and nurses were very efficient and friendly. They took the time to see how I was doing not because it was their job but because they cared. Whenever I need anything, they were just one press of a button awayand, most importantly both I and my baby had a safe birthing experience.

MEEt tHE tEAM

Editors Dr. Maria Asuncion A. Silvestre, Dr. Cynthia Fernandez Tan Managing Editor Marcia F. Miranda Feature Editors Donna Miranda Medical Editor Dr. Louell Sala Medical Contributors Dr. Teresita Cadiz-Brion, Dr. Donna Capili Dr. Ma. Lourdes Imperial, Dr. Jessamine Sareno, Dr. Francesca Tatad-To Dr. Ernesto Uichanco Bulletin Advisors Dr. Anthony Calibo, Dr. Ivan Escartin, Dr. Mariella Castillo

FEEDBACK, Comments and Questions PlEASE! Ask your questions and Team EINC will be pleased to respond. Write us at unangyakap@gmail.com and we will answer you quickly. Give us your feedback and comments so we can improve our Bulletin. Thank You! the Editors Go Unang Yakap 4 & 5

Programang EINC ating tangkilikin, Sa lahat ng Ospital pribado man o pambayanan Klinika man o lying in Kalinga sa Inat sanggol tunay na bigay pansin Kaligtasan nilay tiyak, Serbisyong Unang Yakap siguradong laging hanap.
-Elly Capito Jose Reyes Memorial Medical Center

The EINC Bulletin is a publication under the Department of Health EINC ScaleUp Project with assistance from the World Health Organization and the Joint Program on Maternal Neonatal Health funded by AusAid . It popularizes and disseminates information and activities related to scale-up efforts of Essential Intrapartum Newborn Care (EINC) in DOH-retained Hospitals for safe and quality care of birthing mothers and newborns. The findings, interpretations and conclusions expressed in this publication are entirely those of the authors and should not be attributed in any manner whatsoever to the Department of Health, the World Health Organization or to AusAid.