Posted in Unang Yakap

Unang Yakap, Part 3 (on Nonseparation of the Newborn and Mother)

Step 4 of the Unang  Yakap protocol is Non-separation of the newborn from mother for early breastfeeding.  It is probably the most difficult step to implement because it requires teamwork, a change in the general mindset surrounding the birthing process, and revising hospital policies.

Non-separation of the newborn and mother are crucial to the success of the Unang Yakap initiative, and of all 4 steps, this has the longest-lasting implications and the greatest benefit.

Scientific Data Supports Breastfeeding as an intervention for preventing newborn death

In 2003, the medical journal The Lancet published its Child Survival Series which identified 15 preventive interventions that together could prevent 60% of childhood deaths worldwide.  Breastfeeding topped this list, and it was projected that if 90% of mothers were to breastfeed exclusively for the first 6 months, 13% of worldwide deaths before the age of 5 could be prevented.

In 2008, a study by L. Mullany and peers involving 28,000 babies in Nepal  (published in the  Journal of Nutrition)  demonstrated that delaying the initiation of breastfeeding increases the risk of newborn death from infections.  Their findings showed that delaying the first breastfeed to anywhere from 1 hour of age to 24 hours of age resulted in a doubling of the risk of death from infection.  Waiting until 24-48 hours for the first breastfeed tripled this risk, and delaying the first breastfeed until 48-72 hours quadrupled the risk of death.  An earlier study from Ghana also showed similar findings.

A randomized control trial by J. Narayanan published in the Lancet almost 20 years ago examined the percent of serious illness among low birth weight infants (infants weighing less than 2500g at birth) who were randomly assigned to feed breast milk or formula.  Results showed that serious illnesses occurred 400% more frequently in infants fed formula alone compared to infants on raw expressed breastmilk alone.  Due to ethical considerations, this type of study cannot be repeated today.

Before and After

What is the traditional birth experience in a hospital in the Philippines without Unang Yakap?  The baby is delivered, the cord cut, the infant taken to a bassinet or warmer for drying, then wrapped in a blanket and briefly shown to its mother and father.  It is quickly spirited away to the nursery for weighing, measuring, a full physical examination, bathing, a Vitamin K shot and Hepatitis B vaccine administration.  The baby is kept in the nursery in a bassinet or incubator until the mother is ‘ready’ or the baby is ‘stable and cleared for rooming-in’ (deemed normal and well enough to be placed in the hands of its mother).  While awaiting this all-important reunion, the baby is fed a bottle of glucose water or formula every few hours.

What Step 4 proposes is that after the baby is dried, placed on its mother’s chest, covered in a bonnet and blanket; and after the cord is cut; that the baby be left in skin-to-skin contact with the mother until he/she is ready for the first breastfeed.  This means delaying weighing and measuring, delaying a full physical exam (a quick one is performed when the infant is being dried, and both mother and infant are regularly monitored every few minutes after birth), delaying the Vitamin K shot and any vaccines, until the first breastfeed has been completed.  Bathing should be delayed until the baby is at least 6 hours old or longer.

The goal of step 4 is to protect the first breastfeed, and to allow it to happen spontaneously at the appropriate time and in the appropriate manner.  Weighing, measuring, unnecessarily handling the baby, and performing painful procedures can all disrupt the infant’s natural instinct to locate the breast and begin feeding.  And while all these are important in newborn care, none of them are so important that they cannot wait until after the first breastfeed is complete.

The study by Dr. Sobel and colleagues that looked at hospital practices in the Philippines showed that most newborns were put to the breast by 10 minutes of age, but they were also removed from the breast a mere 2 minutes later.  The truth is, most babies are not ready to breastfeed until they are about 20-60 minutes old, and it is a process that happens gently and gradually.  The new baby who is placed on its mother’s chest begins to look around, lick its lips and will salivate.  He or she uses smell to localize the mother’s areola (which is why we shouldn’t ‘clean’ the mother’s nipples with alcohol or other substances), kicks gently and moves over to the breast, finds the breast and latches on.  A good first breastfeed can last 10, 20 or 30 minutes.  Sometimes it will last longer.
Once the first breastfeed is complete, measuring, weighing, examinations and injections can all be done at the bedside.  Mother and newborn should be treated as a single unit – they should be monitored together and transferred to the room together.
Mother and baby being transferred to their room together. Photo courtesy of the Essential Intrapartum and Newborn Care Team
Mother and baby being transferred to their room together. Photo courtesy of Team EINC and WHO Philippines
Soon-to-be parents who are hearing about non-separation for the first time often worry that being with the baby from the very beginning means they will be more tired and that the mom will have no opportunity to rest.   But feedback from mothers who have undergone the Unang Yakap experience, especially mothers who are giving birth for the 2nd or 3rd time, has been overwhelmingly positive.   Many have said that the experience is beautiful and joyful, and that they wish they had been able to do it with their previous births.  Nurses who were once concerned that monitoring babies and mothers together would be too taxing, have said that it is much easier to continue to assist mothers who were able to successfully breastfeed at the very beginning, rather than try to teach a mother how to breastfeed her baby who is already a day or 2 old.
Babies who are breastfed within the first hour of life have a lower risk of infection and death, and a higher chance of breastfeeding exclusively and for a longer period of time.  This translates to numerous long-term benefits including an increase in IQ, protection against gastrointestinal infections, allergic disease, obesity, diabetes, childhood leukemia and lymphoma, and SIDS (Sudden Infant Death Syndrome).  Breastfeeding benefits for the mother include decreased postpartum blood loss, improved child spacing, decreased risk for  postpartum depression, chid abuse or neglect, type 2 diabetes, rheumatoid arthritis, cardiovascular disease, and breast and ovarian cancer.  The economic benefits are significant as well.
Early reports from hospitals that have committed to the practice of Unang Yakap show that it does work – fewer babies are sick,  less babies are admitted to NICUs.  But in order to have the fullest impact, the program needs to be adopted by all. Ask your Obstetrician, Pediatrician or midwife about Unang  Yakap.  Talk to other parents and to your local health care providers about it and please help spread the word!
Posted in Unang Yakap

Unang Yakap, Part 2

This post is a continuation of Unang Yakap, Part 1 posted a few days ago.  Today I will discuss step 3 in the newborn protocol:  Properly-timed cord clamping.

But before we do that, let’s review our steps.  1) Immediately after a baby is born, he/she should be dried thoroughly for at least 30 seconds.  2) Once the baby is dry (and at this point should be breathing well),  he/she is placed naked on the mother’s bare tummy or chest.  A bonnet should be placed on the baby’s head and a blanket on its back to help keep him/her warm.

At this point, the person attending the delivery (Obstetrician or midwife) should be holding the umbilical cord, feeling for its pulse and waiting for those pulsations to stop.  When the pulsations stop, the cord is clamped and cut. This is step 3.

Until recently, cutting the umbilical cord immediately after birth was the standard of care in the Philippines and many other parts of the world.  Studies have shown that this practice is not beneficial, and can actually deprive a baby of part of its blood volume.

While inside the womb, a newborn’s blood circulates through its own body, the umbilical cord and the placenta.  When the baby is born, blood that is contained in the placenta moves through the cord and back to the baby.  The cord pulsates during this time and pulsations stop when the job is done.  This typically takes about 1-3 minutes.  If the cord is cut immediately after birth, there isn’t enough time for blood that is in the placenta and cord to be returned to the baby, and the baby is deprived of a portion of his/her own blood.

Why does the extra blood matter?  Blood carries oxygen, and this extra oxygen is very helpful to babies when they make the transition from life in the womb to life in the outside world.  Blood also holds most of the iron in our body, so babies whose cords are cut immediately are 80% more likely to develop anemia in their first year of life.

In preterm babies, the standard practice is to cut the cord immediately.  This is because doctors assume that the baby is going to need some assistance with breathing and may need even further resuscitation.  However, more recent published data has shown that waiting 30 seconds to 1 minute to clamp the cord of a preterm infant decreases the risk of brain hemorrhage (a serious complication that premature babies are at risk for) and cuts the risk of anemia in half.  There are many other potential benefits to preterm babies as well, including protection against infection.

Here is a wonderful video by Penny Simkin that clearly illustrates where a baby’s blood goes when it is born, and why it is a good idea to wait before clamping the cord.

Waiting to clamp the cord until the appropriate time is clearly helpful to babies and poses no danger to the infant or its mother.  This is Step 3 in the Unang Yakap protocol.

I hope this was helpful.  I will discuss step 4 ( Non-separation of the newborn from the mother for early breastfeeding)  in my next post.  In the meantime, feel free to comment and ask questions!

To read on to Part 3, click here https://drzeka.wordpress.com/2013/08/27/unang-yakap-part-3-on-nonseparation-of-the-newborn-and-mother/

Posted in Unang Yakap

All About ‘Unang Yakap’ (or “First Embrace” in English), Part 1

“Unang Yakap” which literally translates to ‘First Embrace’ is the tagline for Essential Intrapartum and Newborn Care (EINC), a program of the Philippine government in cooperation with the United Nations Joint Program for Maternal and Newborn Health (JPMNH – World Health Organization and UNICEF), supported by AusAid.   The program aims to decrease neonatal mortality and improve maternal health.  It was designed for implementation in the Philippines but is universally applicable and should be beneficial to mothers and babies everywhere.

This series of posts is designed to help the lay person understand this life-saving initiative and will discuss the scientific evidence behind it.  For this reason I will be leaving out some technical detail, but I hope it will be interesting to medical professionals and health care personnel as well.

How serious is the problem of neonatal mortality in the Philippines?

The Philippines is one of 42 countries that account for 90% of worldwide deaths in children under age 5.  According to WHO statistics from 2011, 25 of every 1000 Filipino children are likely to die by age 5.   Half of these children are neonates (infants 0-28 days of age).   In 2011, there were approximately 2,358,000 live births in the country.  This translates to over 28,000 newborn deaths in one year alone.  While 12 newborn deaths per 1000 live births is an improvement from 22 per 1000 in 1990, the rate has not decreased significantly in the last 6 years.  To compare, the neonatal mortality rate (NMR) in the United States is 4 per 1000 as of 2011.  In Japan, it is 1 per 1000.

Prematurity, asphyxia and infection together cause over 60% of neonatal deaths, and 75% of deaths occur within the first 7 days of life, with the vast majority dying within the first 48 hours.  Because of this, the Unang Yakap protocol addresses the first 7 days of life, focusing on the time immediately surrounding birth.

In the Philippines, health care is more accessible to those who can afford it. As such, one might assume that the majority of newborn deaths occur among the poorest in the country.  While it is true that the rates are higher among the poor (20 per 1000), even among the richest quintile of our population, the NMR is unacceptably high at 10 per 1000 live births.  The logical conclusion is that the problem is system-wide and may not be solely financial in origin.

A study by Drs. Sobel, Silvestre, Mantaring, Oliveros and Nyunt-U published in 2011 evaluated the minute-to-minute newborn care performed in 51 large hospitals in the Philippines.  The data they obtained allowed them to identify and address steps in early newborn care that were likely contributing to neonatal infection and death.   This resulted in the creation of the Essential Intrapartum and Newborn Care Protocol, more commonly known as “Unang Yakap”.   The hope is to provide a standard of care for mothers and newborns at the time of birth regardless of where they deliver, be it a birthing center, a primary care hospital or a large referral center.

Performing these 4 Simple Steps in proper sequence at the time of birth can save newborn lives:

  1. Immediate Thorough Drying
  2. Immediate Skin-to-Skin Contact
  3. Appropriately-Timed Cord Clamping
  4. Nonseparation of newborn from mother to allow for early breastfeeding

*Edit: More than 90% of babies being born are eligible for all 4 steps – well term babies, well preterm babies, babies delivered via Cesarean Section (with minor modifications in the protocol), even multiples (twins, triplets).  Babies who require immediate resuscitation or babies of mothers who are critically ill may need to be separated temporarily but can still benefit from some of these steps.

I will discuss the first 2 steps today.

IMMEDIATE THOROUGH DRYING

It used to be standard practice (and is probably still common) for a doctor or midwife delivering a baby to first take a bulb suction or catheter as soon as the baby is out, and use it to clear the mouth and nose of the newborn.  This practice is no longer recommended, in the same way that we no longer hang a baby upside down by its feet or slap its back to make him/her cry.  The current recommendation is to suction a baby’s mouth and nose only if it is blocked by secretions.  Suctioning provides no benefit to babies who have clear airways, and may cause a slowing of the baby’s heart rate and breathing.  It can also injure mucosal surfaces, increasing the risk for infection in the newborn.

Instead, experts in newborn resuscitation recommend immediate thorough drying (wiping off any moisture with a dry, warm blanket, taking care to leave the vernix -that white, cheesy substance covering a newborn – intact) for a full 30 seconds as the first step to be performed when a baby is born.  Drying stimulates breathing and prevents hypothermia, which can lead to numerous undersirable consequences in a newborn, including infection, breathing abnormalities and a delayed adjustment of the blood circulation.   With drying alone, 95% of newborns will breathe normally at birth. Less than 5% of babies will require further resuscitation and even so, immediate and thorough drying needs to be done before anything else can follow.

IMMEDIATE SKIN-TO-SKIN CONTACT

Most women who have given birth in a hospital in the past few decades will remember that their baby was immediately wrapped in a blanket and put in a bassinet or taken away to the nursery.  Many women who are having babies in the Philippines today may be shocked when instead of doing that, their physician or midwife places their naked newborn on their tummy or chest immediately after the baby is wiped dry.

While it is commonly thought that the sole benefit of skin-to-skin contact between a mother and her newborn is to promote mother-infant bonding, current evidence shows that the benefits of immediate skin-to-skin contact extend way beyond forging an emotional connection.  The act reduces infant crying, keeps the baby warm, and promotes successful breastfeeding.  It exposes babies to helpful bacteria on the mother’s skin, helps them maintain their temperature, and keeps their blood sugar levels from dropping.  In the past, it was thought that this practice could wait until the mother and baby were both declared ‘stable’, but we now know that doing this immediately actually helps ‘stabilize’ the baby.

Immediate skin-to-skin contact.  Photo courtesy of the Essential Intrapartum and Newborn Care Team.
Immediate skin-to-skin contact. Photo courtesy of Team EINC and WHO Philippines

To read on to Part 2, click here https://drzeka.wordpress.com/2013/08/27/unang-yakap-part-2/