final report maternal-newborn advisory · pdf filefinal report maternal-newborn advisory...

DECEMBER 15, 2010

FINAL REPORT

Maternal-Newborn Advisory Committee

MOTHER BABY DYAD WORK GROUP

FEBRUARY 6, 2011

Provincial Council for Maternal and Child Health Page i

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 ......................................................................................................... 22

CONCLUSION ............................................................................................................................................... 23

Appendix I - Membership ................................................................................................................ 24

Appendix II – Terms of Reference .................................................................................................... 25

Appendix III – Survey Data .............................................................................................................. 28

Appendix IV – CIHI Data .................................................................................................................. 29

Appendix V – GTA West Cluster Initiative ....................................................................................... 32

END NOTES .................................................................................................................................................. 33

Provincial Council for Maternal and Child Health Page 1

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 harmfuli. 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 maternal-

newborn 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 Reportii published in January, 2010. 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


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 evidence-

based 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 2010iii.

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, family-

centered care at the appropriate level for all pregnant women and newborns in Ontarioiv.

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.


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


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 Surveyv,

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 30-60 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 Reportvi 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


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 birthvii 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 yearsviii. A concerted effort is required to translate evidence into practice.


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 self-

confidence as parents. Keeping babies and parents together should clearly be of the

highest priorityix.”


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 Implementation Considerations

(Resources, Costs)

1. Initiate continuous, uninterrupted skin- to- 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 pre-warmed blankets. Diaper is optional. SSC can be provided by a support person in lieu of mother if

Cochrane Review 2009,:“Early Skin-to-skin Contact for Mothers and their Healthy Newborn Infants Review, is a comprehensive evidence source for the following benefits of early skin-to-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 skin- to- 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- to- skin 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.

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, www.healthychildren.ca )

http://www.healthychildren.ca/




(Resources, Costs)

she is unable to participate i.e. in operating room during a cesarean section.

procedures that occur during 3

rd

and 4th

stage of labour.

Pilot within a region to establish process and outcomes. Engage regional networks / LHINs to support educational roll -out. 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.

Letter from PCMCH to all hospital offering maternal-newborn services with a cc to the LHIN contact for Maternal-Child) services




(Resources, Costs)

2. Maintain skin- to- skin 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 cardio-

respiratory 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).

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.




(Resources, Costs)

3. Avoid unnecessary interventions, particularly those that may result in complications requiring transfer to the nursery. Suction according to Neonatal Resuscitation Program (NRP)

standardsxvii

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. 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.

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

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.




(Resources, Costs)

Avoid suctioning vigorously or deeply. Stimulating the posterior pharynx can produce a vagal response, resulting in severe bradycardia or apnea. 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.




(Resources, Costs)

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.

Variations exist regarding who pays for NRP training. It is often an organizational responsibility.




(Resources, Costs)

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.

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

jaundicexxii

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.




(Resources, Costs)

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.




(Resources, Costs)

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.

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.




(Resources, Costs)

cord clamped is acceptable practice.

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.




(Resources, Costs)

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 semi-private 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.

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.




(Resources, Costs)

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.

8. Create therapeutic environments that support mother-baby dyad care.

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.

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.

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 mother-baby dyad care.

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.

Potential for long term cost savings when the hospital environment is well designed to meet the needs of patients, family and staff.

9. Develop coding requirements to measure baseline and degree of change.

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:

All hospitals do not require documentation of all the fields mentioned.

Baseline data may not be available at

Monitoring compliance with hospital policies will enable measuring of practice changes as well as the frequency that

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.




(Resources, Costs)

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

every site. evidence-based practice is routinely performed.

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.

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.

May be built into BORN database and incorporated into planned BORN hospital dashboard. Conduct retrospective chart audits. Measurement is central to quality improvement initiatives.

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.

Electronic patient care records will enable the potential to automatically populate necessary data into BORN.

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.

Develop provincial audit tool. Work with BORN to ensure the necessary metrics are included in the database.

11. Reduce harmful

outcomes

associated with

early elective

delivery of the

neonate before 39

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

Overcome current practice routines. Physician on-call arrangements. Variations in practice exist between hospitals.

SOGC clinical practice guidelines are evidence based. Midwifery model of care Review/sharing of

Implement standardized booking criteria for elective inductions and c/s based on SOGC clinical practice guidelines. Improve and standardize coding for inductions and

Regional Coordinators to develop multiple intervention strategy approach to implement required changes in practice.




(Resources, Costs)

weeks gestation.

Follow SOGC policy

and guidelines,

including elective

inductions, normal

childbirth and

cesarean section.

completed weeks of pregnancyxxxiii

. 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.

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 2004-2009

xxxviii.

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.




(Resources, Costs)

62% of all elective repeat c/s among low risk women who were not in labour, were done prior to 39 weeks gestation.in 2008-2009

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 37-39 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


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 Guidelinesxli.

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.


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.


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

West Cluster Maternal Child Network

7 Susan Guest CNS, Mother Baby Unit Mt. Sinai Hospital

8 Lois MacInnis Clinical Team Manager North York General Hospital

8 Joanne MacKenzie (Chair) Director, Maternal-Child and Oncology Services

Markham Stouffville Hospital

10 Donna Cooper Interim Program Manager for Obs/Gyne and L&D Charge Nurse

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


Appendix II

Background / Context

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 maternal-newborn 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 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

Provincial Council for Maternal and Child Health Maternal-Newborn Advisory Committee

Mother-Baby Dyad Care Work Group

Terms of Reference


contact with the baby affirms their sense of accomplishment and promotes their self-confidence as parents. 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.”1

Work Group Purpose

Develop an implementation strategy for the recommendations in the Access Work Group report to:

promote consistent admission criteria for Special Care Nurseries

optimize transition of newborn period care and

promote care of the infant with the mother.

Objectives

To:

Identify the current state of mother-baby dyad care across the province

Identify best practices in mother-baby dyad care

Review best practices for maintaining mother-baby dyad care in the instance of potential or actual complications such as Neonatal Abstinence Syndrome, jaundice, intravenous access required, etc.

Identify resources, skills and educational requirements to support mother-baby dyad care

Recommend strategies to standardize best practice in mother-baby dyad care

Identify a methodology for benchmarking Level II nursery admissions

Membership

The Work Group membership will be multidisciplinary and represent the following areas of expertise: Level I administrator at a site without a nursery Postpartum administrator at a site with a Level II nursery Postpartum administrator at a site with a Level III nursery Level I in-hospital infant care providers Midwife L&D nurse Post partum nurse L&D physicians Level II infant care providers Respiratory Therapist Educator (maternal-newborn) Family MD from level I Paediatrician

1Health Canada. Family-Centred Maternity and Newborn Care: National Guidelines, Minister of Public Works and

Government Services, Ottawa, 2000. p 6.6


Reporting Relationship

The Mother -Baby Dyad Care Work Group will report to the Maternal-Newborn Advisory Committee.

Frequency of Meetings

To be determined by the Work Group

Timeframe

February to November 2010

Decision-Making Process

Members share accountability for decisions. There should be open and direct communication based on honesty, respect and transparency, to ensure that all perspectives are heard. Decisions should be evidence or most-promising practice-based. Decisions will be made by consensus whenever possible.


Appendix III

Newborn Care Practices Across Levels of Care

Data source: PCMCH Access to Services Survey, December 2008.

Level I (N 43)

Level II, A II, M III (N 42)

Level III (N 8)

Yes No Blank Yes No Blank Yes No Blank

Summary Statements

Do You Have A Physically Separate Level I Nursery?

11 23 9 1 25 16 1 5 2 More likely at Level I sites.

Do You Include Stays < 12 Hours In Your Nursery Admission Counts?

17 15 11 34 4 4 5 1 2

The higher the level the more likely to count short stay.

Are Newborns With IV Lines Managed On Your Postpartum Unit?

10 (28%)

26 7 16

(40%) 24 2

3 (50%)

3 2

The lower the level, the less likely to manage IV lines on the postpartum unit.

Are Newborns Requiring Phototherapy Managed On Your Post Partum Unit?

34 4 5 37 3 2 6 0 2

Largely but not completely done.

Do You Have An Observation Area For Level I Babies?

24 13 6 8 32 2 2 4 2 More likely the lower the level.

Are Well Newborns Managed Entirely In Room With Mother?

34 5 4 39 2 1 6 0 2 More likely the higher the level.

Are Well Newborns Managed Partially In Room And Partially In Nursery?

7 28 8 1 37 4 0 6 2 More likely the lower the level.


Appendix IV

CIHI Data*: Diagnosis for Newborns admitted to NICU at least once in Ontario by LHIN. Average

Length of Stay in NICU ≤ 4 hours, 5-12 hours, > 12 hours**

LHIN NICU LOS

Total 0-4 hrs 5-12 hrs 12+ hours

3526 The District of Algoma Health Unit <5 <10 99 110

3527 Brant County Health Unit 19 49 310 378

3530 Durham Regional Health Unit 36 59 188 283

3531 Elgin-St. Thomas Health Unit 0 <5 0 <5

3533 Grey Bruce Health Unit 23 13 131 167

3536 Halton Regional Health Unit 68 67 336 471

3537 City of Hamilton Health Unit 56 73 984 1113

3541 Kingston, Frontenac and Lennox and Addington Health Unit

16 52 304 372

3544 Middlesex-London Health Unit 69 38 499 606

3546 Niagara Regional Area Health Unit 23 32 328 383

3547 North Bay Parry Sound District Health Unit 173 67 175 415

3551 City of Ottawa Health Unit 165 189 1042 1396

3553 Peel Regional Health Unit 209 182 1618 2009

3554 Perth District Health Unit <5 <10 80 93

3555 Peterborough County-City Health Unit 19 70 323 412

3560 Simcoe Muskoka District Health Unit 61 121 605 787

3561 Sudbury and District Health Unit 85 33 174 292

3562 Thunder Bay District Health Unit 63 30 235 328

3565 Waterloo Health Unit 13 25 189 227

3566 Wellington-Dufferin-Guelph Health Unit 427 97 156 680

3568 Windsor-Essex County Health Unit 35 12 374 421

3570 York Regional Health Unit 161 188 1184 1533

3595 City of Toronto Health Unit 828 698 4111 5637

Ontario hospitalizations 08/09 fiscal year NICU admits

**Excludes CHEO and SickKids

*Parts of this material are based on data and information provided by the Canadian Institute for Health Information. However, the analyses,

conclusions, opinions and statements expressed herein are those of the author, and not necessarily those of the Canadian Institute for Health

Information.


Appendix IV* continued

CIHI Data*: Cross reference newborns with select diagnosis (P704,Z038, Z3801, P929, Z3800, P073, P599, P928) by CMG (as related to gestational age & birth weight) **

CMG code CMG Definition P073 P599 P928 P929 Z038 Z3800 Z3801 P704 Total**

570 NB/Neo 1500+ w Maj GI/Dphm Int 19 <5 8 <5 <5 0 0 0 34

571 NB/Neo 1500+ w Maj Cardiov Int <5 0 <5 0 0 0 0 0 <10

572 NB/Neo 1500+ w Maj Neuro Int <5 0 0 0 0 0 0 0 <5

576 Normal Newborn Sing Vag Deliv 0 0 0 0 0 767 0 0 767

577 Normal NB Mult/C-Sect Deliv 0 0 0 0 0 0 989 0 989

578 NB/Neo <750 grams 23 27 37 <10 <5 0 0 19 115

579 NB/Neo 750-999 grams, <29 Wks 30 25 51 8 6 0 0 14 134

580 NB/Neo 750-999 grams, 29+ Wks 58 10 9 <5 <5 0 0 14 96

581 NB/Neo 1000-1499 gm, <29 Wks 122 16 48 <10 <5 0 0 <10 201

582 NB/Neo 1000-1499 gm, 29+ Wks 513 65 83 33 22 0 0 61 777

583 NB/Neo 1500-1999 gm, <32 Wks 322 46 43 25 <5 0 0 <15 452

584 NB/Neo 1500-1999 gm, 32-34 Wks 769 74 103 73 44 0 0 62 1,125

585 NB/Neo 1500-1999 gm, 35+ Wks 354 42 40 44 26 0 0 85 591

586 NB/Neo 2000-2499 gm, <35 Wks 1068 121 120 113 71 0 0 61 1,554

587 NB/Neo 2000-2499 gm, 35-36 Wks 1090 104 78 92 44 0 0 161 1,569

588 NB/Neo 2000-2499 gm, 37+ Wks 27 98 35 46 27 0 0 204 437

589 NB/Neo 2500+ gm, Maj Resp Comp 59 54 18 13 18 0 0 24 186

590 NB/Neo 2500+, Asp Syn/Fet Asph 8 36 10 12 11 0 0 25 102

591 NB/Neo 2500+, Oth Resp Prob 187 297 59 68 161 0 0 162 934

592 NB/Neo 2500+, Sept/Oth Neo Inf <5 24 6 12 <5 0 0 7 55

593 NB/Neo 2500+, Shrt Gest/Low BW 1430 141 108 114 59 0 0 166 2,018

594 NB/Neo 2500+ gm, Jaundice 36 357 9 18 16 0 0 27 463

595 NB/Neo 2500+, Anom Nrv/Resp/GI <5 5 <5 0 <5 0 0 <5 16

596 NB/Neo 2500+, Chrom/Mult Anom <5 14 6 <5 <5 0 0 <5 27

597 NB/Neo 2500+, Cardiovasc Anom 6 9 <5 <5 <5 0 0 <5 27

598 NB/Neo 2500+, Oth Congen Anom 10 13 12 <5 <10 0 0 10 53

599 NB/Neo 2500+, Oth Maj Prob 8 6 <5 0 0 0 0 <5 19

600 NB/Neo 2500+, Oth Mod Prob 23 73 22 17 32 0 0 32 199

601 NB/Neo 2500+, Oth Min Prob 104 191 87 99 364 0 0 549 1,394

999 Ungroupable 0 0 <5 0 0 0 0 <5 <5

Total** 6,277 1,851 1,004 814 927 767 989 1,714 14,343

Note: Previous output did not include all NICUs due to coding error. **Totals represent diagnosis MRDx, type 1 or type 2 - type 1 or 2 indicate presence at time of birth or arising later during birth record), not patients. There were 11,174 pts in the above table, representing 62% of NICU admits in Ontario (excluding CHEO and SickKids)


P073 Other preterm infants, 28 completed weeks or more but less than 37 completed weeks (196 completed days but less than 259 completed days) of gestation. Prematurity NOS

P599 Neonatal jaundice, unspecified, Physiological jaundice (intense)(prolonged) NOS

P928 Other feeding problems of newborn, Feeding intolerance of newborn

P929 Feeding problem of newborn, unspecified

Z038 Observation for other suspected diseases and conditions, Suspected: infectious or respiratory condition

Z3800 Singleton, born in hospital, delivered vaginally

Z3801 Singleton, born in hospital, delivered by caesarean

P704 Other neonatal hypoglycaemia, Transitory neonatal hypoglycaemia

*Parts of this material are based on data and information provided by the Canadian Institute for Health Information. However, the analyses, conclusions, opinions and statements expressed herein are those of the author, and not necessarily those of the Canadian Institute for Health Information.


Appendix V

GTA West Cluster Maternal Child Network – Transition of the Newborn Initiative

The West Cluster Maternal Child Network represents a partnership among 4 hospitals within the framework of the Child Health Network (CHN) for the Greater Toronto Area. In 2002, the West Cluster identified a high newborn admission rate of 28% for inborn babies to their Level 2/2+ nurseries. At this same point in time, another peer hospital had an admission rate of only 8%. A multidisciplinary taskforce was struck to research transitional care practices for the newborn. These were compared to existing practices. Recommendations were made and educational workshops were developed and delivered by a multidisciplinary work group. 25 workshops were delivered to more than 650 care providers, including RNs, RPNs, midwives, physicians and respiratory therapists. The objective of this quality improvement initiative was to provide evidence-based care and improve outcomes for newborns and their family by minimizing the number of separations of babies and mothers, thereby promoting family-centered care and decreasing admission rates to the nurseries. Implementation methods varied at each hospital as they utilized strategies to meet their unique needs, culture and environment.

Implementation strategies included:

Designated RN to formally mentor birthing & postpartum nurses

Nursery nurse scheduled to attend every birth

Workshop team developed informal leaders among front line staff

Staff meetings to discuss progress, problem solve and reinforce practice change

Supplemental education provided to front line providers who did not attend regional workshops

Documentation on patient care record updated to reflect new practices

Pre-natal education for families to inform and prepare them for their hospital experience, including skin- to -skin care

Orientation of new hires to transitional care practices through regional orientation program

Collectively, the West Cluster has sustained a decrease in nursery admissions rates of 47% over 6 years. In 2008-2009, only 13% of inborn babies were admitted to the Level 2/2+ nurseries.

Improved outcomes:

Sustained a decrease in nursery admission rates

Improved family-centered care

Improved utilization of resources

Enhanced newborn assessment skills

Leaders were created as front line staff were engaged as active participants and change agents:

• peer- to- peer education has a powerful impact on transforming knowledge into practice

• expertise, wisdom and perspectives from the front line are represented

Challenges and Lessons learned

Change is difficult.

Fear of “what if something happens”

Engage all stakeholders early and throughout the process

Scheduling staff to attend meetings and workshops

Mandatory education is beneficial

Presenting opportunities for both the novice and the expert

Financial commitment from the organizations

Follow-up is essential

Sustainability

Monitoring nursery admission rates

Chart audits

Formal and informal discussion

Transition incorporated into orientation for new staff

Refresher in-service for L&D

Audit performance of best practice recommendations


END NOTES

i Moore ER, Anderson GC, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Syst Rev. 2007; 3. Art. No.: DOI: 10.1002/14651858.CD003519.pub2.

ii Provincial Council for Maternal and Newborn Health. Final Report of the Provincial Maternal-Newborn Advisory Committee Access Work Group Report. 2010, 16

iii http://www.health.gov.on.ca/en/legislation/excellent_care/

iv Provincial Council for Maternal and Newborn Health. Final Report of the Maternal-Newborn Advisory Committee Access Work Group. 2010, 4

v Public Health Agency of Canada. What Mothers Say: The Canadian Maternity Experiences Survey. Ottawa, 2009.

vi Provincial Council for Maternal and Newborn Health. Final Report of the Provincial Maternal-Newborn Advisory Committee Access Work Group Report. 2010, 16

vii Personal communication: ME Salenieks PCMCH on behalf of Work Group with BORN Manager, B. Chapman.

viii World Health Organization. Postpartum care of the mother and newborn: A practical guide. (WHO/MSM/98.3).Geneva, Switzerland: WHO 1998. http://www.who.int/reproductive-health/publications/msm_98_3/postpartum_care_mother_newborn.pdf

ix Health Canada. Family-Centred Maternity and Newborn Care: National Guidelines, Minister of Public Works and Government Services, Ottawa, 2000. p 6.6

x Moore ER, Anderson GC, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003519. DOI: 10.1002/14651858.CD003519.pub2.

xi Gray L, Watt l, Blass E. Skin-to-skin is analgesic in healthy newborns. Pediatrics. 2000, 105(1), e14-e28.

xii World Health Organization. Postpartum care of the mother and newborn: a practical guide. Geneva, World Health Organization. 1998

xiii A joint position statement of the Fetus and Newborn Committee, Canadian Paediatric Society (CPS), and the Committee on Child and Adolescent Health, College of Family Physicians of Canada., Routine administration of vitamin K to newborns. Paediatr Child Health 1997; 2(6):429-31., Reference No. FN97-01. Reaffirmed February 2009, http://www.cps.ca/english/statements/fn/fn97-01.htm

xiv Infectious Diseases and Immunization Committee, Canadian Paediatric Society (CPS), Recommendations for the prevention of neonatal ophthalmia. Paediatr Child Health 2002; 7(7): 480-3., Reference No. ID02-03, Reaffirmed in January 2009

xv Gentry, C., Young, P., Buchi, K. (2001). Significance of grunting respirations in infants admitted to a well-baby nursery. Arch Pediatr Adolesc Med. 155, 372-375

xvi Gray L, Watt L, Blass E. Skin-to-Skin Contact is Analgesic in Healthy Newborns. Pediatrics. 2000; 105 (1)

xvii American Academy of Pediatrics; American Heart Association; Canadian Pediatric Society. Neonatal Resuscitation Textbook, 5th Edition. 2006; 2-6,7

http://www.cps.ca/english/statements/fn/fn97-01.htm#Fetus and Newborn

http://www.cps.ca/english/statements/fn/fn97-01.htm#Child Adol Health

http://www.cps.ca/english/statements/ID/ID02-03.htm#Committee


xviii Canadian Pediatric Society. Position Statement: Screening Guidelines for Newborns at risk for Low Blood Glucose. 2004

xix American Academy of Pediatrics; American Heart Association; Canadian Pediatric Society. Neonatal Resuscitation Textbook, 5th Edition. 2006; p 1– 16

xx American Academy of Pediatrics; American Heart Association; Canadian Pediatric Society. Neonatal Resuscitation Textbook, 5th Edition. 2006; p 1-16

xxi Health Canada. Family-Centred Maternity and Newborn Care: National Guidelines, Minister of Public Works and Government Services, Ottawa, 2000.

xxii Canadian Paediatric Society. Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks’ gestation) POSITION STATEMENT (FN 2007-02). Paediatr Child Health Vol 12 Suppl B May/June 2007

xxiii Provincial Council for Maternal and Child Health Infection Prevention and Control Prevention of Group B Strep Policy. http://www.pcmch.on.ca/LinkClick.aspx?fileticket=8ZOTX5LJI38%3d&tabid=89

xxiv Hutton, EK; Hassan, ES, Late vs Early Clamping of the Umbilical Cord in Full-term Neonates: Systematic Review and Meta-analysis of Controlled Trials, JAMA. 2007; 297(11):1241-1252

xxv Society of Obstetricians and Gynecologists of Canada. Fetal Health Surveillance: Antepartum and Intrapartum Consensus Guideline. 2007; S42

xxvi Hutton EK, Hassan ES. Late vs Early Clamping of the Umbilical Cord in Full-term Neonates: Systematic Review and Meta-analysis of Controlled Trials. JAMA. 2007; 297(11):1241-1252

xxvii Society of Obstetricians and Gynecologists of Canada. Clinical Practice Guideline - Umbilical Cord Blood banking: Implications for Perinatal Care Providers. 2005; No 156

xxviii Society of Obstetricians and Gynecologists of Canada. Fetal Health Surveillance: Antepartum and Intrapartum Consensus Guideline. 2007; S41-43

xxix Society of Obstetricians and Gynecologists of Canada. Fetal Health Surveillance: Antepartum and Intrapartum Consensus Guideline. 2007; S41-43

xxx Health Canada. Family-Centred Maternity and Newborn Care: National Guidelines, Minister of Public Works and Government Services, Ottawa, 2000

xxxi Keefe, M. R.. The Impact of Infant Rooming-In on Maternal Sleep at Night. 1998; Journal of Obstetric, Gynecologic, & Neonatal Nursing, 17: 122–126.

xxxii Institute for Family-Centered Care. Advancing the Practice of Patient- and Family-Centered Care. 2008. Bethesda, MD. P 1

xxxiii Society of Obstetricians and Gynecologists of Canada. Induction of Labour at Term Clinical Practice Guideline. 2001

xxxiv Canadian Institute for Health Information. (2004). Giving Birth in Canada: A Regional Profile, 2004. Ottawa: CIHI.

xxxv Reisner, D. P., Wallin, T. K., Zingheim, R. W., & Luthy, D. A. (2009). Reduction of elective inductions in a large community hospital. American Journal of Obstetrics and Gynecology, 200(6), 674.e1–674.e7.


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xxxvii Gülmezoglu, AM, Crowther, CA, & Middleton, P. (2007). Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database of Systematic Reviews, Issue 4.

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