Better Intrapartum Practices to Reduce Newborn Infection

Laura Fitzgerald, MSN, CNM Maternal Health Advisor Jhpiego/MCHIP

Global Picture of Newborn Mortality

Causes of Newborn Mortality

What is newborn sepsis ?

Newborn sepsis is defined as: the presence of bacteria in the bloodstream, and systemic signs of infection (often nonspecific and can be confused with clinical signs of other infections)

Categories of Newborn Sepsis

Early onset sepsis
presents within the first 72 hours of life usually acquired from the maternal genital tract during

the course of labor. constitutes 30 40% of infections resulting in neonatal sepsis deaths (Blencowe et al, 2011).

Late onset sepsis

presents after the first 72 hours of life usually caused by organisms present in the hospital,

home or community that are acquired after the delivery

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Intrapartum Maternal Fetal Link: Chorioamnionitis

Maternal - newborn infection closely linked Chorioamnionitis
maternal infection of amniotic fluid and

membranes usually bacterial if untreated, can result in maternal and newborn sepsis substantial cause of mortality for both mothers and newborns
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Intrapartum Factors Affecting Newborn Sepsis

Intrapartum factors leading to chorioamnionits:
prolonged labor, especially if more than 24 hours PROM > 18 hours prior to the birth a single unclean or frequent vaginal exams poor infection prevention practices (handwashing, instrument

processing) current cervical or vaginal infections

Debilitating maternal conditions, e.g. anemia, maternal undernutrition, or HIV Newborn lacks microbial flora at birth and has immature immune system
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Intrapartum Care to Prevent Sepsis

Infection prevention measures and hygiene Limit vaginal exams (especially with ROM) Use of partograph Appropriate use of antibiotics

Infection Prevention to Prevent Sepsis Infection Prevention

handwashing HLD/ sterile gloves HLD/ sterile equipment clean delivery surface table, bed, plastic

sheeting clean cord cutting clean towels for wrapping, warming newborn
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Memory Aid: The Six Cleans

Clean hands vigilant handwashing and HLD gloves Clean perineum Nothing unclean introduced into vagina Clean birthing surface Clean cord cutting instrument Clean cord tie or clamp

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Limit Vaginal Exams

Limit vaginal exams to those that are necessary multiple vaginal exams increase risk of chorioamnionitis. Do not conduct digital exam if woman is not in labor or if a womans membranes have ruptured. Use only a sterile speculum exam Avoid pushing the tip of finger through the cervix until active labor or the decision to induce occurs even when membranes are intact.
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Use of the Partograph

Partograph:
Monitors fetal condition Monitors maternal

condition Monitors progress of labor

Combines all needed data for decision-making Provides documentation Ob and Peds leaders should ensure its use
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Use of the Partograph

How does the partograph prevent newborn sepsis?
Limits frequency of vaginal

exams Prevents prolonged labor Taking temperature to identify chorioamnionitis Encourages greater vigilance

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Appropriate use of antibiotics

Prophylactic
PROM 18 hours or more before birth Risk of infection increases as duration of ROM

lengthens

Treatment early and immediate at first sign of chorioamnionitis

Clinical signs: maternal fever, fetal tachycardia,

uterine tenderness, foul odor of the amniotic fluid. Give polymicrobial antibiotic coverage

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Immediate Newborn Care

Cord care Clean cutting instrument Clean tie or clamp Eye care Clean and apply antibiotic Breastfeeding Provides passive immunity Immunoglobulins Lactobacillus bifidus, lactoferrin, lysozymes, WBCs
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Program considerations
Data for decision-making Rates of newborn infection and chorioamnionitis Local organisms Antibiotics and any emerging resistance Community behavior change including care seeking behavior Know danger signs and where to seek care Have all supplies for infection prevention in place if home birth Mother-baby dyad in policies and practices
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In summaryEvidence-based intrapartum interventions save lives! Hand hygiene, HLD/ sterile gloves The Six Cleans Minimize vaginal examinations Use of the partograph to reduce prolonged labor Prevention and prompt diagnosis and treatment of chorioamnionitis Clean cord and eye care Immediate and exclusive breastfeeding
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