FINAL REPORT Maternal-Newborn Advisory Committee MOTHER BABY DYAD WORK GROUP

Transcription

1 FINAL REPORT Maternal-Newborn Advisory Committee MOTHER BABY DYAD WORK GROUP FEBRUARY 6, 2011 DECEMBER 15, 2010

2 Report of the Maternal-Newborn Advisory Committee Mother Baby-Dyad Work Group Table of Contents EXECUTIVE SUMMARY... 1 BACKGROUND... 2 PURPOSE... 3 CURRENT STATE... 3 CODING... 5 HOW MUCH AND WHAT KIND OF SUPPORT IS RECOMMENDED TO FACILITATE BEST PRACTICE?... 5 Why is evidence not always enough to change practice?... 6 TABLE I: RECOMMENDATIONS OF THE MOTHER-BABY DYAD WORK GROUP... 7 SUMMARY OF RECOMMENDATIONS CONCLUSION Appendix I - Membership Appendix II Terms of Reference Appendix III Survey Data Appendix IV CIHI Data Appendix V GTA West Cluster Initiative END NOTES Provincial Council for Maternal and Child Health Page i

3 Report of the Maternal-Newborn Advisory Committee Mother-Baby Dyad Work Group EXECUTIVE SUMMARY The practice of separating a newborn from its mother soon after birth is common. This is a variation from an evolutionary perspective considering a newborns survival was dependent upon close and continuous maternal contact. Modern day hospital routines often significantly disrupt the early maternal-infant relationship and may, in fact, be harmful i. Newborn care practices often developed out of convenience and efficiency and have never been validated. Many evidence-based newborn care practices are not only beneficial, but also have no harm associated with them. Mother-baby dyad care, including skin-to-skin contact of healthy infants and mothers from birth and as much as possible in the early postpartum days must become an essential component of maternalnewborn care. The health of infants, mothers and our health care system are directly and indirectly affected by these practices. Please note that recommendations in this report may require modification to meet the needs of the pre-term infant. There is a wide variation (15-30%+) in special care nursery admission rates across the province according to PCMCH s Access Work Group Report ii published in January, This wide variation in admission rates suggests that there may be significant variations in newborn care practices across the province. Important benefits of caring for the mother and baby together include utilizing skin-to-skin care to reduce heat loss and promote thermoregulation, promoting mother-infant attachment behaviours, and increased breastfeeding success. A review of the evidence that skin-to-skin care is the best possible way to support physiologic transition of the healthy newborn is compelling. A mother s body will warm up or cool down to moderate the temperature of her infants body, thereby preventing hypothermia. Hypothermia and cold stress can lead to increased oxygen consumption resulting in respiratory distress and increased metabolism which depletes glucose stores resulting in hypoglycemia. An infant cared for skin-to-skin has slower respirations and is more coordinated in its movements. The vast majority of newborns will go to the breast within an hour of birth if they are kept skin-to-skin with their mother. This not only increases the success of initial breastfeeding but research confirms that the duration of breastfeeding is associated with early successful feeding and skin-to-skin care. Once an infant is past the first few hours of life the benefits of skin-to-skin contact continue with increased attachment, an increased duration of breastfeeding, decreased crying and less expression of pain during procedures such as heel prick blood sampling. A commitment of nurses, midwives and physicians to provide as many interventions as possible in the mother s room is essential in order to minimize separation of mother and baby. Admissions to nurseries Provincial Council for Maternal and Child Health Page 1

4 should be based on established criteria and guidelines. The use of respite care should be an exception based on clear criteria. This practice requires regular monitoring and review. Spacious hospital rooms, preferably private rooms where the mother labours, births and remains until discharge, are recommended to allow for increased continuity of care, encourage mother-baby dyad care and allow for a family member to stay and help the mother care for the infant. Hospital rooms have traditionally been designed for ill individuals and do not serve the family-centered model of care. Future planning for new or renewed birthing and postpartum units must make family-centred care a priority throughout the planning, implementation and evaluation phases. Supporting change in the hospital setting will entail a comprehensive approach including evidencebased practices, education and mentoring of individuals and champions from all disciplines to spearhead change. Consistent coding and documentation of separations of infants from mothers is a critical success factor in order to measure baseline practices, benchmark across sites and provide feedback to inform the discussions through which change occurs. Implementation of the recommendations contained in this report requires minimal financial expenditures. The recommendations primarily require establishing new practice routines that are achievable within existing resources. A small financial investment in knowledge translation strategies will be required to support implementation of these recommendations. Regional networks will be instrumental for successful implementation and to support and sustain practice change. The recommendations within this report for best practices and a change initiative, together with the data that will be available through the BORN rebuild will offer sites the blueprint and tools to address the quality improvement imperative as prescribed in the Excellent Care for All Act, legislated in Ontario in 2010 iii. BACKGROUND In June, 2008 the Maternal-Newborn Advisory Committee (M-NAC) was convened by the Provincial Council for Children s Health (now PCMCH) and the MOHLTC to address system issues related to maternal-newborn care in Ontario. M-NAC has initiated several work groups to address a number of system issues that affect access to tertiary services. M-NAC s Access Work Group recommended strategies to achieve a coordinated system of maternal and neonatal services that will provide equitable access to timely, high quality, evidence-based, familycentered care at the appropriate level for all pregnant women and newborns in Ontario iv. During the deliberations of the Access to Care Work Group the need for consistent practice in the area of support for mother-baby dyad care was recognized. The Work Group recommended that separation of mom and baby, often due to admission of baby to a Special Care Nursery, should be minimized. Provincial Council for Maternal and Child Health Page 2

5 Demand for maternal-newborn services is expected to increase. This growing demand places increasing pressure on the already stressed specialized maternal and newborn care system. Many Level III Obstetrical Units and Neonatal Intensive Care Units (NICU s) are operating at levels that do not allow for accommodation of surges resulting in high risk pregnant women and the most fragile neonates being transferred out-of-region or out-of-country for care. Optimal utilization of this scarce resource through sound practice is imperative. PURPOSE To develop an implementation strategy for the recommendations of the Access to Care Work Group to: promote consistent admission criteria for Special Care Nurseries optimize transition of newborn period care and promote care of the infant together with the mother, referred to as mother-baby dyad care. The membership of the Mother- Baby Dyad Work Group can be found in Appendix I. The full Terms of Reference for the Mother- Baby Dyad Work Group can be found in Appendix II. This report reflects the deliberations and recommendations of the Mother- Baby Dyad Work Group. The current state, coding that will support benchmarking and evaluation, evidence- based care and lessons learned from groups who have undertaken initiatives to improve mother- baby dyad care have been rigorously reviewed by our content experts during their deliberations. CURRENT STATE Current state was ascertained through three sources: All questions relevant to mother- baby dyad practices were pulled from the PCMCH Access to Services survey (Appendix III) which was sent to Ontario hospitals in 2008 CIHI data regarding nursery admission rates by LHIN (Appendix IV) Members contributed information about current state from their sites Until the introduction of rooming in, where the newborn is cared for in the mother s room, normal newborn nurseries were used routinely for all healthy babies. This practice began to change in the late 1970 s and 1980 s as normal newborn nurseries were phased out while rooming-in progressed from daytime care to 24 hours a day. Today, most nurseries exist to provide specialized care to sick babies. A newborns adaptation from intrauterine to extrauterine life is a critical period of transition. Optimal care during this time promotes thermoregulation, cardio-respiratory stability, breastfeeding initiation Provincial Council for Maternal and Child Health Page 3

6 and regulation of blood glucose levels. If a newborn experiences complications during this time additional care and interventions may be required. Some complications during the transitional period are easily prevented or managed when skin-to-skin care with the mother is routinely provided. According to the Canadian Maternity Experiences Survey v, only 31% of mothers reported holding their baby skin-to-skin when they first held their baby. This number excludes mothers whose infant went to the NICU or special care nursery. Unfortunately infant care practices at birth are highly variable across the province. Some centres promote best practices such as delayed cord clamping, immediate and sustained skin-to-skin care (ssc) and provide the first feeding within minutes after birth. Other centres routinely admit every infant born by caesarean section to the nursery for four hours, a practice that has not been recommended for many years. Separation of mom and baby during or following a cesarean section often occurs in centres where the surgery takes place in the main operating room which is located in a different part of the hospital than the birthing suite. The operating room nurses do not have the knowledge and expertise to care for the newborn, therefore the baby is transferred immediately to the nursery or postpartum unit. This situation is an excellent example of how the physical layout of a unit or hospital can support or interfere with providing evidence- based family-centred care. Most maternal-newborn centres perform caesarean sections using obstetrical nurses who have training to fulfill the expanded role of operating room nurses so that the cesarean section can be performed in the birthing suite. In this situation the woman s support person can often be present throughout the surgery. This system enables the newborn infant to stay in the operating room while the surgery is completed. Optimally the infant is placed across the mother s chest for skin-to-skin contact. Alternatively, skin-to-skin care can be provided by the father or other support person. The benefits of skin-to-skin care and other important practices will be reviewed more thoroughly within the recommendations. The maintenance of the mother-baby dyad as a unit during the postpartum hospital stay varies between centres when an infant requires interventions such as intravenous therapy for medication administration or phototherapy. Some sites move the infant to the nursery for the treatment while others provide the treatment in the mother s room. The treatments are managed by either the nursery nurse or a specially trained RN on the postpartum unit. If all newborns receive evidence- based care that promotes successful transition the risk of complications will be minimized. This will result in decreased demand for specialized neonatal care, promoting a better use of these precious resources. As a result, additional bassinettes will be available for sicker babies and retro-transfers thus supporting improved access to specialized care, when required, and to care closer to home. 47.5% of Ontario hospitals responding to a survey for M-NAC s Access Work Group Report vi indicated their special care nursery admission rates were greater than the targeted 15%. Of these, 42% reported rates greater than 25%. Other hospitals that responded to the survey reported rates as low as 5%. A group of hospitals, known as the West Cluster Maternal-Child Network, in the western part of the Greater Toronto Area, successfully implemented a Transition of the Newborn Program which reduced Provincial Council for Maternal and Child Health Page 4

7 nursery admission rates by 47% over 6 years. Mother- baby dyad care was a fundamental part of this initiative. Further details can be found in Appendix V. CODING In Ontario there is wide variation between units in the percentage of newborns admitted to the Special Care Nursery. This variation is not correlated with an underlying risk of the population served within the hospital. The variations have two sources. The first relates to clinical practice, with some sites going to great effort to keep mother and baby together and other sites automatically admitting babies such as those born by caesarean section to the nursery for four hours of observation. The second source relates to inconsistent documentation practices. Some hospitals admit babies through the admission, discharge, transfer (ADT) system to the nursery even if they are in for a short period of observation while other hospitals do not make location changes ( admissions ) in the ADT system unless a baby has been in the nursery for four hours or sometimes even longer. Some postpartum units have formal or informal nurseries, known as observation nurseries, on their postpartum units. These are often used for respite care for the mother. They may also be used to provide assessment and interventions for minor complications that resolve easily. Although this practice may prevent admissions to the Level 2 nurseries it will also skew data related to the separation of the mother and baby as it is similar to observation periods in the nursery that are not counted until after four hours. Currently there is a lack of documentation that will help track those infants who receive skin-to-skin care at birth and postpartum. The BORN Ontario database will, after the rebuild, include documentation of skin-to-skin care during the hours after birth vii however this information will only be available if hospitals ensure documentation of this care in their patient records. It is impossible to quantify practices without consistent documentation processes throughout the province. Reliable and consistent data is essential in order to understand resource utilization, monitor progress, evaluate care and measure risk. HOW MUCH AND WHAT KIND OF SUPPORT IS RECOMMENDED TO FACILITATE BEST PRACTICE? The evidence to manage mothers and infants as a dyad with limited physical separation has been strong for a number of years viii. A concerted effort is required to translate evidence into practice. Provincial Council for Maternal and Child Health Page 5

8 Why is evidence not always enough to change practice? Knowledge transfer strategies are vital to supporting change in the clinical setting. These are essential in order to improve the health of mothers and newborns, provide effective care and services and ultimately strengthen the health care system. Changing the behaviour of health care providers is a complex process. The Mother-Baby Dyad Work Group invested a great deal of time in examining the barriers and enablers to change for this initiative. As hospitals proceed to implement the recommendations of the Mother-Baby Dyad Work Group, they will need to understand the current state in their institution including clinical practices, the attitudes, beliefs and skills of the health care providers, as well as those of the women and families that receive care within their institution. Identifying the gap between their current state and the best practice recommendations is a critical step. Throughout implementation of these recommendations and beyond progress will have to be monitored in order to ensure results are not only achieved but also sustained. The Mother-Baby Dyad Work Group has made 9 recommendations (Table 1). The recommendations are accompanied by evidence, identified barriers and enablers for change as well as implementation steps and considerations. In 2000 the Family-Centred Maternity and Newborn Care: National Guidelines were published. The guidelines state that: During the immediate postpartum period, the mother and newborn, within the context of their family or personal support, should be viewed as a unit. Whenever possible, disruption of the close parent-infant relationship during the crucial few hours following birth is to be avoided and direct physical contact between the baby, mother, and father strongly encouraged. The parent-infant bond the first step in the infant s subsequent attachments is formative to a child s sense of security and has long-lasting effects. Indeed, the benefit to the parents should not be underestimated: this early physical contact with the baby affirms their sense of accomplishment and promotes their selfconfidence as parents. Keeping babies and parents together should clearly be of the highest priority ix. Provincial Council for Maternal and Child Health Page 6

9 TABLE I: RECOMMENDATIONS* OF THE MOTHER-BABY DYAD WORK GROUP *These recommendations may require modification in order to meet the needs of the pre-term infant. # Recommendation Evidence /Rationale Barriers Enablers Implementation Steps 1. Initiate continuous, uninterrupted skinto- skin care (ssc) immediately post birth and continue for a minimum of 2 hours. Encourage ssc throughout postpartum stay with mother or support person. Method: Upon birth place infant, chest down, on mothers chest or abdomen. Dry with warm towels then discard. Apply dry cap on infant s head. Cover mother and baby with prewarmed blankets. Diaper is optional. SSC can be provided by a support person in lieu of mother if Cochrane Review 2009,: Early Skinto-skin Contact for Mothers and their Healthy Newborn Infants Review, is a comprehensive evidence source for the following benefits of early skinto-skin contact for the newborn x : Stabilizes the physiologic parameters: heart rate, respiratory rate, oxygen saturation, oxygen consumption, apnea and bradycardia spells Maintenance of newborn body temperature Regulates blood glucose levels Decreased pain during invasive procedures xi for example, Vitamin K injection Reduces crying Increases breastfeeding success Improves mother -baby interaction The World Health Organization (WHO), in 1998, recognized ssc as an essential aspect of newborn care. xii Overcoming current practice routine. Physical layout of unit and hospital, for example, are cesarean sections done in the birthing unit or the main operating room? Culture of promoting skinto- skin care Simple to implement No cost Mother willing and eager to hold baby immediately after birth Benefits of bonding experience resulting from skin- to- skin contact Warm blankets readily available Mother is comforted by presence of her newborn skin- toskin Mother is distracted by presence of baby skin- to- skin and therefore less bothered by the discomforts and Incorporate skin-to-skin care into practice standards, policies, procedures and documentation in the patient care record. Develop and implement an educational initiative as required learning for front line health care providers. Understanding the benefits of ssc is a pre-requisite for implementing practice change. Include the development of local champions from within individual hospitals. Develop a public health campaign to increase awareness among prenatal patients and families. For example, pamphlets, posters, advertisements, etc. Teaching the public about the importance of ssc is key. This should also be integrated with breastfeeding recommendations. Implementation Considerations (Resources, Costs) Expert development of universal educational program for health professionals and families 1. (Similar to ffn educational module.) Utilize existing resources that have been developed and tested by the West Cluster Maternal Child Network s Transition of the Newborn initiative Educator, technical resources. Cost of developing communications tool kit. Regional Networks/BORN Coordinators can help with dissemination 1 Work Group members contributed resources already developed and / or in use at their respective sites. A skin-to-skin poster and education module were contributed by S. Guest of Mount Sinai Hospital. A. Gervais informed the work group about a for purchase skin- to- skin educational module to the attention of the group. (The Healthy Children Project Skin- to- skin in the first hour after birth: Practical advice for staff after Vaginal and Cesarean Birth. Produced 2010, ) Provincial Council for Maternal and Child Health Page 7

10 *These recommendations may require modification in order to meet the needs of the pre-term infant. # Recommendation Evidence /Rationale Barriers Enablers Implementation Steps she is unable to participate i.e. in operating room during a cesarean section. procedures that occur during 3 rd and 4 th stage of labour. Pilot within a region to establish process and outcomes. Engage regional networks / LHINs to support educational roll -out. Implementation Considerations (Resources, Costs) Letter from PCMCH to all hospital offering maternal-newborn services with a cc to the LHIN contact for Maternal-Child) services Consider holding provincial / regional webcasts/ workshops for hospital champions prior to implementation. Assign provincial resource person as recognized expert and create regional communities of practice. Engage stakeholders at every site including physician (all disciplines), midwife, and nurse champions. Organizational support for local champions to engage obstetrical care providers in discussions that share evidence and challenge commonly held beliefs about ssc. Provincial Council for Maternal and Child Health Page 8

11 *These recommendations may require modification in order to meet the needs of the pre-term infant. # Recommendation Evidence /Rationale Barriers Enablers Implementation Steps 2. Maintain skin- toskin contact while doing assessments and interventions. For example observation and assessment of grunting can be done while infant is skin-to-skin as can administration of Vitamin K & Erythromycin, and heel pricks for blood glucose screening. (see number 1) Routine newborn care practices are often performed under a radiant warmer. For example: examinations, blood sampling. This interrupts ssc. Routine assessments and interventions can be done during ssc. For example, medication administration, vital sign assessment, oxygen saturation measurement and free flow oxygen can all be done without disrupting ssc. Some procedures can also be delayed, so that initial bonding is not interrupted. Vitamin K should be given within six hours after birth xiii Erythromycin ointment should be given within one hour of birth xiv It is not uncommon for healthy newborns to have grunting respirations during their first 4 hours of life. This usually resolves spontaneously within 2 hours of birth xv SSC is beneficial for cardiorespiratory stabilization therefore grunting infants will benefit from ssc. Overcoming current practice routines. Staff resistance to change due to: Discomfort performing procedures in front of the parents. Perceived difficulty to carry out procedures during ssc, i.e. injection of Vitamin K. Fear of forgetting treatment leads to task orientation of nurses. Easy access to newborn for assessment and care Clinicians already have the skills to perform newborn assessments and interventions. Learning how to do this during ssc is not difficult. Care pathway Pain management enhanced during heel stick if baby is breastfeeding or skin- to- skin xvi Management support to change organization policy, procedures and practice in order to support ssc. Support required to increase confidence and competence for care providers to assess and care for newborn during ssc. Engage clinical leadership at sites to support / teach assessment of variations in transition, including mild respiratory distress, such as grunting. Bring specialists to the bedside to support nurses to develop their assessment skills. For example: SCN nurse, RRTs, pediatrician, anesthesiologist). Implementation Considerations (Resources, Costs) Regional Networks to facilitate knowledge translation strategy. Education module. Practice champions. Practice routines require minimal financial expenditures to implement. They are a matter of establishing a new practice routine. Provincial Council for Maternal and Child Health Page 9

12 *These recommendations may require modification in order to meet the needs of the pre-term infant. # Recommendation Evidence /Rationale Barriers Enablers Implementation Steps 3. Avoid unnecessary interventions, particularly those that may result in complications requiring transfer to the nursery. Suction according to Neonatal Resuscitation Program (NRP) standards xvii The NRP guidelines acknowledge that at least 90% of newborns are vigorous term babies who do not need to be separated from their mothers after birth for the initial steps of resuscitation. Initial steps of resuscitation include: Providing warmth through direct skin-to-skin contact with the mother Drying the skin, stimulating breathing and repositioning the head to open the airway. Clearing mucous from the upper airway by wiping the baby s mouth and nose Ongoing observation of breathing, heart rate, activity and colour Suctioning, in the absence of indications is harmful because it may lead to complications, including: apnea, bradycardia, trauma, and oral aversion. These complications may require transfer to the nursery, resulting in unnecessary separation of mother and baby. Resistance to change as a result of deeply ingrained practices. Some practitioners are more aggressive in their management of meconium than current standards dictate. Suction standards are already taught widely through NRP so should be widely practiced. NRP training is common for clinicians in the birthing setting. Due to the risk of Meconium Aspiration Syndrome, the NRP guidelines recommend that neonatal nurses, respiratory therapists & pediatricians be available to provide specialized support when meconium is present in the amniotic fluid at the time of birth. Education module for all regarding routine suctioning. Suctioning policy/practices Implementation Considerations (Resources, Costs) Cost savings realized through: Reduced use of suction catheters Avoiding unnecessary transfers to the Special Care Nursery Minimizing the need for specialized personnel, including physicians and respiratory therapists. NRP guidelines recommend that, if the airway is blocked by mucous, the care provider should wipe the nose and mouth with a towel or do brief, gentle suctioning of the mouth and nose with a catheter. Vigorous babies, born with meconium present in the amniotic fluid, should be treated the same way. Provincial Council for Maternal and Child Health Page 10

13 *These recommendations may require modification in order to meet the needs of the pre-term infant. # Recommendation Evidence /Rationale Barriers Enablers Implementation Steps Avoid suctioning vigorously or deeply. Stimulating the posterior pharynx can produce a vagal response, resulting in severe bradycardia or apnea. Implementation Considerations (Resources, Costs) A non-vigorous baby, born with meconium present in the amniotic fluid, should be suctioned through a laryngoscope then endotracheal tube. Oral & pharyngeal suctioning is a contributing factor for oral aversion. This may disrupt the initiation of feeding by breast or bottle. It is easier to prevent oral aversion than it is to treat it. Follow Canadian Pediatric Society (CPS) position statement for screening at-risk newborns for low blood glucose. Perform glucose testing at bedside to prevent separation of baby from mother. Infants at risk for hypoglycemia who are asymptomatic should have their first glucose check at 2 hours of age. xviii Centres that initiate glucose screening for asymptomatic at-risk newborns earlier than 2 hours put the newborn at risk for unnecessary interventions that increase the possibility that the baby will be separated from its mother. CPS position statements are widely used across the province to guide neonatal care practices. Education for all practioners regarding CPS recommendations. Cost savings realized if there is a decrease in unnecessary glucose testing. Provincial Council for Maternal and Child Health Page 11

14 *These recommendations may require modification in order to meet the needs of the pre-term infant. # Recommendation Evidence /Rationale Barriers Enablers Implementation Steps 4. Manage transition using assessment skills recommended in the NRP Guidelines xix. The NRP guidelines recommend that every birth should be attended by at least 1 person skilled in neonatal resuscitation. This person s only responsibility should be the management of the newborn At every delivery, there should be at least 1 person who can be immediately available to the baby as his or her only responsibility and who is capable of initiating resuscitation. Either this person or someone else who is immediately available should have the skills required to perform a complete resuscitation, including endotracheal intubation and administration of medications. It is not sufficient to have someone on call (either at home or in a remote area of the hospital) for newborn resuscitations in the delivery room. xx It further recommends that when a high risk delivery is anticipated, at least 2 persons should be present just to manage the baby. One of these people should be able to perform a full resuscitation and 1 or more to assist. Skills in neonatal resuscitation are obtained through the Neonatal Resuscitation Program (NRP) coordinated by the Canadian Paediatric Society and the Canadian Heart and Stroke Foundation. Training and registration at the Provider or Instructor level and periodic re-registration are Lack of clinicians who are trained to perform endotracheal intubation and who can be present at every birth. Pediatricians and respiratory therapists may not be on-site 24/7. Respiratory therapists may not be qualified to perform neonatal intubation. Willingness of delivering physician (obstetricians and family physicians) and midwives to become competent to perform neonatal intubation according to NRP standards. NRP training is common for all clinicians attending births. All physicians attending births to become competent to perform neonatal intubation. Leadership team to implement policy to support this practice. Implementation Considerations (Resources, Costs) Variations exist regarding who pays for NRP training. It is often an organizational responsibility. Provincial Council for Maternal and Child Health Page 12

15 *These recommendations may require modification in order to meet the needs of the pre-term infant. # Recommendation Evidence /Rationale Barriers Enablers Implementation Steps recommended for all personnel likely to care for babies immediately after birth. The efforts by institutions to provide on-site programs to achieve this goal should be supported xxi. Implementation Considerations (Resources, Costs) 5. Bring the resources (expertise & equipment) to the infant instead of the infant to the resources. Clinical therapies or treatments for the baby should be carried out at the mother s bedside whenever possible. Newborns with symptoms of mild respiratory distress and hypoglycemia benefit from ssc. Assessment of these conditions at the mother s bedside enables the infant to stay with the mother. The skills required to support this practice can be learned by birthing and postpartum nurses. During the initial stages of resuscitation, strive to perform this in presence of parents. Room layout and space can facilitate this. Stable newborns who require phototherapy or prophylactic IV antibiotics are often transferred to the nursery. These babies would be better off rooming-in with mom while receiving these treatments. This requires increased workload for the postpartum nurse or flexible staffing models which would enable the SCN nurse to go to the postpartum unit to manage the treatment, i.e. intravenous. Refer to Access to Care Level II admission guidelines for management of jaundice xxii asymptomatic sepsis (IPC guidelines) xxiii Overcoming current practice routines. Increased workload of managing an infant who requires extra care, i.e. phototherapy. Resistance to change as a result of clinicians who feel it is easier to move baby to the nursery than keep it with the mother. Distance of nursery from birthing unit Nurses may lack assessment skills for some situations. Individual nursing units are managed under their specific budgets for staffing and resources. This may challenge the organizations flexibility to share staff between units, for example when a consultant role is performed by a Flexible staffing model: Availability of respiratory therapists and neonatal nurses to consult when neonates experience variations during the transitional period Staff skilled in neonatal assessment exists in most hospitals. Utilize these clinicians to coach and mentor the birthing and postpartum RN s to manage mild respiratory distress. Decreased admissions to the nursery if interventions in birthing unit are effective thus freeing up time within the SCN for Leadership team to implement policy to support this practice. Support required to increase confidence and competence for care providers, to assess and care for newborn during ssc, Consultant assessment to take place in mother s room. (SCN nurse, pediatrician, respiratory therapist). Flex / align staffing resources to reflect location of care / census / acuity. Assign local clinical champions and nursing education and resources as necessary to provide care of infant at mother s bedside. Consultant responsibility to include including mentoring role. Educate staff about how infants can receive ssc and bedside care for: APGAR score weighing & measuring resuscitation phototherapy saline locks Regional networks to conduct monthly teleconferences to share ideas, resources, communities of practice (multiple sites). Utilize expertise of centers where changes have already occurred. They can act as resources for change and act as role models. Physical design of unit will impact opportunities to provide some therapies at the bedside. Provincial Council for Maternal and Child Health Page 13

16 *These recommendations may require modification in order to meet the needs of the pre-term infant. # Recommendation Evidence /Rationale Barriers Enablers Implementation Steps nursery nurse who goes to the postpartum unit to give IV antibiotics to a stable infant who is rooming in with mother. staff to consult/assist in the postpartum unit with these infants. Also, SCN nurses will have more time to care for the sicker babies in the unit, including retrotransfers. heel prick blood sampling antibiotic therapy Develop portable tool kits with equipment required for infant care in mother s room. Physical layout of birthing rooms and cesarean/operating rooms will determine ability to resuscitate infant in presence of mother/support person. Implementation Considerations (Resources, Costs) Provincial Council for Maternal and Child Health Page 14

17 *These recommendations may require modification in order to meet the needs of the pre-term infant. # Recommendation Evidence /Rationale Barriers Enablers Implementation Steps 6. Incorporate delayed cord clamping for a minimum of 2 minutes after birth into day-to-day practice. The practice of delayed cord clamping is easily integrated into a gentle birth culture that also promotes ssc and discourages separation of mom and baby. Early cord clamping is usually defined as within the first 10 seconds. xxiv Delayed cord clamping is defined by the SOGC as up to 2 minutes, the average amount of time it takes for the cord to stop pulsating xxv. Hutton and Hassan s systematic review and meta-analysis of late vs early cord clamping xxvi revealed that delayed cord clamping: Is beneficial for the neonatal period and beyond. It results in a decreased risk of anemia and decreased risk of iron deficiency during the first 3 months after birth. Showed a non-significant finding of polythcythemia (increased red blood cells) In the preterm population, was found to decrease the incidence of anemia, sepsis, and intraventricular hemorrhage. No difference in outcomes when the infant is placed on mother s chest vs held below the introitus in delayed clamping results, therefore placing the infant on the mother s chest without the Overcoming current practice routines by physicians, midwives and nurses. May require a change in the management of the second and third stages of labour as it relates to oxytocin administration No cost to implement delayed cord clamping. Reduced incidence of separation of baby from mother when treatment for anemia is not required. Develop local champions to initiate discussions that share evidence and challenge common beliefs among obstetrical care providers about delayed cord clamping. Develop informed consent for families planning stem cell collection when the In utero method of collection will be used. Explore the possibility of using the Ex- utero collection methods for families who wish to collect stem cells and also choose delayed cord clamping for their newborn. Implementation Considerations (Resources, Costs) Cost savings realized through decreased incidence of infants requiring treatment for anemia and iron deficiency during the first 3 months after birth. Additional savings will result among the pre-term population relating to sepsis and intraventricular hemorrhage. Provincial Council for Maternal and Child Health Page 15

18 *These recommendations may require modification in order to meet the needs of the pre-term infant. # Recommendation Evidence /Rationale Barriers Enablers Implementation Steps cord clamped is acceptable practice. Implementation Considerations (Resources, Costs) Considerations for stem cell collection: The SOGC describes two techniques for collecting cord blood from the umbilical vein for stem cells xxvii : In utero before the placenta is delivered (quicker method and most common technique). This method is not compatible with delayed cord clamping. Ex utero after the placenta is delivered (more time consuming and less commonly practiced). This is the only technique that is compatible with delayed cord clamping. Considerations for cord blood gas collection: The SOGC recommends that arterial and venous cord blood gasses be routinely collected for all births xxviii. Although cord gases should be collected immediately after birth, the SOGC acknowledges that delaying cord clamping until the cord stops pulsing (average 2 minutes) does not interfere with the collection of cord blood gases. xxix The only exception is a depressed baby who should have cord gases drawn immediately. Provincial Council for Maternal and Child Health Page 16

19 *These recommendations may require modification in order to meet the needs of the pre-term infant. # Recommendation Evidence /Rationale Barriers Enablers Implementation Steps 7. Use of respite / observation nurseries (separate spaces in post partum areas) should be discouraged unless there are maternal medical indications or for safety. Keeping babies and parents together should clearly be of the highest priority. Institutional policies can at times restrict this contact, so flexibility should be the guiding principle xxx Mother and baby will benefit when the support person stays in hospital with them. The support person will begin bonding with baby which will increase attachment and parenting behaviours. Mothers who room-in with their baby at night report better quality of sleep compared to mothers whose baby slept in the nursery. xxxi Inflexible staffing models as a result of fiscal limitations. Nurses sometimes think they are helping mothers to rest when they take the baby out of her room to an observation area. Lack of private rooms. Physical space and layout of patient rooms may prevent a support person from staying to help mother. Hospitals currently charge additional fees for semi-private and private patient rooms. These are referred to as preferred accommodations. An obstetrical unit with only private rooms would be ideal for family-centred care however insurance regulations prevent hospitals from charging for preferred accommodations when ward and semiprivate rooms do not Staffing models that allow nurses adequate time to support and care for mother-baby dyad and minimize need for respite care. High ratio of private rooms to semi s and wards will facilitate support person to stay. Flexible staffing to support variable workload. All hospitals should develop strategies to avoid separation of mother and baby dyads. Provide information to families prenatally to educate them about the importance of dyad care and rooming-in. Implementation Considerations (Resources, Costs) Appropriate flexible nursing staff at bedside to prevent maternal exhaustion and frustration and provide education and support re: coping techniques. Move to private room model of care so family support can stay overnight in order to provide support. Provincial Council for Maternal and Child Health Page 17

20 *These recommendations may require modification in order to meet the needs of the pre-term infant. # Recommendation Evidence /Rationale Barriers Enablers Implementation Steps Create therapeutic environments that support motherbaby dyad care. Develop coding requirements to measure baseline and degree of change. Quality of care and patient safety are enhanced in a patient and family centred environment. Creating therapeutic environments is especially relevant as hospitals renovate existing units or build new units. The Institute for Patient and Family Centered care reports that studies increasingly show that when health care administrators, providers, and patients and families work in partnership, the quality and safety of health care rise, costs decrease, and provider and patient satisfaction increase xxxii. Baseline measurements and benchmarking are crucial to support change. Hospital sources of baseline data may include documentation on the patient care record of the following types of information: exist on the nursing unit. Loss of insurance revenue will be significant if hospitals cannot charge for preferred accommodations when only private rooms are available. Lack of private rooms. Physical space and layout of patient rooms may prevent a support person from staying to help mother, interfere with the mothers ability to rest and encourage use of respite nurseries. Limited fiscal resources to finance renovations. Limited physical space. All hospitals do not require documentation of all the fields mentioned. Baseline data may not be available at Architectural firms are gaining expertise in designing specialized spaces that meet the needs of patients and families as well as the health care teams in the hospitals of the future. Hospitals with a family advisory committee can utilize this partnership to improve existing environments to support motherbaby dyad care. Monitoring compliance with hospital policies will enable measuring of practice changes as well as the frequency that Assess existing environment to determine current and future needs. Partner with families to guide the development of a patient and family centered environment that meets the needs of the local community. Develop coding to document initiation and duration of skin-to-skin care during the first hour of life; these data elements should be captured within CIHI or the BORN database. Implementation Considerations (Resources, Costs) Potential for long term cost savings when the hospital environment is well designed to meet the needs of patients, family and staff. Provincial Council for Maternal and Child Health Page 18

21 *These recommendations may require modification in order to meet the needs of the pre-term infant. # Recommendation Evidence /Rationale Barriers Enablers Implementation Steps Sustain practice change through periodic evaluation of implementation strategies to increase motherbaby dyad maintenance. Evaluate success of practice change through audits that evaluate compliance with recommendations, ultimately ensuring sustainability of recommendations. Reduce harmful outcomes associated with early elective delivery of the neonate before 39 Time umbilical cord is clamped Skin-to-skin care: frequency and duration; rationale for not doing skin-to-skin care Timing of first feeding (breast or bottle) Transfer of infant to a different unit, i.e. SCN Observation times under 4 hours in the SCN Use of informal nurseries i.e. for respite care on postpartum unit May be built into BORN database and incorporated into planned BORN hospital dashboard. Conduct retrospective chart audits. Measurement is central to quality improvement initiatives. According to the Society of Obstetricians and Gynecologists of Canada (SOGC), the rate of elective inductions is increasing. One of the most common reasons to induce labour is post-term pregnancy, which is defined by the SOGC as at least 41 every site. Hospital patient care records are not standardized and therefore they may not currently support all fields relating to the recommendations. Manual data collection is required in hospitals that do not use an electronic patient care record. Overcome current practice routines. Physician on-call arrangements. Variations in practice exist between hospitals. evidence-based practice is routinely performed. Electronic patient care records will enable the potential to automatically populate necessary data into BORN. SOGC clinical practice guidelines are evidence based. Midwifery model of care Review/sharing of Standardize coding for nursery admission to include any separation of the infant from the mother for two hours or longer when done to facilitate infant care. Infant care in observation, respite or resuscitation areas included in coding as a nursery admission. Baseline rates of items defined in coding requirements (as above). Baseline rates of nursery admission by length of stay. Stratify term births by vaginal and c/section. Compare like hospitals through benchmarking. Implement standardized booking criteria for elective inductions and c/s based on SOGC clinical practice guidelines. Improve and standardize coding for inductions and Implementation Considerations (Resources, Costs) Develop provincial audit tool. Work with BORN to ensure the necessary metrics are included in the database. Regional Coordinators to develop multiple intervention strategy approach to implement required changes in practice. Provincial Council for Maternal and Child Health Page 19

22 *These recommendations may require modification in order to meet the needs of the pre-term infant. # Recommendation Evidence /Rationale Barriers Enablers Implementation Steps weeks gestation. Follow SOGC policy and guidelines, including elective inductions, normal childbirth and cesarean section. completed weeks of pregnancy xxxiii. Rising cesarean section (c/s) rates are partially attributed to obstetrical policies and practices, including increased rates of induction of labour prior to 41 weeks gestation xxxiv. It is well documented that for both primiparous and multiparous women, induction of labour prior to 41 weeks gestation significantly increased the risk of c/s xxxv. The practice of routine repeat c/s also contributes to a high c/s rate despite good evidence that this practice is unnecessary. The recent increases in routine repeat c/s appears to be based on healthcare providers fear of litigation, and economic incentives in terms of higher fees for surgical services that can be delivered in a more predictable, timely and convenient manner xxxvi. Documentation and coding are not standardized across the province. strategies used by other hospitals to effect this change in practice. elective cesarean births to establish baseline rates and monitor practices. Communities of practice/regional Coordinators Monitor compliance to recommendation. Implementation Considerations (Resources, Costs) Women who are induced between 37 and 40 weeks gestation are more likely to experience a c/s than those with spontaneous onset of labour xxxvii. According to the GTA CHN Birthing Review Project, the cesarean section rate in nulliparous women (first baby) with non-medically indicated inductions is almost double that of nulliparous women who had a spontaneous labour (32% vs 16%) every year between xxxviii. Provincial Council for Maternal and Child Health Page 20

23 *These recommendations may require modification in order to meet the needs of the pre-term infant. # Recommendation Evidence /Rationale Barriers Enablers Implementation Steps 62% of all elective repeat c/s among low risk women who were not in labour, were done prior to 39 weeks gestation.in xxxix. Elective inductions and c/s prior to 39 weeks gestation that are not medically indicated may adversely affect neonatal outcomes, including increased respiratory symptoms, infections and length of stay. The American College of Obstetricians and Gynecologists report the complications of elective deliveries between weeks gestation xl include: Increased NICU admissions Increased transient tachypnea of the newborn (TTN) Increased respiratory distress syndrome (RDS) Increased ventilator support Increased suspected or proven sepsis Increased newborn feeding problems and other transition issues Increased length of stay 5 days Implementation Considerations (Resources, Costs) Provincial Council for Maternal and Child Health Page 21

24 SUMMARY OF RECOMMENDATIONS Summary of Recommendations 1. Initiate continuous, uninterrupted skin- to- skin care immediately post birth and continue for a minimum of 2 hours. Encourage skin- to- skin care throughout postpartum stay with mother or support person. 2. Maintain skin- to- skin contact while doing assessments and interventions. 3. Avoid unnecessary interventions, particularly those that may result in complications requiring transfer to the nursery, i.e. routine suctioning. 4. Manage transition using assessment skills recommended in the NRP Guidelines xli. 5. Bring the resources (expertise & equipment) to the infant instead of the infant to the resources. Clinical therapies or treatments should be carried out at the bedside whenever possible. 6. Incorporate delayed cord clamping for a minimum of 2 minutes after birth into day-to-day practice. 7. Use of respite/observation nurseries (separate spaces in post partum areas) should be discouraged unless there are maternal medical indications or for safety (5 day stay for mental health, CCU, ICU,OR) 8. Create therapeutic environments that support mother-baby dyad care. 9. Develop coding requirements to measure baseline and degree of change. 10. Sustain practice change through periodic evaluation of implementation strategies to increase mother-baby dyad maintenance. Evaluate success of practice change through audits that evaluate compliance with recommendations, ultimately ensuring sustainability of recommendations. 11. Reduce harmful outcomes associated with early elective delivery of the neonate before 39 weeks gestation. Follow SOGC policy and guidelines, including elective inductions, normal childbirth and cesarean section. Provincial Council for Maternal and Child Health Page 22

25 CONCLUSION Consistent mother-baby dyad care in hospital settings, whenever possible, with education and support for clinicians to change their practice and for families to embrace this model of care has far reaching consequences. Improved attachment will promote better maternal and infant mental health. The risk of cold stress, which results in respiratory distress syndrome and hypoglycemia, are reduced when thermoregulation is achieved quickly and efficiently. Breastfeeding success is increased as a result of increased initiation and duration that result when skin-to-skin care is practiced. Breastfeeding benefits are profound, including decreased incidence of short term illnesses such as otitis media and gastrointestinal infections which place high demand on emergency room and primary care utilization. In addition, the long term benefits of breastfeeding, including decreased obesity, diabetes and a host of other conditions (many metabolic) which continue to come to light through longitudinal epidemiologic studies, will improve the health of Ontarians and avoid unnecessary health care costs. Special Care Nursery admissions will decrease as infants transition from intra to extra-uterine life with fewer incidents of physiologic stress. Precious SCN resources can be focused on infants who unavoidably need special care. This will allow current physical capacity to better meet the demand that will come with the rising birth rate projected for Ontario. In summary, practice changes to support keeping mother and newborn together immediately after birth and during the postpartum period will have both short and long-term benefits for the infant, the family and the system. Provincial Council for Maternal and Child Health Page 23

26 Appendix I MOTHER-BABY DYAD WORK GROUP MEMBERSHIP LHIN FIRST NAME JOB TITLE ORGANIZATION 1 Krista Turner L&D/PP Bluewater Health 3 Nicole Roach Midwife St. Jacobs Midwives 4 Trudy Cooper Manager Hamilton Health Sciences- Hamilton 6 Kathryn Doren Manager, NICU Level 2 Halton Healthcare Services 6 Kim Moore Manager, Birthing Services Trillium Health Centre 5 & 6 Ruth Turner Regional Maternal Child Education Coordinator 7 Susan Guest CNS, Mother Baby Unit Mt. Sinai Hospital West Cluster Maternal Child Network 8 Lois MacInnis Clinical Team Manager North York General Hospital Director, Maternal-Child and Oncology 8 Joanne MacKenzie (Chair) Services Interim Program Manager for 10 Donna Cooper Obs/Gyne and L&D Charge Nurse Markham Stouffville Hospital Kingston General Hospital 13 Anne Gervais North Bay General Hospital 5 Deborah Walker Patient Care Manager WCHS - EGH Mary Ellen Salenieks Senior Project Manager PCMCH Provincial Council for Maternal and Child Health Page 24

27 Appendix II Provincial Council for Maternal and Child Health Maternal-Newborn Advisory Committee Mother-Baby Dyad Care Work Group Background / Context Terms of Reference Building a brighter future for children begins by ensuring a good start to life with access to appropriate levels of care for mothers and newborns in Ontario. We require an integrated and coordinated provincial system of maternal and neonatal services capable of delivering timely, equitable, accessible, high quality, evidence-based, family-centred care in an efficient and effective manner. The Issue Demand for maternal-newborn services is expected to increase. This growing demand places increasing pressure on the already stressed specialized maternal and newborn care system. Many Level III Obstetrical Units and Neonatal Intensive Care Units (NICUs) are operating at levels that do not allow for accommodation of surges resulting in high risk pregnant women and the most fragile neonates being transferred out-of-region or out-of-country for care. In June, 2008 the Maternal-Newborn Advisory Committee (M-NAC) was convened by the Provincial Council for Children s Health (now PCMCH) and the MOHLTC to address system issues related to maternal-newborn care in Ontario. M-NAC has initiated several work groups to address a number of system issues that affect access to tertiary services including: Fetal Fibronectin Testing; remote screening for retinopathy of prematurity; infection prevention and control policies for maternalnewborn units; access to maternal-newborn services; and transport services for pregnant women, newborns and children. During the deliberations of the Access to Care Work Group the need for consistent practice in the area of support for mother-baby dyad care and avoidance, whenever possible, of separations due to admission to the Special Care Nursery was raised by work group members. During the immediate postpartum period, the mother and newborn, within the context of their family or personal support, should be viewed as a unit. Whenever possible, disruption of the close parentinfant relationship during the crucial few hours following birth is to be avoided and direct physical contact between the baby, mother, and father strongly encouraged. The parent-infant bond the first step in the infant s subsequent attachments is formative to a child s sense of security and has longlasting effects. Indeed, the benefit to the parents should not be underestimated: this early physical Provincial Council for Maternal and Child Health Page 25