Essential Newborn Care Implementation

Table of Content

Newborn care is the most essential procedure in the delivery room, it is a procedure or a proper way of handling the baby and implementing the proper way for the newborn. A newborn baby can acquire complications if the procedure was incorrectly performed.

The Intrapartum/Newborn Practices assessment tools were developed through a collaboration between the Philippine General Hospital and World Health Organization (WHO) with Department of Health (DOH) (Sala, 2011). The Essential newborn care protocol is a step-by-step guide for health workers and medical practitioners issued by the Department of Health for implementation under Administrative order 2009-0025 (Sala, 2011).

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The Department of Health embarked on Essential Newborn Care , a new program to address neonatal deaths in the country. Under the umbrella of the Unang Yakap Campaign, Essential Newborn Care is an evidenced based strategic intervention aimed at improving newborn care and helping neonatal mortality ( KATHARINA, 2010). The Essential Newborn Care package is a four-step newborn care time-bound intervention undertaken to lessen newborn death.

First is Immediate and thorough drying to stimulate breathing after delivery of the baby; and provision of appropriate thermal care through mother and newborn skin-to skin contact maintaining a delivery room temperature of 25-28 degrees centigrade and wrapping the newborn with clean dry cloth; properly timed clamping and cutting of the umbilical cord, (1-3 minutes or until cord pulsation stops);non-separation of the newborn and mother for early breast-feeding for the immediate latching on and initiation of breastfeeding within first hour after birth (KATHARINA, 2010).

A study conducted at the University of Alabama at Birmingham (UAB) Division of Neonatology shows that training birth attendants in essential newborn-care techniques reduced stillbirths by more than 30 percent and potentially could save as many as 1 million lives worldwide each year (Carlo 2011). Another study by U. S. researchers looked at the effectiveness of a newborn care program developed by the World Health Organization (WHO), and found that it reduced by more than one-third the number of newborn stillbirths in six countries where it was tried (Berman 2010).

Berman (2010) states that the effectiveness birth techniques, among 120,000 births revealed the rate of stillbirths dropped from 23 per 1,000 deliveries and 16 stillborn babies per 1,000 births. World Health Organization(WHO) (2012) states that Philippine research has also documented that these evidence-based newborn care interventions are not practiced sufficiently. It is on this premises that the current study was conducted to determine the essential newborn care emplementation among delivery/operating room nurses at Adventist Medical Center, Tibanga, Iligan City.

Theoretical Framework The study made use of the Social Learning Theory by Albert Bandura(1977) and the Human Care by Jean Watson(2003). Albert Bandura’s (1977) Social Learning theory is a learning theory based on the ideas that people learn by watching what others do, and that human thought processes are central to understanding personality. The social learning theory of Bandura emphasizes the importance of observing and modeling the behaviors, attitudes, and emotional reactions of others.

Bandura (1977) states: “Learning would be exceedingly laborious, not to mention hazardous, if people had to rely solely on the effects of their own actions to inform them what to do. Fortunately, most human behavior is learned observationally through modeling: from observing others one forms an idea of how new behaviors are performed, and on later occasions this coded information serves as a guide for action. ” Social learning theory explains human behavior in terms of continuous reciprocal interaction between cognitive, behavioral, an environmental influences.

The component processes underlying observational learning are:

  • Attention, including modeled events (distinctiveness, affective valence, complexity, prevalence, functional value) and observer characteristics (sensory capacities, arousal level, perceptual set, past reinforcement).
  • Retention, including symbolic coding, cognitive organization, symbolic rehearsal, motor rehearsal).
  • Motor Reproduction, including physical capabilities, self-observation of reproduction, accuracy of feedback,
  • Motivation, including external, vicarious and self-reinforcement.

Because it encompasses attention, memory and motivation, social learning theory spans both cognitive and behavioral frameworks (Kendra Cherry, 2012). This study is also anchored on the theory of human care by Jean Watson (2003) , as cited by kozier (2008) that the practice of caring is central to nursing: it is unifying focus for practice.

Watson outlines the 10 following factors which she reffered to as carative factors like forming a humanistic-altruistic system of values; instilling faith and hope; cultivating sensitivity to one’s self and others; developing a helping- trust relationship; promoting and accepting the expression of positive and negative feelings; systematically using the scientific problem-solving method for dcision making; promoting interpersonal teaching-learning, providing a supportive, protective, or corrective mental, physical, socio-cultural, and spiritual evironment; assisting with the gratification of human needs and; allowing for existential-phenomenological forces Watson’s theory of human caring has received worldwide recognition and is a major force in rendering nursing as a caring-healing model. Conceptual Framework Essential Newborn Care (ENC) represents the highest standard for safe and quality care for birthing mothers and healthy newborns in the 48 hours of the intrapartum period and up to a week of life of the newborn.

Its adoption helps reduce maternal and newborn morbidity and deaths. It supports the national commitment to the United Nations millennium Development Goals (MDG) 4 by the year 2015 (DOH, 2012). This study composed of independent variables which might influence on the dependent variables of the study. The first box is the Independent Variables identified includes the personal profile of the respondents such as age, gender, years of hospital experience, employment status and the Essential Newborn Care (ENC) Training. The dependent variable focuses on the Essential Newborn Care such as drying newborn, skin to skin contact, followed by the Properly Timed Cord Clamping and Initiation of Breastfeeding.

Drying is for protecting from cold stress and hypothermia, immediate and thorough drying stimulates breathing. It should be the immediate first action for all newborns, regardless of gestational age or birth weight (DOH , 2012). Skin to skin contact is generally perceived to be an intervention for provision of warmth and bonding between newborn and mother. less well appreciated are its conbtributions to immunoprotection of the newborn and to the protection hypoglycemia (DOH, 2012). Properly timed cord clamping has traditionalluy been the standard in the country. Properly timed cord clamping increases the infant’s blood volume and iron reserves, and reduces the incidence of iron-deficiency anemia in infancy (DOH, 2012).

Initiation of breastfeedingmay reduce neonatal mortality by decreasing the ingestion of infectious pathogens. Early breast milk also provides many immunocompetent fctors, including immunoglobulins (antibodies) and lymphocytes (white blood cells) that may stimulate humoral or cell-mediated immune systems (DOH, 2012).

Is there a significant relationship between the respondents ENC implementation and their personal profile in terms of age, gender, years of hospital experience, employment status and essential newborn care training? Hypothesis The null hypothesis was tested at 0. 05 level of significance: Ho1: There is no significant relationship between the respondents personal profile and their ENC implementation status. Significance of the Study Essential Newborn Care must ensure the quality of needs and to spread the use the protocol to prevent at least half of newborn deaths without additional cost to both families and hospital. It is time to rapidly reduce neonatal mortality (DOH,2012).

The result of this study woud be beneficial to: Clientele: The study will be benificial to both mother and newborn to improve health, enhance recovery and prevent complications. Nursing Service: The result of the study will give them information on the implementation status of the Essential Newborn Care (ENC) among OR/DR Staff in the hospital. Nursing Education: The findings of the study will strengthen the implementation of the ENC procedure by the Clinical Instructor during skills enhancement, lectures and as well as during clinical exposure in the hospital among the students. This will help the students to be better equipt on tthe Essential newborn Care(ENC) Practice.

Future Researchers: The findings of the study will serve as basis for similar and other related studies in this particular area. Scope and Delimitation This study consists of 10 registered nurses who assisted the OB-Gyne Doctors during the essential Newborn Care Implementation at the delivery room regardless of their age, gender, years of hopital experience, employment status, ENC training at Adventist Medical Center, Tibanga, Iligan City. The study was conducted from February to March 2013.

This refers whether the respondents is male or female. Years of Hospital Experience. This refers to the time in which the respondents works in the delivery room. Employment Status. This refers to the respondent working either as a regular, contractual or reliever in the hospital. Essential Newborn Care (ENC) training. This refers to the ENC training received by nurses as well as the doctors either from the CHO or DOH for hospital implementation. Immediate and thorough drying of the newborn. This refers to keeping the Newborn warm with blanket within 30 seconds to one minute while on the abdomen of the mother. Early skin-to-skin contact between mother and newborn.

This refers to early skin-to-skin contact between mother and newborn after immediate and thorough drying of the newborn. Proper cord clamping. This refers proper clamping and cutting of the cord between 1 to 3 minutes. Non-separation of the newborn from the mother for early breastfeeding. This refers to unhurried breastfeeding of the newborn after proper cord clamping and cutting.

Neonatal and post-neonatal deaths declined the slowest over the past 20 years with the reduction of only 9 percent and 7 percent, respectively, from 1988 to 2003. An estimated 82,000 Filipino children die annually before their 5th birthday. More than one-third (37 percent) of these children are newborns less than 28 days old. These newborns die mostly of preventable causes such as asphyxia (lack of oxygen to the brain) or sepsis (severe infection). The highest number of newborn deaths occur in the first two days of life. Factors and conditions surrounding labor, delivery, and the immediate postpartum period have been seen as reasons. Department of Health has emphasized the need to strengthen health services of children throughout the stages.

The neonatal period has been identified as one of the most crucial phase in the survival and development of the child (DOH, 2009). The Millennium Development Goal (MDG) 4, aims for a reduction in under-five mortality by two-thirds by 2015. Childhood death rates in the Philippines have shown a downward trend, but the decline dangerously slowed down in the past 10 years because the neonatal mortality rate has remained almost unchanged. Adminstration Order (AO) outlines specific policies and principles for health care providers with regard the prescribed systematic implementation of interventions that address health risks known to lead to preventable neonatal deaths.

This AO is consistent with AO no. 008-0029 on Implementing Health Reforms for Rapid Reduction of Maternal and Newborn Mortality and supports all DOH initiatives and programs for newborn and child health (DOH, 2009). Department of Health (DOH) Secretary Francisco Duque III convened recently at Hotel Sofitel to discuss the state of newborn care system in the country. Joining Secretary Duque were executives from key health institutions in the country such as officials from health maintenance companies as well as doctors,’ nurses,’ and midwives’ associations. The occasion also formalized the launch of the Essential Newborn Care (ENC) protocol endorsed by the World Health Organization, which offers an evidence-based strategic intervention aimed at improving newborn care and helping curb neonatal mortality (Duque, 2012).

The guidelines are categorized into to the time bound and non-time bound and unnecessary procedures. Time bound procedures should be routinely performed first which is immediate drying, skin to skin contact followed by clamping of the cord after 1-3 minutes, non-separation of the newborn from the mother and breastfeeding initiation. Non-time bound interventions include immunizations, eye care, Vitamin K administration, weighing and washing while unnecessary procedures include routine suctioning, routine separation of newborn for observation, administration of prelacteals like glucose water or formula (The News Today, 2009).

This are the step by step interventions such as: Immediate drying it is Use to clean, dry cloth, thoroughly dry the aby, wiping the face, eyes, head, front and back, arms and legs; Uninterrupted skin-to-skin contact- Aside from the warmth and immediate bonding between mother and child, it has been found that early skin-to-skin contact contributes to a host of medical benefits such as the overall success of breastfeeding/colostrums feeding, stimulation of the mucosa—associated lymphoid tissue system, and colonization with maternal skin flora that can protect the newborn from sepsis and other infectious disease and hypoglycemia; Proper cord clamping and cutting- Waiting for up three minutes or until the pulsations stop is found to reduce to chances of anemia in full term and pre-term babies. Evidence also shows that delaying cord clamping has no significant impact on the mother; Non-separation of the newborn from the mother for early breastfeeding initiation and rooming-in- the earlier the baby breastfeeds, the lesser the risk of death.

Keeping the baby latched on to the mother will not only benefit the baby (see skin-to-skin contact) but will also prevent doing unnecessary procedures like putting the newborn on a cold surface for examination (thereby exposing the baby to hypothermia), administering glucose water or formula and foot printing (which increases risk of contamination from ink pads) and washing (the WHO standard is to delay washing up to 6 hours; the vernix protects the newborn from infection) (WHO, 2012).

According to health center directors, who coordinated the health districts, health posts were not exposed to the The Promotion and Essential Obstetric and Neonatal Care strategy (ProCONE) strategy through this document, but instead through meetings and in an informal verbal manner from the coordinators or professional nurses of the centers to auxiliary nurses of health posts. The auxiliary nurses of health posts became part of quality improvement teams of the health centers. In health center meetings, the use of medical records and the monthly measurement of indicators were explained to personnel (EINC Bulliten, 2011). Related Studies

Noting an alarming stagnation in the country’s neonatal mortality, rate, subsequent studies have documented a marked lack in the practice of newborn care interventions in the biggest health facilities in the country (World Health Organization, 2011). An observational study of consecutive deliveries using a standardized assessment tool to document minute-by-minute newborn care done in the first hour of life was undertaken in 51 hospitals in 9 regions of the country in 2008. The study found that philippine hospital practices prevented newborns from benefitting from their mother’s natural protection in the first hour of life. Further, the performance and timing of evidenced-based interventions in immediate newborn care (WHO, 2012).

In these hospitals, their practices prevented Philippine newborns from benefiting from their mothers’ natural protection in the first hour of life and almost none in the study newborns benefited from the natural transfusion from delayed cord clamping. It should be known that any unnecessary delay and restriction on immediate thorough drying, early and sustained skin-to-skin contact, early latching, rooming in and full breastfeeding, compromised the newborns’ chance for maintenance of warmth and survival beyond the newborn period. Further, these interventions can be integral to hospital infection control practices as they directly reduce risk of neonatal sepsis ( EINC Bulletin, 2011).

Only 3% of the study newborns were dried prior to or with cord cutting and only 1 of 26 with difficult breathing was dried first. Hypothermia can lead to infection, coagulation defects, acidosis, delayed fetal to newborn circulatory adjustment, hyaline membrane disease and brain hemorrhage. Unnecessary delays and resrictions on immediate and sustained skin-to-skin contact, early latching on, rooming in and full breastfeeding compromised the newborns chance for maintenance of warmth and sustained breastfeeding. These earliest interventions contribute to hospital infection control as they directly reduce risk of neonatal sepsis. Almost no newborn benefited from the natural transfusion through non-immediate cord clamping.

A Cochrane systematic review of 7 Randomized Controlled Trials(RCTs) showed that among infants less than 37 weeks of gestation, non-immediate cord clamping is asspciated with fewer transfusions due to anemia or low blood pressure and fewer intraventricular hemorrhages. Full-term neonates also benefit by having lower incidence of anemia (WHO, 2012). Only 61. 3% of newborns was inititated to breastfeeding within the first hour. However, newborns were given a median of only about two minutes to get colostrumn, their immunization. Furthermore, they were being forced to breastfeed at a median of 10 mins, long before the typical newborn would be ready. More than 80% was exposed to hypothermia during washing. The WHO recommends that initial bathing should be six hours after birth or longer.

The vernix was washed off at a median of 8 minutes thereby removing a protective barrier to bacteria such as E. coli and Group B Strep. Furthermore, washing removes the crawling reflex. Virtually all healthy newborns were suctioned unnecessarily, 80% more than once- a practice WHO discourages (WHO, 2012). Accordingly, of all the changes implemented by health posts, 13% (251) were replicas (identical or similar) of the changes implemented in the demonstration phase and 87% (1699) were new changes. The intervention replicated by most health posts (52%) was training in norms, procedures and/or clinical records of care for infants and young children.

The second change most frequently replicated by health posts (48%) was home visits to increase the coverage of care for postpartum women. It is possible that home visits were also implemented in the case of neonates. Most new changes implemented by health posts related to content of care and information, and education and communication (IEC) activities. IEC activities were important to increase the coverage of care (Feria, 2011). The study concludes that the expansion of the Basic strategy from health centers to health posts in San Marcos was informal and not based on proven and documented “change packages. ” The study recommends future spread activities make more deliberate use of existing documentation.

However, the supposition that increased and more systematic use of best practices documentation leads to better implementation and more improvement in indicators could be the subject of another study. Further, the methodology used in collecting data for this study did not allow for a thorough understanding of the process of reception, adaptation and integration of “best practices” into the daily activities of health units. A complementary case study could gain a better understanding of these processes (EINC Bulletin, 2011). Chapter 3 RESEARCH METHODOLOGY This chapter presents the research design, research locale, sampling design, respondents of the study, research instruments, scoring of the instruments, data gathering procedures, and statitical tools. Research Design

This study utilize the descriptive type of research design, to determine the personal profile of the resspondents such as age, gender, years of hospital experience, employment status and there implementation status on the essential newborn care. It further looks into whether their is a significant relationship between the respondents profile and their on essential newborn care implementation. Research Locale This study was conducted at Adventist Medical Center – Iligan City formerly known as Mindanao Sanitarium and Hospital, located at Barangay San Miguel, Iligan City. It is an accredited ISO tertiary hospital with 130 bed capacity. It offers the following services: out-patient department, Radiology, Hemodialysis, Intensive Care,medical, surgical, ob-gyne, pediatric, Dental, Optical services. Respondent of the Study

The respondents of the study consist of all the 10 registered nurses assisting the Pediatrician in the delivery of the newborn regardless of age, gender, years of hospital experience, employment status and there implementation on the essential newborn care. Sampling Technique A purposive sampling technique was used in choosing all the respondents of the study. Accoring to Polit and Beck (2004) purposive sampling, the target population of aggregate cases which we would like to make generalization. Research Instrument This study made use of 9 item questionaire which consist two parts. Part one includes the respondents personal profile such as age, gender, years of hospital experience, employment status and essential newborn care training.

Part two includes 4 items on Essential Newborn Care implementation taken from Essential Newborn Care Unang Yakap Bulliten (2012) such as the Immediate and thorough drying for 30 seconds to one minute warms the newborn and stimulates breathing, early skin to skin-to-skin contact between mother and newborn and delayed washing for at least six hours to prevents hypothermia, infection and hypoglycemia, properly-timed cord clamping and cutting prevents anemia and protects against brain hemorrhage in premature newborns. Properly timed cord-clamping means waiting for the cord pulsations to stop (between 1-3 minutes), non-separation of newborn and mother for early breastfeeding. Scoring of the Instrument

Essential Newborn Care implementation in the hospital and the questionnaire was scored by the respondents using this methods and it vary according to its parts. The first part was to observe the respondents through checking the corresponding box that aligns the entry of each category. The second part of the questionnaire was answered through ticking the number that corresponds to its answer. These numbers contain a specific description that identifies their level of knowledge. These are the descriptive rating scale or perception scale which was used and given below: Fully implemented= 100% Implemented= 75% Partially implemented= 50% Not implemented= 0% Data Gathering Procedure

This study followed a step- by-step process to ensure that the data gathering procedure adheres according to the guidelines concerned and involved. The processes are depicted below: First, a letter or approval was made by the researchers was noted by the thesis adviser. Second, this letter of approval was addressed to the thesis adviser, research coordinator, dean of nursing, vice president of academic affairs and to the vice president for nursing services of the hospital. All signature affixed was also reflected on the letter for the respondents. Third, after the signatories was gathered. The implementation process on the designated date was conducted.

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