March 12, 2012
A personal experience with EINC
Just the other week, I attended a workshop on Essential Intrapartum and Newborn Care (EINC). This is a program of the Department of Health, Philippine Health Insurance Corporation and the World Health Organization in an effort to make the Philippines meet the Millenium Development Goal (MDG) 5 (reduce maternal deaths). EINC are evidence-based standards recommended for both government and privately-owned hospitals. In layman's lingo, it is called "Unang Yakap" which literally means "first embrace".
(To explain everything here would take too long so let me direct those who are interested to the EINC brochure.)
The program is divided into Essential Intrapartum Care (EIC) and Essential Newborn Care (ENC or Unang Yakap).
For the EIC, the usual interventions such as enemas, shaving, restriction of food and fluid intake, intravenous fluid, early amniotomy (rupturing of the bag of waters), augmentation of labor and fundal pressure to aid in the expulsion of the baby, are discouraged. Instead, the following are recommended:
1. Continuous maternal support by having a companion of choice during labor and delivery
2. Freedom of movement during labor
3. Monitoring progress of labor by the partograph (labor graph)
4. Non-drug pain relief before offering labor anesthesia
5. Position of choice during labor and delivery
6. Spontaneous pushing in the semi-upright position
7. Non-routine episiotomy
8. Active management of the third stage of labor
In a nutshell, the four main interventions (or more aptly, non-interventions) of Unang Yakap are:
1. Immediate and thorough drying of the newborn
2. Early skin to skin contact between the mother and the newborn
3. Properly timed cord clamping and cutting
4. Non-separation of the mother and newborn for early breastfeeding
After half a day of lectures on the evidences which formed the basis for the EINC, the policies of the program and the actual steps involved, we were given a chance to role-play using a baby doll. I was assigned to the group of Dr. Pinky Imperial who patiently tried to change our usual habits in labor and delivery. For somebody who has been in practice for more than 25 years (moi!), it is quite difficult to change my almost instinctive movements.
THE ACTUAL EXPERIENCE
The most difficult part of a journey is the first step. In this case, I resolved to do it in my next delivery. And so it came to pass that my next delivery is from my cousin's daughter-in-law named Red, in a hospital where we have not had the EINC workshop so I had to call out the steps to the staff. They have an idea of what Unang Yakap was, but there was never an actual experience, until today, March 7, 2012.
Let me run through the EIC:
1. Companion - our standard hospital policy is that non-medical personnel are not allowed in the sterile areas, which includes the delivery room (that is why the EINC requires the hospital administration to be part of the program). I am an aunt-in-law to the 2nd degree of the woman in labor. Maybe that can qualify me for the companion who gave moral support.
2. Freedom of movement during labor - not done because I gave epidural anesthesia when the pain became too much for Red.
3. Labor graph - fortunately, this is a standard practice in our hospital.
4. Non-drug pain relief before anesthesia - we did give "verbal anesthesia" (encouragement) but eventually we had to give epidural (see no. 2).
5. Position of choice - although Red was lying down, we allowed her to flex her legs because her pushing was more effective in this position.
6. Semi upright position - since our OR bed was a straight one, we made her hold onto the bed railings to attain a semi-upright position, while a staff supported her back.
7. I held out doing an episiotomy (cutting of the vaginal outlet) until it became clear that she was going to tear. I did a modest cut just enough to let the head out.
8. Oxytocin drip was increased to aid in expelling the placenta.
NOW THE ENC
1. As soon as the baby was out, I placed him on Red's abdomen and helped the staff in drying up.
2. As soon as the baby was dry, I held him face down against Red's bare chest and changed the wet blanket with a dry one. I asked Red to hold her baby. Not having a bonnet ready, the pediatric resident used the upper portion of the blanket to make a makeshift bonnet.
3. While I was busy drying the baby, my assistant held on to the umbilical cord and notified me when the pulsations stopped. I asked for the plastic clamp but being not ready for this, the nurses did not have it with them. So, instead of cutting 2 cm from the stump, I clamped the cord with the forceps 5 cm from the stump, placed the 2nd forceps about an inch away and cut. When the staff came with the plastic clamp, they put it in the proper distance and I cut off the excess cord.
4. As soon as the baby came out, he was crying his lungs out but as soon as we placed him down against his mother's chest, he slept. In about 10 minutes, he started drooling saliva. About five minutes later, he started sucking his fingers. Having seen the feeding signs, we helped him find the nipple by placing him against the nipple. As soon as he felt the nipple, he sucked. All done in 20 minutes. Hooray!
It was quite difficult to adhere to EINC when the facilities are not compatible with the guidelines. Newer hospitals have birthing beds which are ideal for this kind of delivery. However, these are quite expensive. Filipino ingenuity produced a delivery bed with a semi-upright back made of wood at Tondo Medical Center. Another suggestion is to make wedge shaped back support which can be placed atop regular OR tables.
All in all, even if we were not prepared and just feeling our way through, I could say the experience taught us that with determination, we can incorporate EINC into our setting. I asked Red what she thought of the experience. She said it was different but she was very happy because she saw and held her baby at once, unlike her previous delivery when she had to wait for a day. Her satisfied smile is enough reward for me.
If you have questions for Dr. Malu, you can email her at email@example.com.
Dr. Ma. Luisa V. Torralba-Mangubat is a Fellow of the Philippine Obstetrical & Gynecological Society, Philippine College of Surgeons and International College of Surgeons. In addition to this, she is also a Fellow in Aesthetic & Medicine Surgery of the Philippine Academy of Medical Specialists and a member of the Philippine Academy of Non-Surgical Aesthetics. For personal consultations, her clinic hours are as follows:
Asian Hospital and Medical Center, Room 722
Monday, Wednesday, and Friday, 8 a.m. to 10 a.m.
Tel. (632) 771-9340
Medical Center Manila, Room 337
Monday, Wednesday, and Thursday, 1 p.m. to 6 p.m.
Saturday, 9 a.m. to 1 p.m.
Tel. (632) 528-1173