MATERNAL ASPECT OF ENC:

THE NEED FOR A PARADIGM SHIFT

Zarinah G. Gonzaga, MD, FPOGS, FPSUOG, FPSMFM

What is ENC?

Essential newborn care (ENC) is a

comprehensive strategy designed to
improve the health of newborn through
interventions before conception, during
pregnancy, at and soon after birth, and
in the postnatal period.

Narayanan I. Rose M. Cordero D. Faillace s. Sanghvi T. The Components of Essential Newborn

Care. Published by the Basics Support for Institutionalizing Child Survival Project (BASICS II) for the
United States Agency for International Development. Arlington, Virginina, June 2004.
 Emergency
Obstetric and
Newborn Care
From ENC to EONC
Essential obstetric and
newborn care (EONC)

all elements of care to

prevent and manage
complications
From ENC to EONC to EmONC
Emergency obstetric and
newborn care (EmONC)

diagnosis and treatment of

complications that arise
during pregnancy and
childbirth
From ENC to EONC to EmONC
Rationale

All women – not just those

considered high risk – need
access to these services
because severe medical
complications can arise
quickly during pregnancy
and labor and delivery.
The Paradigm Shift
Identifies high risk pregnancies for referral during the
prenatal period

Risk based approach

Considers all pregnant women at risk of complications

EmONC approach
Ineffective Routine: The Risk Approach
• Risk factors are poor predictors of maternal risk. All
women are at risk of life-threatening complication.
• Low specificity
• Low sensitivity
• Scarce resources are concentrated on the “high risk”
group
• Women who are not “high risk” are often:
• Not taught the danger signs
• Not encouraged to give birth with a skilled attendant
• Given a false sense of security
Why is there a need for a paradigm shift?
Maternal mortality
ratio (MMR) remains
high and decreased
very slowly from 1990
to 2006.

At this rate, the MDG5

goal will not be
reached by 2015.
Why is there a need for a paradigm shift?
Infant mortality rate
(IMR) have
considerably declined
but the rates of
decline have
decelerated over the
last ten years.

At this rate, the

MDG4 goal will not be
reached by 2015.
Factors contributing to maternal and
neonatal deaths
Factors contributing to maternal and
neonatal deaths
Factors contributing to maternal and
neonatal deaths

• Focus on antenatal clinics

• Training of traditional birth attendants
Things we have
done that did • Encouraged home births
not work
 “Implementing Health Reforms for the Rapid
Reduction of Maternal and Neonatal Mortality”

Department of Health
Adminstrative Order 2008-0029
 The MNCHN services aims to achieve
the following intermediate results:
Every mother and
newborn pair
secures proper
postpartum and
Every delivery is
Every pregnancy is newborn care
Every pregnancy is facility-based
adequately with smooth
wanted, and managed by
managed transition to the
planned and skilled birth
throughout its women’s health
supported. attendants/health
course. care package for
professionals.
the mother and
child survival
package for the
newborn.
MNCHN Core Package of Services

Maternal nutrition
Oral health
Family Planning services
Deworming/antihelminthic
Counseling on health lifestyle
Information on health caring and
seeking behaviors
MNCHN Core Package of Services
Essential antenatal services
Maternal nutrition
Early detection and management of
danger signs and complications
Tetanus toxoid immunization
Antenatal administration of steroids
for preterm labor
Counseling on FP methods
Counseling on healthy lifestyle
Diagnosic screening tests
Prevention and management of other
diseases as indicated
MNCHN Core Package of Services

Clean and safe delivery

Basic emergency obstetric newborn care
Comprehensive emergency newborn care
Care of the preterm babies and/or low birthweight babies
MNCHN Core Package of Services
POSTPARTUM SERVICES
Identification of early signs of
postpartum complications
Maternal nutrition
Family planning
Counselling on healthy lifestyle
Prevention and management of
other diseases as indicated
Correction of anemia
Antitetanus injection
Immediate essential newborn
care
Care prior to discharge
Emergency newborn care
Emergency obstetric and
newborn care (EmONC)
components:

1. Early detection and treatment of

problem pregnancies to prevent
progression to an emergency 
FOCUSED ANC

2. Management of complications 
BEmONC and CEmONC
• For the mother: hemorrhage,
obstructed labor,
preeclampsia/eclampsia, infection
• For the newborn: infection,
asphyxia, hypothermia
FOCUSED (GOAL-DIRECTED)
ANTENATAL CARE
EmONC component #1
Early detection and treatment of problem
pregnancies to prevent progression
EmONC component: Early detection and treatment of problem
pregnancies to prevent progression
 FOCUSED ANTENATAL CARE

Emphasized the number and frequency of visits

Traditional model of ANC

The quality of, rather than the number of, visits is important

Focused (goal-directed) ANC

Principles of Focused (goal-directed) ANC
To help women maintain normal pregnancies through goal-
direct assessment and individualized care, including:

Early detection and treatment of

existing conditions and
complications

Prevention of complications and

diseases

Birth-preparedness and
complication-readiness

Health promotion
Principles of Focused ANC

Early • Signs or symptoms of chronic

detection and diseases, medical conditions,
treatment of infectious diseases
existing • Signs or symptoms of conditions
conditions and that may cause or be indicative of
complications a life-threatening infection
Principles of Focused ANC

• Iron and folate supplementation

• Tetanus toxoid immunization
Prevention of • Malaria/hookworm prevention (if
endemic)
complications • Vitamin A supplementation (in areas of
and diseases deficiency)
• Iodine supplementation (in areas of
deficiency
Principles of Focused ANC
Newborn care begins before birth
Element of antenatal care Newborn problem that may be
prevented
Maternal tetanus immunization Neonatal tetanus

Syphilis screening Abortion, stillbirth, congenital syphilis

Screening and treatment of other STIs Newborn gonococal or chlamydia

infections
Malaria prevention Abortion, prematurity, low birth weight

Screening and ARVs for HIV HIV transmission to the fetus/newborn

Screening and treatment for anemia and LBW

hookworm
Micronutrient supplementation LBW, prematurity, spinal cord defects,
cretinism
Principles of Focused ANC

• Provision for a skilled attendant

Birth- • Appropriate setting for birth
preparedness •
•
Transportation
Funds for birth and emergency
and • Decision-making in case of emergency
• Emergency blood donors
complication- • Recognition and appropriate response to danger
readiness signs
• Companion for birth
The Birth Plan
• Contains information on:

• the woman’s condition during pregnancy

• preferences for her place of delivery and choice of birth attendant

• available resources for her childbirth and newborn baby

• preparations needed should an emergency situation arise during

pregnancy, childbirth and postpartum.
Emergency Plan
• Advise on danger signs
• Where to go?
• How to go?
• Who will go with you to health center?
• How much will it cost? Who will pay? How will you pay?
• Start saving for these possible costs now.
• Who will care for your home and other children when you
are away?
Principles of Focused ANC

• Nutrition
• Self-care
Health • Optimal infant feeding
promotion • HIV
• Family planning
Focused (goal-directed) History
Elements of focus When to focus
Personal information First visit
Previous pregnancies and childbirths, transportation availability,
problems and concerns, other caregivers
Last menstrual period and contraceptive plans First visit
Present pregnancy Every visit
Fetal movements and adjustments to pregnancy
Daily habits and lifestyle First visit
Daily workload, dietary habits, living situtation and exposure to
violence, potentially harmful substances
Obstetric history First visit
Previous complications, breastfeeding experience
Medical history First visit
Allergies, HIV, anemia, syphilis, chronic disease, previous
hospitalizations, current medications, tetanus immunization history

Interim history Return visits

Problems or significant changes, change in other histories, ability to
carry out previous plans
Focused (goal-directed) Physical Exam
Elements of focus When to focus
General well-being Every visit
Gait, facial expression, skin, conjunctiva

Blood pressure measurement Every visit

Breast inspection First visit/as needed

Abdominal examination Every visit

Surface of abdomen, fundal height, fetal parts, fetal lie and
presentation (after 36 weeks), fetal heart sounds (after 20
weeks)
Genital exam First visit/as needed
Skin, labia, Skene’s and Bartholin’s glands, purulent discharge
Focused (goal-directed) Lab investigation
Elements of focus When to focus
Hemoglobin First visit and repeat at
28 to 30 weeks

RPR for syphilis Fist visit

HIV First visit
After counseling, if does not “opt out”
Blood group and RH First visit
Screening to Detect, Not Predict, Problems

Ineffective Routines
• The “risk approach” to predict who will develop a problem
or complication
• Assessment of ankle edema to screen for preeclampsia
• Measurement of maternal height to screen for those who
will develop obstructed/difficult labor
• Palpating fetal position before 36 weeks gestation to
screen for those who will have a malpresentation in
labor/birth
BASIC AND COMPREHENSIVE
EMERGENCY OBSTETRIC
AND NEWBORN CARE
EmONC component #2

Management of Complications
EmONC component: Management of Complications
 Emergency Obstetric and Newborn Care

• EmONC does not require that all babies be born in

hospitals or that all births be attended by a doctor.

• Everyone who attends a birth needs to have BEmONC

skills, equipment, drugs, infrastructure to provide – or
provide access to – BEmONC.
EmONC Addresses Causes of Mortality
Complication Complication
contributing to contributing to
EmONC functions maternal mortality newborn mortality
Administration of antibiotics Sepsis Sepsis
to mothers and newborn
Administration of oxytocics Postpartum hemorrhage
Administration of Eclampsia
anticonvulsants
Manual removal of placenta Postpartum hemorrhage
Removal of retained products Postpartum hemorrhage
of conception
Newborn resuscitation Asphyxia
Cesarean section Obstructed labor
Blood transfusion Hemorrhage
BEmONC services
Administration of parenteral antibiotics to
the mother
• Early diagnosis and treatment

• Recommended antibiotic treatment: combination

antibiotics for metritis, a penicillin every 6hours, an
aminoglycosides every 24hrs and
clindamycin/metronidazole every 8hrs

• Continued oral antibiotics after clinical improvement

is not necessary in cases of uncomplicated
endometritis.
BEmONC services
Administration of parenteral oxytocics
• Prophylactic use of oxytocin is recommended.
• Prophylactic use of ergot alkaloid is recommended.
• Prophylactic use of oxytocin over ergot alkaloid is
recommended.
• Prophylactic uterotonics may be given before or after
delivery of placenta.
• Prophylactic uterotonics may be given through IM or IV
route.

POGS Clinical Practice Guidelines for Intrapartum and Immediate Postpartum Care, 2012
BEmONC services

Administration of parenteral
anticonvulsants

• Magnesium sulfate should be used for the prevention

and treatment of seizures in women with severe
preeclampsia or eclampsia.

ACOG Practice Bulletin Number 33, January 2002.

BEmONC services
Performance of manual removal of
placenta
• If, in spite of controlled cord traction, administration of
uterotonics, the placenta is not delivered, manual
extraction of the placenta should be offered as the
definitive treatment. Level II-3, Grade B

• A single dose of antibiotics should be offered after

manual removal of the placenta. Level II-3, Grade B.

POGS Clinical Practice Guidelines for Intrapartum and Immediate

Postpartum Care, 2012
BEmONC services
Performance of removal of retained products of
conception following a miscarriage or abortion

• Manual vacuum aspirator or dilatation and curettage

• An essential element of postabortion care is providing

the woman with a family planning method before she
leaves the facility
BEmONC services
Performance of imminent breech
delivery

• Planned cesarean section is recommended in term

singleton breech presentation since it reduces risk for
perinatal or neonatal death and neonatal morbidity
compared to planned vaginal birth. Level I, Grade A

• Planned vaginal delivery remains a viable option,

provided the criteria are met, a skilled obstetrician and
facilities for CS are immediately available and the
woman is informed of all possible risks. Level I, Grade B
POGS Clinical Practice Guidelines on Abnormal Labor and Delivery, 2009
BEmONC services
Administration of corticosteroids in preterm labor
• A single course of corticosteroids is recommended for pregnant
women between 24 to 34 weeks AOG who are at risk of preterm
delivery within 7 days.
• A single course of corticosteroids should be administered to women
with PPROM before 32 weeks. The efficacy of corticosteroid use at
32-33 weeks in women with PPROM is unclear but treatment may
be beneficial.
• Sparse data exist on the efficacy of steroid use before fetal age of
viability, and such use is not recommended.
• A single rescue course of ACS may be considered if the antecedent
treatment was given more than 2 weeks prior, the gestational age is
less than 32 6/7 weeks and the women are judged to be likely to
give birth within the next week.

ACOG Committee Opinion Number 475, February 2011.

BEmONC services
Performance of essential newborn care
CEmONC Services

• All of the BEmONC

Comprehensive functions PLUS
Emergency • Capability for blood
Obstetric and
Newborn Care transfusion
(CEmONC) • Capability for cesarean
section
MATERNAL ASPECTS OF
ESSENTIAL INTRAPARTUM
CARE
Interventions that are recommended for
intrapartum care
• Among low risk parturients, admission into the labor
room during the active phase of labor is recommended.

POGS Clinical Practice Guidelines on Intrapartum and Immediate

Postpartum Care, 2012

• Continuous maternal support compared to usual care is

recommended for women in labor.

POGS Clinical Practice Guidelines on Intrapartum and Immediate

Postpartum Care, 2012
Interventions that are recommended for
intrapartum care
• The routine use of the WHO partograph to monitor the
progress of labor is recommended

POGS Clinical Practice Guidelines on Intrapartum and Immediate

Postpartum Care, 2012

• The use of the WHO partograph, 2hour action line (over

the 4hour action line) is recommended.

POGS Clinical Practice Guidelines on Intrapartum and Immediate

Postpartum Care, 2012
Interventions that are recommended for
intrapartum care
• The total number of internal examinations that a woman
receives during the course of labor should be limited to 5
examinations or less

POGS Clinical Practice Guidelines on Intrapartum and Immediate

Postpartum Care, 2012

• Upright maternal positions are recommended for women

in the first stage of labor.

POGS Clinical Practice Guidelines on Intrapartum and Immediate

Postpartum Care, 2012
Maternal Position and Mobility
• Review of 21 studies (N=3706 women)
• Randomized to upright or supine position
• Shorter 1st stage of labor ( approximately one hour )
MD -0.99, (95% CI -1.60 to -0.39)
• Less likely to have epidural analgesia
RR 0.83 (95% CI 0.72 to 0.96)
• No differences between groups for length of 2nd stage
of labor, mode of delivery, or other outcomes related
to wellbeing of mothers and babies
Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, Styles C. Maternal positions and mobility during first stage labour. Cochrane
Database of Systematic Reviews 2009, Issue 2.
There is no evidence supporting strict bed
rest in supine position during the first
stage of labor. In the absence of
complications, women should be
encouraged to change to positions or
move around during labor.
Interventions that are NOT recommended
for intrapartum care

• Routine perineal shaving

• Routine enema
• Admission CTG for low risk women
• Routine amniotomy for parturients in spontaneous labor

POGS Clinical Practice Guidelines on Intrapartum and Immediate

Postpartum Care, 2012
Interventions that are NOT recommended for
intrapartum care: Routine perineal shaving

• 3 RCTs
• No significant difference with regards
• Maternal febrile morbidity (OR 1.16, 95% CI 0.70 to 1.90)
• Wound infection (OR 1.52, 95% CI 0.79 – 2.90)
• Wound dehiscence (OR 0.13, 95% CI 0.00 to 6.7)

POGS Clinical Practice Guidelines on Intrapartum and Immediate

Postpartum Care, 2012
Interventions that are NOT recommended for
intrapartum care: Routine enema

• Cochrane review of 4 RCTs

• No significant difference in terms of
• Maternal infections during puerperium (RR 0.66, 95% CI 0.42 to
1.04)
• Overall neonatal infections (RR 1.12, 95% CI 0.76 to 1.67)
• Neonatal pneumonia (RR 0.10, 95% CI 0.01 to 1.73)
• Episiotomy dehiscence (RR 0.69, 95% CI 0.41 to 1.14)

POGS Clinical Practice Guidelines on Intrapartum and Immediate

Postpartum Care, 2012
Interventions that are NOT recommended for
intrapartum care: Admission CTG for low risk
parturients

• Cochrane review of 4 RCTs

• No benefit for use of CTG on admission of low risk women
• Not statistically significant trend towards an increased CS
rate by 20% (RR 1.20, 95% CI 1.00 to 1.44)

POGS Clinical Practice Guidelines on Intrapartum and Immediate

Postpartum Care, 2012
Interventions that are NOT recommended for
intrapartum care: Routine amniotomy for
parturients in spontaneous labor
• Cochrane review of 14 RCTs
• No significant difference in terms of
• Duration of first stage of labor (MD 20.43minutes lower, 95% CI 95.93minutes
lower to 55.06minutes higher)
• Duration of second stage of labor (MD 2.38minutes loer, 95% CI 5.27minutes lower
to 0.50minutes higher)
• Risk of CS (RR 1.26, 95% CI 0.98 to 1.62)
• Risk of cord prolapse (RR 0.33, 95% CI 0.01 to 8.18)
• Risk of maternal infection (RR 0.81, 95% 0.38 to 1.72)
• Women in amniotomy group had a significantly reduced risk of dysfunctional
labor (RR 0.75, 95% CI 0.64 to 0.88)
• Not statistically significant but there is a lower risk of having an APGAR <7 at
5minutes for babies to mothers in the amniotomy group

POGS Clinical Practice Guidelines on Intrapartum and Immediate

Postpartum Care, 2012
Early Amniotomy
• No conclusive evidence that early amniotomy has
a clear advantage over expectant management.
• Routine amniotomy does not significantly
reduce the duration of 1st stage labor in either
primiparous or multiparous women.
• Slightly shortens 2nd stage labor in primis only.

POGS CPG on NORMAL LABOR and DELIVERY, 2009

Interventions that are NOT recommended for
intrapartum care: Routine amniotomy for
parturients in spontaneous labor

• Significant risks of amniotomy

• Cord prolapse
• Abruptio placenta
• Intrauterine infection

• Amniotomy should only be undertaken during the active

phase of labor when there are clear indications

POGS Clinical Practice Guidelines on Intrapartum and Immediate

Postpartum Care, 2012
Interventions that are recommended during
delivery

• Restrictive episiotomy (over routine episiotomy)

• Delayed cord clamping
• Use of absorbable synthetic suture materials (over chromic
catgut) for primary repair of episiotomy or perineal lacerations
• Active management of the third stage of labor
• Prophylactic use of oxytocin (over no uterotonic, over ergot alkaloid)
• Controlled cord traction
• Uterine massage after placental delivery

POGS Clinical Practice Guidelines on Intrapartum and Immediate

Postpartum Care, 2012
Restrictive vs. Routine Episiotomy
for Vaginal Birth
(Cochrane review: 8 studies, 5541 women)
RR (95% CI)
Anterior perineal trauma 1.84 (1.61 – 2.10)  79%
Posterior perineal trauma 0.88 (0.84 – 0.92)  12%
Need for perineal suturing 0.71 (0.61 to 0.81)  26%
Perineal pain at discharge 0.72 (0.65 – 0.81)  28%
Healing complications at 7 days 0.69 (0.56 – 0.85)  31%
Dyspareunia at 3 months 1.02 (0.90 – 1.16) NS
Urine incontinence at 3 months 0.98 (0.79 – 1.20) NS
Apgar < 7 at 1 minute 1.09 (0.78 – 1.51) NS
Admission to NICU 0.74 (0.46 – 1.19) NS

Carroli G, Mignini L., Cochrane Database of Systematic Reviews 2009

Controlled Delivery of the Head
During delivery of the head,
encourage woman to stop
pushing and breathe rapidly
with mouth open.

Keep one hand on the

head as it advances
during contractions while
the other hand supports
the perineum.
Interventions that are NOT recommended
during delivery

• Use of fundal pressure during the second stage of labor

POGS Clinical Practice Guidelines on Intrapartum and Immediate

Postpartum Care, 2012
Fundal pressure during the 2nd stage of labor : A
prospective pilot study

Deliveries Deliveries
WITH WITHOUT
p-value
fundal fundal
N= 627 pressure pressure
2nd degree perineal 10% 4% < 0.01
tears Significant
Fetal acidosis 21% 9% < 0.001
(pH < 7.10) Significant
* variable methodological quality

Schulz-Lobmeyr, I., et.al.,1999

Alternatives to fundal pressure during
the 2nd stage of labor
• PATIENCE of both nursing and medical care providers

• Avoidance of arbitrary time frames to determine length of

second stage
• Analgesic versus anesthetic level for labor epidural

• Allowing passive fetal descent and delayed pushing

• Directed coaching supporting the woman’s urge to push

when appropriate
 EINC
Delivery

1. Call out sex of baby

and the time of birth.
• Place the baby on the mother’s abdomen.
• Thoroughly dry the baby, assess the baby’s
breathing and perform resuscitation if
needed;
• Place the baby in skin-to-skin contact with
the mother
 EINC
Delivery

2. Administer 10 IU of
oxytocin IM within one
minute of the baby’s
birth.
3. Clamp and cut the
umbilical cord 2-3 mins.
after the delivery of the
baby or when cord
pulsations have stopped.
 EINC
Delivery

4. Keep the baby warm.

Discard the wet cloth
used to dry the baby.
Maintain skin-to-skin
contact. Wrap mother
and baby with linen.
Put bonnet on baby.
 EINC
Delivery

5. Perform controlled cord traction (CCT) with

counter-traction on the uterus
Place the palm of the other hand on the LOWER
abdomen
 EINC
Delivery

• Support the placenta with both hands.

• Gently move membranes up and
down until delivered
 EINC
Delivery

6. Massage the uterus

7. Examine the
placenta and
the membranes
 EINC
Delivery
8. Examine the lower vagina and the
perineum.
9. Provide immediate care to the
mother-baby dyad.
10. Monitor the mother & baby immediately
after the delivery of the placenta.
POPPHI. Prevention of Postpartum Hemorrhage: Implementing ActiveManagement of the Third Stage of Labor (AMTSL): A Reference Manual
for Health CareProviders. Seattle: PATH; 2007.
During the 4th Stage of Labor
• Routinely inspect the vulva, vagina, perineum and anus to
identify genital lacerations.
• Inspect the placenta and membranes.
• DO NOT DO routine manual exploration of the uterine
cavity .
• Evaluate if the uterus is well contracted and massage the
uterus at regular intervals.
• Teach the woman to massage her own uterus to keep it
firm. DO NOT put ice pack on the mother’s abdomen.
WHERE ARE WE NOW?
Lancet 2013; 381:1747-55
High coverage but high MMR?
• Delays in implementation of intervention
• Poor implementation of intervention
• In the case of PPH:
• Shock management and prompt surgical care are also vital
• In the case of eclampsia:
• Other aspects of care are also essential – predelivery stabilization,
severe hypertension management, airway management
• Prevention, early identification and appropriate
management of secondary infections and other non
obstetric infections

Lancet 2013; 381:1747-55

 No quick fix exists to
reduce maternal mortality.

There are evidence-based

practices that may be life-saving
for both mother and baby.
“Women are not dying because we
cannot treat… they are dying because
societies have yet to make the decision
that their lives are worth saving.”

-Mahmoud Fathalla