Introducing and sustaining EENC in hospitals:
Kangaroo Mother Care for preterm and low-birthweight infants
Introducing and sustaining EENC in hospitals:
Kangaroo Mother Care
for preterm and low-birthweight infants
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Suggested citation. Introducing and sustaining EENC in hospitals: kangaroo mother care for pre-term and low-birthweight infants (Early Essential Newborn Care, Module 4). Manila. World Health Organization Regional Office for the Western Pacific. 2018. Licence: CC BY-NC-SA 3.0 IGO.
Cataloguing-in-Publication (CIP) data. 1. Infant, Low Birth Weight. 2. Infant care. 3. Kangaroo-Mother Care Method. I. World Health Organization Regional Office for the Western Pacific. (NLM Classification: WS420)
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Cover: © WHO/Y. Shimizu – p. 1: © Courtesy of Wao Birthing Clinic Dr Mianne Silvestre/Lanao del Sur – p. 3, by column, a, c, e: © Courtesy of Neonatal Unit, Da Nang Hospital for Women and Children; b: © WHO/Dr Luong Kim Chi; d: © Dr Helenlouise Taylor; f: © WHO/WPRO – p. 5, by column, a, b: © Courtesy of Neonatal Unit, Da Nang Hospital for Women and Children; c: © WHO/WPRO; d: © WHO/Dr Trevor Duke – p. 71, d: © WHO/Dr Luong Kim Chi – pp. 35, 69–73:
© Courtesy of Neonatal Unit, Da Nang Hospital for Women and Children
Foreword ...v
About the EENC modules ...vi
1. Why do we need to focus on preterm infants in the Western Pacific Region? ...1
2. What do we need to do to save preterm infant lives? ...2
2.1 Prevention of preterm births and their complications ...2
2.2 First Embrace: A healthy start for every newborn ...2
2.3 Kangaroo Mother Care (KMC) ...4
3. If KMC is effective, why is it not widely practised? ...6
4. What key actions are required to introduce and sustain KMC in hospitals? ...7
ANNEXES 1. Checklists for reviewing hospital capacity to support KMC ...11
CHECKLISTS 1–9. Review of hospital capacity to support KMC 2. Checklist for developing the KMC action framework...25
CHECKLIST 10. KMC action framework 3. Facilitator’s guide for KMC clinical coaching ...28
4. Checklists for reviewing KMC skills of health workers ...56
CHECKLISTS 11–14. Review of KMC skills of health workers 5. Family support for KMC ...64
CHECKLIST 2. Preterm and LBW practices: Chart reviews of postpartum mothers interviewed ...14
CHECKLIST 3. Preterm and LBW practices: Observations of environments in PNC areas and NCU...16
CHECKLIST 4. NCU admissions for preterm and LBW babies ...17
CHECKLIST 5. Review of availability of key medicines, supplies and equipment for management of preterm and LBW babies ...19
CHECKLIST 6. Review of hospital policies, protocols and standards to support management of preterm and LBW babies ...20
CHECKLIST 7. Staff coaching summary: KMC and EENC ...21
CHECKLIST 8. Hospital register data on preterm and LBW babies ...22
CHECKLIST 9. Staff, space and bed requirements for preterm and LBW babies ...24
– Checklist for developing the KMC action framework CHECKLIST 10. KMC action framework ...26
– Checklists for reviewing KMC skills of health workers CHECKLIST 11. Helping mother position her baby correctly for KMC ...57
CHECKLIST 12. Helping mother breastfeed in KMC ...58
CHECKLIST 13. Helping mother express breast milk herself while practising KMC skills ...60
CHECKLIST 14. Helping mothers and families prevent infection and monitor progress ...62
The World Health Organization, Member States and stakeholders in the Western Pacific Region share a vision for mothers and their children: that every newborn infant has the right to a healthy start in life. Sadly, every two minutes, death comes too quickly – and often need- lessly – to a newborn infant in the Region.
Together, we have taken bold steps to make childbirth and newborn life safer. Member States endorsed the Action Plan for Healthy Newborn Infants in the Western Pacific Region (2014–2020). The plan aims to improve the quality of care for mothers and babies in health facilities, where the vast majority of children in the Region are born.
We offer five teaching modules of Early Essential Newborn Care, or EENC, starting with the Early Essential Newborn Care Clinical Practice Pocket Guide. Countries have already shown that reductions in newborn deaths, infections and intensive care unit admissions are possible in facilities employing EENC.
This volume, Introducing and sustaining EENC in hospitals: Kangaroo Mother Care for pre- term and low-birthweight infants, is the fourth module to guide and accelerate EENC health provider practices in facilities across the Region.
These modules are critical components of the regional plan of sustained action and strong policies utilizing proven methods for saving money and lives. Governments, health-care facilities and families are already saving precious resources, making health systems more accountable and quality care more attainable.
We must push to meet the ambitious but reachable targets of the Sustainable Development Goals: a global maternal mortality ratio of less than 70 per 100 000 live births with no country above 140; and neonatal mortality rates of less than 12 per 1000 births.
To reach these lofty goals, we must work together with Member States and partners to bring high-quality EENC to all mothers and newborn infants in every corner of the Western Pacific Region.
Shin Young-soo, MD, Ph.D.
Regional Director
Module Title Primary user level 1 Annual implementation review and planning guide National and subnational 2 Coaching for the First Embrace:
Facilitator's Guide National and subnational
facilitators 3 Introducing and sustaining EENC in hospitals:
Routine childbirth and newborn care
Hospitals with national support for scale-up 4 Introducing and sustaining EENC in hospitals: Kangaroo
Mother Care for preterm and low-birthweight infants 5 Introducing and sustaining EENC in hospitals:
Managing childbirth and postpartum complications
Module 1 is used at the national and subnational levels to collect data for the development of annual implementation plans and five-year national action plans. National and subnational facilitators use Module 2 to upgrade skills of health workers involved in the management of routine childbirth and newborn care nationwide. In hospitals, EENC teams are formed to regularly assess quality of care and use of data for action using Module 3.
Once excellent routine childbirth and newborn care are well established, coaching and quality of care follow-up are added for Kangaroo Mother Care (KMC) for preterm and low-birthweight infants in Module 4.
Management of childbirth and postpartum complications are treated in Module 5.
FACILITATORS GUIDE
Coaching guide for the First Embrace
E A R L Y E S S E N T I A L N E W B O R N C A R E ( E E N C ) M O D U L E 2
M O D U L E 2
Routine childbirth and newborn care
INTRODUCING AND SUSTAINING EENC IN HOSPITALS E A R L Y E S S E N T I A L N E W B O R N C A R E ( E E N C ) M O D U L E 3
M O D U L E 3
Kangaroo mother care (KMC) for preterm infants INTRODUCING AND SUSTAINING EENC IN HOSPITALS E A R L Y E S S E N T I A L N E W B O R N C A R E ( E E N C ) M O D U L E 4
M O D U L E 4
Managing childbirth and postpartum complications INTRODUCING AND SUSTAINING EENC IN HOSPITALS E A R L Y E S S E N T I A L N E W B O R N C A R E ( E E N C ) M O D U L E 5
M O D U L E 5
2-day coaching KMC for pre-
term & low- birthweight infants
Managing complications Formation
of EENC team
Quarterly EENC assessments through weekly / biweekly progress monitoring meetings to improve clinical practice
p
p
Pacific Region?
Each year 1.9 million infants (12% of all births) in the Western Pacific Region are born preterm (less than 37 weeks of gestational age). An estimated 81 600 of these preterm infants die, representing 50% of all newborn deaths. Approximately 85% of preterm infants are born at 32–36 weeks gestational age and do not require highly specialized care. More than half of preterm deaths are preventable, even without intensive care units.
Kangaroo Mother Care (KMC) – which consists of prolonged skin-to-skin contact, exclusive breastfeeding by the baby sucking or by feeding with the mother’s own breast milk, and close monitoring for illness – prevents the main causes of preterm death and promotes growth and brain development.
What do we need to do to save preterm infant lives?
Primary prevention of preterm births and their complications is the first step in reducing pre- term deaths. After birth, all preterm babies should be cared for according to the principles of the First Embrace and KMC, as these interventions help prevent morbidity and mortality, improve breathing and growth, and contribute to better bonding between mothers, families and babies. In addition, sick preterm babies require special care to manage infections and other problems. This guide describes an approach to KMC, starting in the delivery room.
Many preterm births can be prevented by actions taken before or during pregnancy, which are described in other WHO guides.1
2.1 Prevention of preterm births and their complications
2The introduction of effective interventions to prevent preterm births and complications of prematurity requires changing facility policies, providing coaching to staff and improving the availability of essential medicines.
Key interventions include:
» eliminating unnecessary preterm inductions of labour and caesarean sections;
» antenatal steroids to reduce the risk of breathing problems and other complications;
» intrapartum magnesium sulfate to prevent cerebral palsy; and
» antibiotics for preterm pre-labour rupture of membranes to reduce the risk of infection.
2.2 First Embrace: A healthy start for every newborn
All newborns, including the preterm infants, benefit from interventions included in the First Embrace (Fig. 1). These include:
» labour monitoring and management using a partograph;
» immediate, careful and thorough drying of the baby;
» immediate skin-to-skin contact after drying;
1. Primary Health Care Quality Improvement Guides (PHCQIGs), Module 1: Preventing unplanned pregnancies and Module 2:
Antenatal care (2017). WHO Regional Office for the Western Pacific, Manila.
2.
This benefits babies This harms babies
Drying carefully and thoroughly prevents hypothermia and stimulates breathing; clamping the cord after pulsations stop reduces the risk of anaemia.
Unnecessary suctioning, immediate cord cutting and delayed drying expose preterm babies to infection, hypothermia, breathing and circulatory problems, anaemia, acidosis, coagulation defects, brain bleeds and trauma.
Skin-to-skin contact with the mother keeps babies warm, calm and healthy.
Separation from the mother results in distress, hypo- thermia and exposure to dangerous bacteria.
Initiating immediate and exclusive breastfeeding once feeding cues are present reduces risk of death by 22%.
The first breastfeed is delayed because of incorrect sequencing of actions immediately after birth.
» delayed cord clamping until after pulsations stop (1–3 minutes after birth) and cutting with a sterile instrument;
» initiating exclusive breastfeeding when cues occur (such as drooling, tonguing, rooting and sucking); and
» delaying routine care – weighing, physical examinations, eye care, vitamin K1, immu- nizations – until after completing the first breastfeed.
2.3 Kangaroo Mother Care (KMC)
WHO guidelines recommend KMC for all stable babies less than 37 weeks of age and weigh- ing less than 2000 grams (g). Babies weighing 2000–2500 g may also benefit from KMC.
The main components of KMC are:
» skin-to-skin (STS) contact, as continuous as possible, between the mother (or relatives) and her baby;
» exclusive breastfeeding by the baby sucking or by feeding with the mother’s own breast milk; and
» close monitoring for illness.
Preterm infant mortality can be reduced by half by the near-continuous application of KMC.
KMC has been shown to increase breastfeeding rates; provide effective thermal control;
help stabilize vital signs; decrease morbidity from apnoea, infection and respiratory disease;
accelerate growth; and promote bonding – all of which improve developmental outcomes.
This benefits babies This harms babies
Prolonged skin-to-skin contact keeps babies warm, prevents apnoea, reduces rates of infection and res- piratory disease, promotes breastfeeding, accelerates growth, improves bonding, and reduces deaths by up to 50%.
Babies are often exposed to the dangers of separation including hypothermia, over-medicalization, lack of attention by busy staff, infection and disease.
Cup- or spoon-feeding with breast milk saves lives and prevents illness and malnutrition.
Feeding small babies infant formula increases the risk of pneumonia, diarrhoea, malnutrition, necrotizing enterocolitis and death.
If KMC is effective, why is it not widely practised?
4Misconceptions, scepticism, fear and cultural factors
People incorrectly believe saving preterm lives requires a neonatal care unit (NCU). Health staff who have had no experience with KMC are often unconvinced of its value, while sceptical experts can be influential in creating a climate that resists evidence-based change in practice.
Families may fear caring for fragile, small babies themselves or feel embarrassed about their bodies being exposed while practising KMC. Parents may feel that it is difficult to practise KMC for long periods when they have work commitments and other children requiring care.
Outdated policies
In many countries, stable preterm and low-birthweight (LBW) babies do not receive pro- longed STS contact and early and exclusive breastfeeding. Instead they are separated from the mother, admitted to NCUs for observation and fed formula milk. Stable babies born by caesarean section (both preterm and term) are often managed the same way. These policies deprive preterm and LBW babies of life-saving interventions, including KMC. Often national or hospital policies restrict access of mothers to NCUs, thereby preventing near-continuous KMC.
Conflicts of interest
Violations of the International Code of Marketing of Breast-milk Substitutes, such as aggressive marketing of infant formula in hospitals and to staff, are common globally and undermine breastfeeding.
Lack of time and physical space
Due to high workloads, hospital staff may see working with families to support KMC as an additional burden. Hospitals often do not allocate physical space and logistical support for mothers and babies to practise KMC.
Limited training and support for KMC
Non-inclusion in government policies and plans, lack of effective training, limited availability of the global evidence base on effectiveness, and limited supportive supervision after KMC coaching mean that health workers may not continue to practise KMC effectively or find solutions to problems encountered.
3.
4. Based on qualitative interviews with people in hospitals who successfully implemented KMC.
KMC in hospitals?
Summary of actions for introducing and sustaining KMC in hospitals
Action Content Annex
1. Build the capacity of the Early Essential Newborn Care (EENC) hospital team to support KMC
All checklists 1–5
2. Review hospital capacity to support KMC
Checklists 1–9: Review of hospital capacity to support KMC 1 3. Develop a KMC action framework
Checklist 10: KMC action framework Considerations of where to put KMC areas
2
4. Secure support of senior hospital staff and managers
Checklist 10: KMC action framework 2
5. Build KMC skills of staff and families
5.1 Staff coaching Facilitator’s guide for KMC clinical coaching
Checklists 11–14: Review of KMC skills of health workers 3, 4 5.2 Learning by doing Checklists 11–14: Review of KMC skills of health workers 4 5.3 Building capacity
of families Frequently asked questions KMC fact sheet
KMC counselling guide: Pictorial summary of key practices
5
6. Monitor progress and support practice
Checklists 1–9: Review of hospital capacity to support KMC Checklist 10: KMC action framework
Checklists 11–14: Review of KMC skills of health workers
1, 2, 3
Action 1. Build the capacity of the Early Essential Newborn Care (EENC) hospital team to support KMC
KMC should be managed by the hospital team responsible for implementing and monitoring EENC. Where a team does not exist, a team should be formed. EENC hospital teams have between 10 and 25 members and include paediatricians, obstetricians, nurses, midwives, and infection control, quality improvement and hospital administration staff. The EENC hospital team reviews hospital capacity to support KMC (Action 2), and supports addressing gaps (Actions 3–5) and monitoring progress (Action 6).
Action 2. Review hospital capacity to support KMC
Using Checklists 1–9: Review of hospital capacity to support KMC (Annex 1), the EENC hospital team leads a review of the management of preterm and LBW babies. This review includes:
birth practices received by preterm/LBW babies (Checklists 1–3); management of pre-term/
LBW newborns currently admitted to an NCU (Checklist 4); availability of medicines, supplies and equipment (Checklist 5); existing hospital policies, protocols and standards (Checklist 6);
staff coaching in KMC and EENC (Checklist 7); hospital register data on preterm/LBW babies (Checklist 8); and space and staff requirements for KMC (Checklist 9). Checklists 1–9 can be completed for regular progress monitoring or as part of full EENC quality assessments (usu- ally conducted quarterly).
Action 3. Develop a KMC action framework to introduce and sustain KMC
The EENC hospital team completes Checklist 10: KMC action framework (Annex 2) for planning and routine monitoring of progress. The framework is divided into five domains:
1) policies, standards and guidelines; 2) space for KMC in postnatal care (PNC) and NCU areas; 3) staff to support KMC; 4) medicines, supplies and equipment; 5) staff coaching in KMC; and 6) communications, counselling materials and support. For each domain, priority issues to be addressed based on findings from Action 2 are entered.
Action 4. Secure support of senior hospital staff and managers and implement action steps
The EENC hospital team presents the KMC action framework to senior management and secures support for proposed actions. Senior staff commit to supporting actions needed to provide necessary space, equipment, amenities and staff. Senior staff members also need to assist in developing and endorsing revised hospital KMC policies, protocols, standard op- erating procedures, standing orders, job aids, and recording and reporting forms. In some
Action 5. Build KMC skills of staff and families
Action 5.1. Staff coaching
The Facilitator’s guide for KMC clinical coaching (Annex 3) outlines an on-the-job approach for coaching staff. Staff coached should include paediatricians, nurses and other staff working in the NCU and other wards where care is provided for newborns. Checklists 11–14: Reviewing KMC skills of health workers (Annex 4) are used for KMC skills coaching.
Action 5.2. Learning by doing
Once staff members are coached, the EENC hospital team establishes mechanisms for “learning by doing”. These include work rosters that pair experienced staff supervisors with less experi- enced staff. Supervisors periodically observe staff practices using Checklists 11–14: Reviewing KMC skills of health workers (Annex 4). Supervisors and staff then identify practice strengths and gaps, and both sign off on agreed actions. Supervisors enter findings from observations of 10 preterm babies on KMC skills Checklist: Summary sheet (Annex 4) including the status of each baby at the end of the hospital stay (discharge, referral or death).
Action 5.3. Building capacity of families
Families require clear counselling on how to practise KMC, and an environment that respects privacy and allows flexibility by using fathers and grandparents to provide STS care. Success- ful families who gain experience with KMC can support families without experience. These families can become a useful resource; however, they can become sources of infection. The KMC fact sheet: DOs and DON’Ts of supporting families to practise KMC and KMC counsel- ling guide: Pictorial summary of key practices (Annex 5) provide basic information to support effective family practices.
Action 6. Monitor progress and support practice
The monitoring of KMC practice, the status of action steps outlined in the KMC action frame- work, and staff coaching needs are accomplished during ongoing EENC progress monitoring meetings and quarterly one-day full EENC quality assessments. At each quality assessment, the EENC hospital team reviews hospital capacity to support KMC (Checklists 1–9) and KMC skills of health workers (Checklists 11–14). EENC progress meetings review data and track the status of action steps using Checklist 10.
ANNEXES
ANNEX 1. Checklists for reviewing hospital capacity to support KMC ...11
ANNEX 2. Checklist for developing the KMC action framework ...25
ANNEX 3. Facilitator’s guide for KMC clinical coaching ...28
ANNEX 4. Checklists for reviewing KMC skills of health workers ...56
ANNEX 5. Family supports for KMC ...64
Checklists for reviewing hospital capacity to support Kangaroo Mother Care (KMC)
Checklists 1–9. Review of hospital capacity to support KMC
The Early Essential Newborn Care (EENC) hospital team members are responsible for collecting Kangaroo Mother Care (KMC) data using checklists. Divide the team into four small groups.
Each small group collects data on two checklists.
Steps:
1. Review the management of 10 inborn (born in a facility) preterm (< 37 weeks) or low-birthweight (LBW) babies (< 2500 grams) by interviewing and conducting a chart review of mothers of babies in the neonatal care unit (NCU) or postnatal wards. Enter the results in Checklists 1 and 2.
2. Review practices for preterm and LBW babies by observing environments in the postnatal care (PNC) and KMC areas and NCU. Enter the results in Checklist 3.
3. Review NCU admissions criteria for 20 inborn preterm and LBW babies by reviewing charts of babies admitted to the NCU. Enter the results in Checklist 4.
4. Review availability of medicines, supplies and equipment and the availability of policies to support management of preterm or LBW babies. Enter the results in Checklists 5 and 6.
5. Review the staff coaching summary form. Enter the results in Checklist 7.
6. Review hospital register data on preterm/LBW babies. Enter the results in Checklist 8.
7. Review NCU and KMC staff and space requirements. Enter the results in Checklist 9.
ANNEX
1
Che ck lis t 1 .
Preterm and LBW practices: Interview of mothers of babies in postnatal wards and the NCUs Randomly select 10 inborn (born in the facility) preterm (< 37 weeks) or LBW babies (< 2500 g): 5 from the postnatal register who were not admitted to NCU and 5 from the NCU register. Use interviews with the mothers to complete questions 1–6. Confirm responses where possible with the medical record. QuestionMother numberSummary Answer the questions with: Y (Yes) or N(No) unless otherwise specifiedPostnatal registerNCU register n* / N** (%) 12345678910 1.Verbal informed consent obtained 2.At the time of birth, was the baby placed in skin-to-skin (STS) contact with the mother? If yes: a. How long after birth? < 1 min / 1–10 min / 11–59 min / ≥ 60 minn (< 1 min)= b. How long did the baby remain in uninterrupted STS contact before being separated from the mother for any reason? < 10 min / 10–29 min / 30–59 min / 60–89 min / ≥ 90 minn (≥ 90 min) = c. Had the baby completed the first breastfeed (attached, deep sucking) before separation from the mother? d. Why was the baby separated from the mother?Reasons: e. Did the baby receive immediate STS contact, with no separation for at least 90 min and until the first breastfeed was completed? Answer Y only if: a . < 1 min, b. ≥ 90 min and c. = Yn (# Yes)= 3.Is the mother giving any breast milk (either directly from the breast or expressed breast milk or both)? 4.Is the mother breastfeeding directly from the breast? If yes: a. How long after birth did the baby first breastfeed? (The baby must have been attached with deep sucking.) Answer: < 15 min / 15–89 min / 90 min–24 h / 1–2 daysn (15–89 min) = b. How many minutes did the baby breastfeed the first time?n (≥ 15 min)= c. Since birth, was the baby fed anything other than breast milk?n (# No)= d. Did the baby receive early (within 15–89 min) and exclusive breast- feeding? Answer Y only if both a. and b. = 15–89 min and c. = Non (# Yes)= e. In the last 24 hours, how many times was breast milk given?n (≥ 8 times)=Preterm and LBW practices: Interview of mothers of babies in postnatal wards
and the neonatal care units (NCU)
QuestionMother numberSummary Answer the questions with: Y (Yes) or N(No) unless otherwise specifiedPostnatal registerNCU register n* / N** (%) 12345678910 5.Is the mother giving breast milk by means other than directly from the breast (e.g. by expressing breast milk and feeding by other means)? If yes: a. How is the breast milk being given? (cup, spoon, syringe, stomach tube or bottle) – Note: if given by bottle this should be marked as an area for improvement
n (# Yes) cup, spoon, syringe tube = b. In the past 24 hours, how often did she express breast milk?n (≥ 8 times) = c. Since birth, was the baby fed anything other than breast milk? d. Is the baby over 32 weeks gestational age now? e. If yes, does the mother attempt breastfeeding before giving breast milk not by breast? 6.If the mother fed the baby anything other than breast milk: a. What was given?Fluids given: b. Was anything given before the first breastfeed or first expressed breast milk? 7.Has the baby been fed anything from a bottle? Note: if yes, this should be flagged as an area for improvement, even if it is breast milk. 8.Does the baby weigh < 2000 g? If yes: a. Did the baby receive any KMC in the past 24 hours? b. For how many hours was KMC applied? 0 / < 1 h / 1–4 h / 5–19 h, / ≥ 20 hn (≥ 20 h) = c. How long was the longest separation?n (< 30 min) = d. Was the baby kept in KMC position (i.e. STS contact) while breastfeeding?
Preterm and LBW practices: Interview of mothers of babies in postnatal wards and the neo- natal care units (NCU)
(continued)* n = total number of “Y” (Yes responses), unless otherwise specified **N = total number of mothers interviewed
Che ck lis t 2 .
Preterm and LBW practices: Chart reviews of postpartum mothers interviewed Use the identification numbers of the mother and baby to identify the charts of women who already received an interview. If the mother’s chart is separate from that of the baby, it may be necessary to review both charts to complete the chart review. QuestionMother numberSummary Answer the questions with: Y (Yes), N(No), or NR (Not Recorded) unless otherwise specifiedPostnatal registerNCU register n* / N** (%) 12345678910 1.Did the mother deliver at 24–34 weeks of gestation? If yes: a. Were maternal criteria for use of antenatal steroids met?1 b. Was a full course of antenatal steroids given to the mother? 2 c. Was the first dose given within 1 hour of her arrival at the hospital? 3,4 2.Did the mother deliver before 32 weeks of gestation? If yes: a. Was magnesium sulfate given to the mother for fetal neuroprotection? b. Was magnesium sulfate given within 1 hour of her arrival at the hospital?3,4 3.Were syphilis test results from antenatal care (ANC) recorded in the mother’s chart? If yes: a. Was the test positive? b. Were actions taken in the antenatal period to address the positive syphilis test? 4.Was point-of-care rapid HIV testing done or HIV test results from ANC written in the record? 5.Was artificial rupture of membranes (amniotomy) done? 6.Was the mother’s labour induced/augmented with oxytocin? a. If yes, what were the indications? 5Preterm and LBW practices: Chart reviews of postpartum mothers interviewed
QuestionMother numberSummary Answer the questions with: Y (Yes), N(No), or NR (Not Recorded) unless otherwise specifiedPostnatal registerNCU register n* / N** (%) 12345678910 7.Was the baby delivered by caesarean section? a. If yes, what were the indications?5Reasons: 8.Were baby vital signs measured at least 4 times in the last 24 h? a. Temperature b. Pulse c. Respiratory rate d. Oxygen saturation
Preterm and LBW practices: chart reviews of postpartum mothers interviewed
(continued)* n = total number of “Y” (Yes responses), unless otherwise specified **N = total number of mothers interviewed 1. Gestational age can be accurately assessed; preterm birth is imminent; no clinical evidence of maternal infection. If there is no record of these criteria, indicate “N” (No). 2. Two 12 mg doses of betamethasone given intramuscularly 24 hours apart or four 6 mg doses of dexamethasone administered intramuscularly every 12 hours. 3. If timing of administration is not specified, indicate “N” (No). 4. If the woman received corticosteroids before arrival, then timely administration should be assessed according to timing of previous dose (at 6 hours after previous dose of dexamethasone or 12 hours of betamethasone). 5. If indications for the procedure were not recorded in the chart, write NR (Not Recorded).
Che ck lis t 3 .
Preterm and LBW practices: Observations of environments in PNC areas and NCU Review all rooms where preterm and LBW babies are staying. These may include postnatal care (PNC) areas, KMC areas, and rooms in the neonatal care units (NCU) allocated for preterm and LBW babies. Observe room environments and enter findings into questions 1–10 of Checklists 1–14. Take photographs of problems such as multiple babies in one bed-space, use of infant formula or other lapses in infection control. IndicatorPNC room(s)KMC room(s)NCU room(s)TOTALComments For questions 1–10, enter a number 1.Number of preterm/LBW babies in the room(s) (NP) 2.Number of beds available in the room(s) (NB) 3.Ratio of number of babies to number of beds in the room(s) (NP/NB) Take a photo if babies are sharing beds 4.Number of bottles of alcohol hand gel available in the room(s) (NHG) 5.Ratio of the number of bottles of alcohol hand gel to the number of beds in the room(s) (NHG/NB) 6.Number of babies separated from the mother 7.Number of babies separated from the mother for caesarean section (CS) 8.Number of babies separated from the mother for prematurity/LBW Number of babies receiving phototherapy9. a. Number of babies receiving phototherapy in the KMC position 10.Number of infant formula products visible in the room(s) (tins, packets bottles) For questions 11–14, answer with Y (Yes), N (No) or NA (Not Applicable) 11.Did any health worker handle any baby without washing hands with soap/ 1water or alcohol hand gel before touching any baby? 12.Did any health worker take any baby’s temperature without disinfecting 1the thermometer with alcohol before use? 13.Did any health worker use a stethoscope on any baby without sterilizing 1with alcohol before use? 14.Did the health worker in the room use a cell phone before or during patient care without washing hands before touching any baby?
Preterm and LBW practices: Observations of environments in PNC areas and NCU
1. Health-worker practices can be observed for any baby in the room.
Che ck lis t 4 .
NCU admissions for preterm and LBW babies Identify the medical records of the last 20 preterm or LBW admissions to the NCU.1 Use medical records to complete the table. For questions 3–6, answer with: Y (Yes) or N(No) Medical record number Summary/ Remarks1234567891011121314151617181920 1.Mode of birth: vaginal (V) or caesarean section (CS) 2.
Indicate month and day of birth (mm/dd)
3.Gestational age a.≥ 37 weeks b. 32 to < 37 weeks c. 28 to < 32 weeks d. < 28 weeks 4.Birthweight a. > 2500 g b. 2000 – 2499 g c. 1500 –1999 g d. 1000 –1499 g e. < 1000 g 5.Did the baby receive any KMC at any time?
NCU admissions for preterm and LBW babies
1. Includes NCU beds, NCU step-down areas and NCU observation areas.
For questions 5–6, answer with: Y (Yes) or N(No) Medical record number Summary/ Remarks
1234567891011121314151617181920 6.Was the baby separated from caregivers for admission to NCU? If yes: a.Did the baby receive any KMC before separation? b. Which of the following signs were present at the time of admission? i. Respiratory distress not responding to continuous positive airway pressure (CPAP) ii. Apnoea more than 3 times per h (stopped breathing > 20 s) iii. Severe hypothermia < 35 °C that does not respond to KMC iv. Convulsions v. No spontaneous movement vi. Neonatal tetanus vii. Blood in stool with abdominal distention viii. Severe congenital abnormality ix.Was at least one sign above present? (at least one Q 6.b i–viii = Y) c. Was the baby placed in KMC at any time after admission to the NCU?
Preterm and LBW practices: chart reviews of postpartum mothers interviewed
(continued)Review by direct observation.
Indicate with: Y (Yes) or N (No) Available on the day of the review?
Indicator Delivery room Operating
room NCU KMC area(s)
(if available) 1 1. Antenatal steroids
2. Magnesium sulfate
3. Flat, dry, warm and clean resuscitation areas – one within 2 m of each delivery bed; at least one in each NCU and KMC area
4. Functional neonatal bag with term and preterm mask at every resuscitation area 5. Oxygen and delivery system (including nasal
cannula and oxygen concentrators) 6. Oxygen saturation monitor 7. KMC wraps or binders 8. Small baby hats
9. Continuous positive airway pressure (CPAP) 10. Alcohol hand gel (at least one bottle in
delivery, operating rooms and KMC areas;
one bottle for each NCU bed) 11. Vitamin K1
12. Routine eye prophylaxis 13. Hepatitis B vaccines
14. Injectable antibiotics for neonatal sepsis 15. Vitamin D, calcium, phosphorus and iron
supplements
16. Phototherapy equipment
1. If more than one room or KMC area is used for preterm and LBW babies, medicines, supplies and equipment must be avail- able for use in all rooms or areas to score Y.
Review of availability of key medicines, supplies and equipment for management
of preterm and LBW babies
Review the most recent EENC review or consult senior staff to obtain available written policies.
Indicate with: Y (Yes) or N (No) Written
policy?
Have staff been oriented on the policy?
Policy, protocol or standard 1
1. Continuous KMC for preterm and LBW babies including STS contact, feeding with mother’s breast milk, monitoring and management of complications 2. Exclusive breastfeeding for all preterm and LBW babies, including giving expressed breast milk by cup, spoon or stomach tube until the baby has a suck-and-swallow reflex
3. Prevention and stabilization of hypothermia, hypoglycaemia, hypoxemia, apnoea/respiratory distress and infection prior to timely referral
4. Care of respiratory distress for preterm including a. Oxygen
b. Continuous positive airway pressure (CPAP) 5. Care of sick preterm babies
6. Patient and bed to staff ratios for:
a. Delivery room
b. Postpartum ward(s) practising KMC c. NCU practising KMC
7. Guidelines on identification and treatment of hypoglycaemia, including:
a. Symptomatic newborns
b. Asymptomatic high-risk newborns requiring glucose monitoring
8. Restricted NCU admission criteria requiring separation from the mother, 2 including:
a. Respiratory distress not responding to CPAP b. Severe hypothermia < 35 °C not responding to KMC
c. Frequent apnoea more than 3 times per hour (stopped breathing > 20 s) d. Convulsions
e. No spontaneous movement f. Neonatal tetanus
g. Blood in stool with abdominal distention h. Severe congenital malformation
9. Daily assessments of preterm infants
10. Criteria for discharge home – including mother confident to be able to practise KMC at home
11. Timing and content of follow-up visits of preterm infants and community follow-up if available
1. Including hospital-specific policies or standards or national policies intended for hospital use.
2. Weight should not be an indication for admission to NCUs. Instead, admission should be based on the presence of one of the signs in Q8.
Review of hospital policies, protocols and standards to support management
of preterm and LBW babies
STAFF COACHING SUMMARY FORM: KMC Type of health
professional Total,
# Coached,
#
Remaining to be coached,
#
KMC facilitator(s) available for coaching? 1
Timeline for conducting
coaching
Other resources
needed 2
1. Facilitators may be staff in the hospital or may be from other hospitals.
2. Other resources may include: coaching materials, KMC binders, manikins for demonstrating childbirth for premature delivery, artificial breasts, fluorescent gel for demonstrating handwashing effectiveness, available space, etc.
STAFF COACHING SUMMARY FORM: EENC Type of health
professional Total,
# Coached,
#
Remaining to be coached,
#
EENC facilitator(s) available for coaching? 1
Timeline for conducting
coaching
Other resources
needed˚2
1. Facilitators may be staff in the hospital or may be from other hospitals.
2. Other resources may include: manikins for demonstrating childbirth for normal delivery, fluorescent gel for demonstrating handwashing effectiveness, full delivery kits, cloths and baby hats, delivery trolleys and resuscitation tables, available space in delivery rooms or other rooms, EENC materials including pre-and post-tests, and clinical checklists.
Staff coaching summary: KMC and EENC
Review the most recent EENC review or consult senior staff to obtain available written policies.
Month Total live births,
#
Inborn preterm births by gestational age (in weeks)
#
Inborn term births
< 2500 g, 2 (B)
#
< 28 28 to < 32 32 to < 37 Total (A) 1 1
2 3 4 5 6 7 8 9 10 11 12 TOTAL
(%) N n (n/NP) n (n/NP) n (n/NP) NP 1 (NP/N) NLBW 2(NLBW/N) 1. Total number of preterm births (< 37 weeks).
2. Total number of term (≥ 37 weeks) and LBW births (< 2500 g).
Hospital register data on preterm and LBW babies
Review hospital delivery register, NCU registers or KMC registers for the previous 12 months to complete the table on hospital data.
Month
Inborn and outborn (born outside the facility) preterm and LBW babies4 Total inborn
(C = A+B) 3
#
Admitted to NCU (D)
#
Admitted to NCU receiving continuous 4
KMC (E)
#
Admitted to PNC ward or KMC areas
(F)
#
Admitted to PNC ward or KMC areas receiving continuous 5
KMC (G)
#
Inborn Outborn Inborn Outborn
1 2 3 4 5 6 7 8 9 10 11 12 TOTAL
(%) NN
In–N–NCU
(n/NN) Out–N–
NCU N–NCUKMC
(n/Total–N–NCU)
In–N–PNC
(n/NN) Out–N–
PNC N–PNCKMC
(n/Total–N–PNC)
Total–N–NCU Total–N–PNC
3. Total number of inborn preterm births (< 37 weeks) and term LBW births (< 2500 g).
4. If the hospital admits outborn newborns to rooms that are separate from inborn newborns, then outborn babies should not be included in the calculations.
5. Continuous KMC is defined as uninterrupted STS contact with the mother or a family member for at least 20 hours of each 24-hour period.
Hospital register data on preterm and LBW babies
(continued)This checklist determines changes that can be expected if 70% of preterm or LBW babies were moved from NCU to KMC areas.i Review Checklist 8 to complete questions a.–d. Consult staff to obtain information on the number of staff, beds and physical space available. If necessary, visit NCU and KMC areas to assess availability of beds and space.
Preterm and LBW admissions
a. Current annual NCU admissions (Inborn and outborn, excluding those with continuous KMC) before letter C, Checklist 8: D
b. Expected NCU admissions (Annual total preterm and LBW babies < 2500 g): Checklist 8: C x 0.3 c. Current annual KMC admissions (Inborn and outborn, including those in the NCU who are kept
in continuous KMC): Checklist 8: E + G
d. Expected KMC: (Annual total preterm and LBW babies < 2500 g) – Checklist 8: C x 0.7 Beds needed for preterm and LBW babies (and caregivers)
e. Current NCU beds
f. Total NCU beds ii needed: Expected NCU admissions (b) x (Average length of stay / 365) x 1.5 iii g. Current KMC beds
h. Total KMC beds needed: Expected KMC (d) x (Average length of stay / 365) x 1.5 Space needed for preterm and LBW babies (and caregivers)
i. Current NCU space (in m2)
j. Total NCU space needed: Total bed spaces needed (f) x 9 m2, iv k. Current KMC space (in m2)
l. Total KMC space needed: Total beds needed (h) x Space per bed (6 m2) v Staff needed for preterm and LBW babies
m. Current NCU staff
n. Number of NCU staff needed: (Total beds needed (f) / 4) x (# shifts/day) vi x (7 / # days worked/week) o. Current KMC staff
p. Number staff needed for KMC: (Total beds needed (h) / 8 )vii x (# shifts/day) x (7 / # days worked/week) q. Total staff needing coaching on KMC: based on the total number of health-care providers
in NCU and KMC ward(s) Facility support for KMC
r. Is additional facility support needed for mothers and families in the area(s) being used for KMC or being considered for KMC? Specify needs.
s. Toilet(s)
t. Washing space(s) for hand hygiene u. Cooking facilities
v. Beds
w. Systems to support delivery of oxygen or CPAP
i. 70% of preterm and low-birthweight babies are estimated to be suitable for KMC.
ii. Beds here refer to bassinettes, incubators or other places where babies are kept.
iii. A factor of 1.5 is to account for fluctuations in bed occupancy.
iv. Assumes each bed is 1 x 1 m, with 2 m between each bed.
v. Beds include cots or other places the family will stay with the preterm baby. These are typically 1 x 2 m in size. For infection control purposes, each bed space should be separated by at least 1 m. Total space allocated per bed space is 3 x 2 m, or 6 m2. vi. Assumes only neonates requiring intensive care are admitted with 1 staff member for 2 (ventilated); for 4 (on CPAP) or for 5
(no respiratory support) newborns in the NCU. This ratio can be modified depending on local hospital policy and resources.
vii. For a basic KMC ward assume 1 nurse or equivalent staff for 8–10 beds; if the KMC ward includes CPAP, phototherapy or
Staff, space and bed requirements for preterm and LBW babies
Checklist for developing the Kangaroo Mother Care (KMC) action framework
Checklist 10. KMC action framework
Review findings from Checklists 1–9
1. Draw the checklists on flip charts and enter data from the review. Additional prob- lems identified that were not on the checklists can also be listed.
2. Post completed flip charts around the room in order (Checklists 1–9).
3. Discuss and highlight the 2–3 most important gaps or problems identified (marked with a different colour pen).
Complete the KMC action framework
1. Draw the KMC action framework column headings on a flip chart.
2. Enter the 2–3 most important gaps or problems identified from the checklists as
“priority issues”. Use the exact language from the checklists.
3. Post completed flip charts for priority issues around the room in order next to Checklists 1–9.
4. Discuss findings and reach consensus on the most important underlying issues, actions, responsibilities and timing. Summarize these on KMC action framework.
ANNEX
2
Priority issue Underlying reasons
for issue Priority actions Person
responsible Timing Status / Date Policies, standards and guidelines
Space for KMC in neonatal care unit (NCU) or postnatal care (PNC) areas (see Considerations for location of KMC areas below)
Staff to support KMC
Medicines, supplies and equipment
Clinical coaching for staff
Communications and counselling materials and support (see Annexes 5.2 and 5.3)
KMC action framework
KMC wards can be established in any PNC ward, provided it has adequate space, supplies and staff available to coach and assist mothers. In most facilities, existing spaces can be reorgan- ized to allow KMC to be practised.
Issue Factors to consider 1. Location of ward
Near NCU (for facilities with one ward):
a. Allows NCU staff to support KMC and rotate easily in and out of NCU.
b. Ensures that sick babies receive immediate attention when needed and can be easily transferred to NCU.
Near delivery room:
a. More convenient for immediate transfer for the majority of stable babies.
b. Mothers who require treatment for complications also will have easier access.
2. KMC with respiratory support
Wall oxygen and medical air (or oxygen cylinder and concentrator) is needed at each bed dedicated to receive respiratory support.
3. KMC for babies not needing respiratory support
One area with wall oxygen and medical air (or oxygen cylinder and concentrator) is required for the rare cases requiring resuscitation.
4. Availability of staff
For basic KMC: at least 1 staff member is needed for 8–10 beds.
For KMC with CPAP or phototherapy: at least 2 staff members are needed for 8–10 beds.
Ensure nurses and midwives have mix of skills to manage both mothers and newborns. There should be at least one nurse or midwife available at all times to cover allocate KMC beds.
5. Physical space and amenities
There should be 1 metre between each bed; and an adequate number of sinks with soap and water or alcohol hand gel for handwashing, functional toilets and adequate space and privacy for mothers and families.
Facilitator’s guide for Kangaroo Mother Care (KMC) clinical coaching
Agenda for two-day KMC clinical coaching
DAY 1
Time Steps Documents
SESSION 1. Opening and assessment
DAY 1
1. Review of objectives
2. Brief introduction of facilitators and participants 3. Pre-coaching assessment
a. Pre-coaching written assessment* Pre- and post-test
Participant's Recording Form SESSION 2. KMC Role play and supervised practice
DAY 1
4. Help the mother position her baby correctly for KMC (use of binder, positioning, clothing)
Checklist 11
a. Baseline scenario of preterm management: health-care providers do their usual practice (plenary)
b. Re-enactment based on current practices and sequence of events – facilitated dialogue on current and evidence-based practice (plenary) c. Role play with coaching and incremental correcting of gaps and
malpractices (plenary)
d. Supervised role-play practice (small group) – participants all demonstrate correct practice.
5. Steps 4 a–d are repeated for the following scenarios – Helping the mother breastfeed in KMC
– Helping the mother express breast milk in KMC
– Helping mothers and families prevent infection and monitor progress
Checklists:
– 12 – 13 – 14
6. Return written pretest to participants for review (10 minutes) Pre- and post-test 7. Discussion and distribution of handouts
1.
SESSION 3. Review and practice
DAY 2
8. Facilitated Q&A on KMC clinical practice (10 minutes) 9. Visit to preterm areas to practise four clinical checklists with
mothers and preterm babies
Checklists 11–14
10. Facilitated discussion: Immediate newborn care of preterm/
low-birthweight (LBW) babies
Preterm delivery checklist SESSION 4. Assessment
DAY 2
11. Final assessments
a. Post-coaching skills assessment – each participant performs skills
observed by facilitator Checklists 11–14
b. Post-coaching written assessment Pre- and post-test
Participant's Recording Form SESSION 5. Review of KMC action plan
DAY 2
12. Review and plan next steps for KMC introduction
a. Review KMC action framework (actions for introducing and sustaining KMC in hospitals), status of current actions and next steps towards taking further action
Annex 5 KMC action framework b. Discuss planned actions with senior hospital staff and managers
13. Closing
* It is expected that all participants have completed EENC coaching prior to beginning KMC clinical coaching. If participants have not completed EENC coaching, consider adding pre- and post-test handwashing assessments using fluorescent gel (see Module 2: Coaching for the First Embrace – Facilitator’s guide. Manila: World Health Organization Regional Office for the Western Pacific; 2016).
