Introducing and sustaining EENC in hospitals › bitstream › handle › 10665.1 › 14166 › ... · 2018-08-09 · Introducing and sustaining EENC in hospitals: Kangaroo Mother

E A R L Y E S S E N T I A L N E W B O R N C A R E ( E E N C ) M O D U L E 4

Introducing and sustaining EENC in hospitals: Kangaroo Mother Care for preterm and low-birthweight infants


Introducing and sustaining EENC in hospitals: Kangaroo Mother Care

for preterm and low-birthweight infants

© World Health Organization 2018Some rights reserved.

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Suggested citation. Introducing and sustaining EENC in hospitals: kangaroo mother care for pre-term and low-birthweight infants (Early Essential Newborn Care, Module 4). Manila. World Health Organization Regional Office for the Western Pacific. 2018. Licence: CC BY-NC-SA 3.0 IGO.

Cataloguing-in-Publication (CIP) data. 1. Infant, Low Birth Weight. 2. Infant care. 3. Kangaroo-Mother Care Method. I. World Health Organization Regional Office for the Western Pacific. (NLM Classification: WS420)

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Photo credits:

Cover: © WHO/Y. Shimizu – p. 1: © Courtesy of Wao Birthing Clinic Dr Mianne Silvestre/Lanao del Sur – p. 3, by column, a, c, e: © Courtesy of Neonatal Unit, Da Nang Hospital for Women and Children; b: © WHO/Dr Luong Kim Chi; d: © Dr Helenlouise Taylor; f: © WHO/WPRO – p. 5, by column, a, b: © Courtesy of Neonatal Unit, Da Nang Hospital for Women and Children; c: © WHO/WPRO; d: © WHO/Dr Trevor Duke – p. 71, d: © WHO/Dr Luong Kim Chi – pp. 35, 69–73: © Courtesy of Neonatal Unit, Da Nang Hospital for Women and Children

CONTENTS

Foreword .................................................................................................................................................................................................................................. v

About the EENC modules .........................................................................................................................................................................................vi

1. Why do we need to focus on preterm infants in the Western Pacific Region? ..................................................1

2. What do we need to do to save preterm infant lives? ...........................................................................................................2

2.1 Prevention of preterm births and their complications ...................................................................................................2 2.2 First Embrace: A healthy start for every newborn ............................................................................................................2 2.3 Kangaroo Mother Care (KMC) ....................................................................................................................................................4

3. If KMC is effective, why is it not widely practised? ...................................................................................................................6

4. What key actions are required to introduce and sustain KMC in hospitals? ......................................................7

ANNEXES

1. Checklists for reviewing hospital capacity to support KMC ...................................................................................11

CHECKLISTS 1–9. Review of hospital capacity to support KMC

2. Checklist for developing the KMC action framework.................................................................................................25

CHECKLIST 10. KMC action framework

3. Facilitator’s guide for KMC clinical coaching ...................................................................................................................28

4. Checklists for reviewing KMC skills of health workers ..............................................................................................56

CHECKLISTS 11–14. Review of KMC skills of health workers

5. Family support for KMC ...............................................................................................................................................................64

CHECKLISTS

– Checklists for reviewing hospital capacity to support KMC

CHECKLIST 1. Preterm and LBW practices: Interview of mothers of babies in postnatal wards and the NCU ........12

CHECKLIST 2. Preterm and LBW practices: Chart reviews of postpartum mothers interviewed ......................................14

CHECKLIST 3. Preterm and LBW practices: Observations of environments in PNC areas and NCU...............................16

CHECKLIST 4. NCU admissions for preterm and LBW babies ...............................................................................................................17

CHECKLIST 5. Review of availability of key medicines, supplies and equipment for management of preterm and LBW babies .......................................................................................................................................................19

CHECKLIST 6. Review of hospital policies, protocols and standards to support management of preterm and LBW babies .......................................................................................................................................................20

CHECKLIST 7. Staff coaching summary: KMC and EENC .........................................................................................................................21

CHECKLIST 8. Hospital register data on preterm and LBW babies ....................................................................................................22

CHECKLIST 9. Staff, space and bed requirements for preterm and LBW babies ........................................................................24

– Checklist for developing the KMC action framework

CHECKLIST 10. KMC action framework ................................................................................................................................................................26

– Checklists for reviewing KMC skills of health workers

CHECKLIST 11. Helping mother position her baby correctly for KMC .................................................................................................57

CHECKLIST 12. Helping mother breastfeed in KMC ......................................................................................................................................58

CHECKLIST 13. Helping mother express breast milk herself while practising KMC skills ........................................................60

CHECKLIST 14. Helping mothers and families prevent infection and monitor progress ..........................................................62

v

Foreword

The World Health Organization, Member States and stakeholders in the Western Pacific Region share a vision for mothers and their children: that every newborn infant has the right to a healthy start in life. Sadly, every two minutes, death comes too quickly – and often need-lessly – to a newborn infant in the Region.

Together, we have taken bold steps to make childbirth and newborn life safer. Member States endorsed the Action Plan for Healthy Newborn Infants in the Western Pacific Region (2014–2020). The plan aims to improve the quality of care for mothers and babies in health facilities, where the vast majority of children in the Region are born.

We offer five teaching modules of Early Essential Newborn Care, or EENC, starting with the Early Essential Newborn Care Clinical Practice Pocket Guide. Countries have already shown that reductions in newborn deaths, infections and intensive care unit admissions are possible in facilities employing EENC.

This volume, Introducing and sustaining EENC in hospitals: Kangaroo Mother Care for pre-term and low-birthweight infants, is the fourth module to guide and accelerate EENC health provider practices in facilities across the Region.

These modules are critical components of the regional plan of sustained action and strong policies utilizing proven methods for saving money and lives. Governments, health-care facilities and families are already saving precious resources, making health systems more accountable and quality care more attainable.

We must push to meet the ambitious but reachable targets of the Sustainable Development Goals: a global maternal mortality ratio of less than 70 per 100 000 live births with no country above 140; and neonatal mortality rates of less than 12 per 1000 births.

To reach these lofty goals, we must work together with Member States and partners to bring high-quality EENC to all mothers and newborn infants in every corner of the Western Pacific Region.

Shin Young-soo, MD, Ph.D.Regional Director

ABOUT THE EARLY ESSENTIAL NEWBORN CARE MODULES

The five Early Essential Newborn Care (EENC) modules support planning, imple-mentation, improvement, and monitoring and evaluation of EENC.

Module Title Primary user level

1 Annual implementation review and planning guide National and subnational

2Coaching for the First Embrace: Facilitator's Guide

National and subnational facilitators

3Introducing and sustaining EENC in hospitals: Routine childbirth and newborn care

Hospitals with national support for scale-up

4Introducing and sustaining EENC in hospitals: Kangaroo Mother Care for preterm and low-birthweight infants

5Introducing and sustaining EENC in hospitals: Managing childbirth and postpartum complications

Module 1 is used at the national and subnational levels to collect data for the development of annual implementation plans and five-year national action plans. National and subnational facilitators use Module 2 to upgrade skills of health workers involved in the management of routine childbirth and newborn care nationwide. In hospitals, EENC teams are formed to regularly assess quality of care and use of data for action using Module 3.

Once excellent routine childbirth and newborn care are well established, coaching and quality of care follow-up are added for Kangaroo Mother Care (KMC) for preterm and low-birthweight infants in Module 4.

Management of childbirth and postpartum complications are treated in Module 5.

FACILITATORS GUIDE

Coaching guide for the First Embrace


M O D U L E 2

Routine childbirth and newborn careINTRODUCING AND SUSTAINING EENC IN HOSPITALS


M O D U L E 3

Kangaroo mother care (KMC) for preterm infantsINTRODUCING AND SUSTAINING EENC IN HOSPITALS


M O D U L E 4

Managing childbirth and postpartum complicationsINTRODUCING AND SUSTAINING EENC IN HOSPITALS


M O D U L E 5

2-day coaching KMC for preterm & low-birthweight infants

Managing complications

Formation of EENCteam

Quarterly EENC assessments through weekly / biweekly progress monitoring meetings to improve clinical practice

vi

p

p

1

Why do we need to focus on preterm infants in the Western Pacific Region?

Each year 1.9 million infants (12% of all births) in the Western Pacific Region are born preterm (less than 37 weeks of gestational age). An estimated 81 600 of these preterm infants die, representing 50% of all newborn deaths. Approximately 85% of preterm infants are born at 32–36 weeks gestational age and do not require highly specialized care. More than half of preterm deaths are preventable, even without intensive care units.

Kangaroo Mother Care (KMC) – which consists of prolonged skin-to-skin contact, exclusive breastfeeding by the baby sucking or by feeding with the mother’s own breast milk, and close monitoring for illness – prevents the main causes of preterm death and promotes growth and brain development.

1.

2

EENC Module 4 – Introducing and sustaining EENC in hospitals: Kangaroo Mother Care for preterm and LBW infants

What do we need to do to save preterm infant lives?

Primary prevention of preterm births and their complications is the first step in reducing pre-term deaths. After birth, all preterm babies should be cared for according to the principles of the First Embrace and KMC, as these interventions help prevent morbidity and mortality, improve breathing and growth, and contribute to better bonding between mothers, families and babies. In addition, sick preterm babies require special care to manage infections and other problems. This guide describes an approach to KMC, starting in the delivery room. Many preterm births can be prevented by actions taken before or during pregnancy, which are described in other WHO guides.1

2.1 Prevention of preterm births and their complications2

The introduction of effective interventions to prevent preterm births and complications of prematurity requires changing facility policies, providing coaching to staff and improving the availability of essential medicines.

Key interventions include:

» eliminating unnecessary preterm inductions of labour and caesarean sections;

» antenatal steroids to reduce the risk of breathing problems and other complications;

» intrapartum magnesium sulfate to prevent cerebral palsy; and

» antibiotics for preterm pre-labour rupture of membranes to reduce the risk of infection.

2.2 First Embrace: A healthy start for every newborn

All newborns, including the preterm infants, benefit from interventions included in the First Embrace (Fig. 1). These include:

» labour monitoring and management using a partograph;

» immediate, careful and thorough drying of the baby;

» immediate skin-to-skin contact after drying;

1. Primary Health Care Quality Improvement Guides (PHCQIGs), Module 1: Preventing unplanned pregnancies and Module 2: Antenatal care (2017). WHO Regional Office for the Western Pacific, Manila.

2. WHO recommendations on interventions to improve preterm birth outcomes. Geneva: World Health Organization; 2015.

2.

This benefits babies This harms babies

Drying carefully and thoroughly prevents hypothermia and stimulates breathing; clamping the cord after pulsations stop reduces the risk of anaemia.

Unnecessary suctioning, immediate cord cutting and delayed drying expose preterm babies to infection, hypothermia, breathing and circulatory problems, anaemia, acidosis, coagulation defects, brain bleeds and trauma.

Skin-to-skin contact with the mother keeps babies warm, calm and healthy.

Separation from the mother results in distress, hypo-thermia and exposure to dangerous bacteria.

Initiating immediate and exclusive breastfeeding once feeding cues are present reduces risk of death by 22%.

The first breastfeed is delayed because of incorrect sequencing of actions immediately after birth.

FIGURE 1. First Embrace in practice: Benefits for all babies3

33. WHO recommendations on newborn health. Geneva: World Health Organization; 2013.

4


» delayed cord clamping until after pulsations stop (1–3 minutes after birth) and cutting with a sterile instrument;

» initiating exclusive breastfeeding when cues occur (such as drooling, tonguing, rooting and sucking); and

» delaying routine care – weighing, physical examinations, eye care, vitamin K1, immu-nizations – until after completing the first breastfeed.

2.3 Kangaroo Mother Care (KMC)

WHO guidelines recommend KMC for all stable babies less than 37 weeks of age and weigh-ing less than 2000 grams (g). Babies weighing 2000–2500 g may also benefit from KMC.

The main components of KMC are:

» skin-to-skin (STS) contact, as continuous as possible, between the mother (or relatives) and her baby;

» exclusive breastfeeding by the baby sucking or by feeding with the mother’s own breast milk; and

» close monitoring for illness.

Preterm infant mortality can be reduced by half by the near-continuous application of KMC.

KMC has been shown to increase breastfeeding rates; provide effective thermal control; help stabilize vital signs; decrease morbidity from apnoea, infection and respiratory disease; accelerate growth; and promote bonding – all of which improve developmental outcomes.

This benefits babies This harms babies

Prolonged skin-to-skin contact keeps babies warm, prevents apnoea, reduces rates of infection and res-piratory disease, promotes breastfeeding, accelerates growth, improves bonding, and reduces deaths by up to 50%.

Babies are often exposed to the dangers of separation including hypothermia, over-medicalization, lack of attention by busy staff, infection and disease.

Cup- or spoon-feeding with breast milk saves lives and prevents illness and malnutrition.

Feeding small babies infant formula increases the risk of pneumonia, diarrhoea, malnutrition, necrotizing enterocolitis and death.

FIGURE 2. KMC: Benefits for babies

5

6


If KMC is effective, why is it not widely practised? 4

Misconceptions, scepticism, fear and cultural factors

People incorrectly believe saving preterm lives requires a neonatal care unit (NCU). Health staff who have had no experience with KMC are often unconvinced of its value, while sceptical experts can be influential in creating a climate that resists evidence-based change in practice. Families may fear caring for fragile, small babies themselves or feel embarrassed about their bodies being exposed while practising KMC. Parents may feel that it is difficult to practise KMC for long periods when they have work commitments and other children requiring care.

Outdated policies

In many countries, stable preterm and low-birthweight (LBW) babies do not receive pro-longed STS contact and early and exclusive breastfeeding. Instead they are separated from the mother, admitted to NCUs for observation and fed formula milk. Stable babies born by caesarean section (both preterm and term) are often managed the same way. These policies deprive preterm and LBW babies of life-saving interventions, including KMC. Often national or hospital policies restrict access of mothers to NCUs, thereby preventing near-continuous KMC.

Conflicts of interest

Violations of the International Code of Marketing of Breast-milk Substitutes, such as aggressive marketing of infant formula in hospitals and to staff, are common globally and undermine breastfeeding.

Lack of time and physical space

Due to high workloads, hospital staff may see working with families to support KMC as an additional burden. Hospitals often do not allocate physical space and logistical support for mothers and babies to practise KMC.

Limited training and support for KMC

Non-inclusion in government policies and plans, lack of effective training, limited availability of the global evidence base on effectiveness, and limited supportive supervision after KMC coaching mean that health workers may not continue to practise KMC effectively or find solutions to problems encountered.

3.

4. Based on qualitative interviews with people in hospitals who successfully implemented KMC.

7

What key actions are required to introduce and sustain KMC in hospitals?

Summary of actions for introducing and sustaining KMC in hospitals

Action Content Annex

1. Build the capacity of the Early Essential Newborn Care (EENC) hospital team to support KMC

All checklists 1–5

2. Review hospital capacity to support KMC

Checklists 1–9: Review of hospital capacity to support KMC 1

3. Develop a KMC action framework

Checklist 10: KMC action frameworkConsiderations of where to put KMC areas

2

4. Secure support of senior hospital staff and managers

Checklist 10: KMC action framework 2

5. Build KMC skills of staff and families

5.1 Staff coaching Facilitator’s guide for KMC clinical coaching Checklists 11–14: Review of KMC skills of health workers

3, 4

5.2 Learning by doing Checklists 11–14: Review of KMC skills of health workers 4

5.3 Building capacity of families

Frequently asked questionsKMC fact sheetKMC counselling guide: Pictorial summary of key practices

5

6. Monitor progress and support practice

Checklists 1–9: Review of hospital capacity to support KMCChecklist 10: KMC action frameworkChecklists 11–14: Review of KMC skills of health workers

1, 2, 3

4.

8


Action 1. Build the capacity of the Early Essential Newborn Care (EENC) hospital team to support KMC

KMC should be managed by the hospital team responsible for implementing and monitoring EENC. Where a team does not exist, a team should be formed. EENC hospital teams have between 10 and 25 members and include paediatricians, obstetricians, nurses, midwives, and infection control, quality improvement and hospital administration staff. The EENC hospital team reviews hospital capacity to support KMC (Action 2), and supports addressing gaps (Actions 3–5) and monitoring progress (Action 6).

Action 2. Review hospital capacity to support KMC

Using Checklists 1–9: Review of hospital capacity to support KMC (Annex 1), the EENC hospital team leads a review of the management of preterm and LBW babies. This review includes: birth practices received by preterm/LBW babies (Checklists 1–3); management of pre-term/LBW newborns currently admitted to an NCU (Checklist 4); availability of medicines, supplies and equipment (Checklist 5); existing hospital policies, protocols and standards (Checklist 6); staff coaching in KMC and EENC (Checklist 7); hospital register data on preterm/LBW babies (Checklist 8); and space and staff requirements for KMC (Checklist 9). Checklists 1–9 can be completed for regular progress monitoring or as part of full EENC quality assessments (usu-ally conducted quarterly).

Action 3. Develop a KMC action framework to introduce and sustain KMC

The EENC hospital team completes Checklist 10: KMC action framework (Annex 2) for planning and routine monitoring of progress. The framework is divided into five domains: 1) policies, standards and guidelines; 2) space for KMC in postnatal care (PNC) and NCU areas; 3) staff to support KMC; 4) medicines, supplies and equipment; 5) staff coaching in KMC; and 6) communications, counselling materials and support. For each domain, priority issues to be addressed based on findings from Action 2 are entered.

Action 4. Secure support of senior hospital staff and managers and implement action steps

The EENC hospital team presents the KMC action framework to senior management and secures support for proposed actions. Senior staff commit to supporting actions needed to provide necessary space, equipment, amenities and staff. Senior staff members also need to assist in developing and endorsing revised hospital KMC policies, protocols, standard op-erating procedures, standing orders, job aids, and recording and reporting forms. In some

9

cases, provincial or district managers may need to be involved to support proposed changes in policies and practices.

Action 5. Build KMC skills of staff and families

Action 5.1. Staff coaching

The Facilitator’s guide for KMC clinical coaching (Annex 3) outlines an on-the-job approach for coaching staff. Staff coached should include paediatricians, nurses and other staff working in the NCU and other wards where care is provided for newborns. Checklists 11–14: Reviewing KMC skills of health workers (Annex 4) are used for KMC skills coaching.

Action 5.2. Learning by doing

Once staff members are coached, the EENC hospital team establishes mechanisms for “learning by doing”. These include work rosters that pair experienced staff supervisors with less experi-enced staff. Supervisors periodically observe staff practices using Checklists 11–14: Reviewing KMC skills of health workers (Annex 4). Supervisors and staff then identify practice strengths and gaps, and both sign off on agreed actions. Supervisors enter findings from observations of 10 preterm babies on KMC skills Checklist: Summary sheet (Annex 4) including the status of each baby at the end of the hospital stay (discharge, referral or death).

Action 5.3. Building capacity of families

Families require clear counselling on how to practise KMC, and an environment that respects privacy and allows flexibility by using fathers and grandparents to provide STS care. Success-ful families who gain experience with KMC can support families without experience. These families can become a useful resource; however, they can become sources of infection. The KMC fact sheet: DOs and DON’Ts of supporting families to practise KMC and KMC counsel-ling guide: Pictorial summary of key practices (Annex 5) provide basic information to support effective family practices.

Action 6. Monitor progress and support practice

The monitoring of KMC practice, the status of action steps outlined in the KMC action frame-work, and staff coaching needs are accomplished during ongoing EENC progress monitoring meetings and quarterly one-day full EENC quality assessments. At each quality assessment, the EENC hospital team reviews hospital capacity to support KMC (Checklists 1–9) and KMC skills of health workers (Checklists 11–14). EENC progress meetings review data and track the status of action steps using Checklist 10.


10

ANNEXES

ANNEX 1. Checklists for reviewing hospital capacity to support KMC ......................11

ANNEX 2. Checklist for developing the KMC action framework ................................... 25

ANNEX 3. Facilitator’s guide for KMC clinical coaching ...................................................... 28

ANNEX 4. Checklists for reviewing KMC skills of health workers ................................ 56

ANNEX 5. Family supports for KMC ................................................................................................ 64

11

Checklists for reviewing hospital capacity to support Kangaroo Mother Care (KMC)

Checklists 1–9. Review of hospital capacity to support KMC

The Early Essential Newborn Care (EENC) hospital team members are responsible for collecting Kangaroo Mother Care (KMC) data using checklists. Divide the team into four small groups. Each small group collects data on two checklists.

Steps:

1. Review the management of 10 inborn (born in a facility) preterm (< 37 weeks) or low-birthweight (LBW) babies (< 2500 grams) by interviewing and conducting a chart review of mothers of babies in the neonatal care unit (NCU) or postnatal wards. Enter the results in Checklists 1 and 2.

2. Review practices for preterm and LBW babies by observing environments in the postnatal care (PNC) and KMC areas and NCU. Enter the results in Checklist 3.

3. Review NCU admissions criteria for 20 inborn preterm and LBW babies by reviewing charts of babies admitted to the NCU. Enter the results in Checklist 4.

4. Review availability of medicines, supplies and equipment and the availability of policies to support management of preterm or LBW babies. Enter the results in Checklists 5 and 6.

5. Review the staff coaching summary form. Enter the results in Checklist 7.

6. Review hospital register data on preterm/LBW babies. Enter the results in Checklist 8.

7. Review NCU and KMC staff and space requirements. Enter the results in Checklist 9.

ANNEX 1

12


Chec

klis

t 1.

Pre

term

and

LBW

pra

ctic

es: I

nter

view

of m

othe

rs o

f bab

ies

in p

ostn

atal

war

ds a

nd th

e N

CUs

Rand

omly

sel

ect 1

0 in

born

(bor

n in

the

faci

lity)

pre

term

(< 3

7 w

eeks

) or L

BW b

abie

s (<

250

0 g)

: 5 fr

om th

e po

stna

tal r

egis

ter w

ho w

ere

not a

dmitt

ed to

NCU

an

d 5

from

the

NCU

regi

ster

. Use

inte

rvie

ws

with

the

mot

hers

to c

ompl

ete

ques

tions

1–6

. Con

firm

resp

onse

s w

here

pos

sibl

e w

ith th

e m

edic

al re

cord

.

Que

stio

n M

othe

r nu

mbe

rSu

mm

ary

Ans

wer

the

que

stio

ns w

ith:

Y

(Yes

) or N

(No)

unl

ess

othe

rwise

spe

cified

Post

nat

al r

egis

ter

NC

U r

egis

ter

n* /

N**

(%)

12

34

56

78

910

1.Ve

rbal

info

rmed

con

sent

obt

aine

d

2.At

the

time

of b

irth,

was

the

baby

pla

ced

in s

kin-

to-s

kin

(STS

) co

ntac

t with

the

mot

her?

If y

es:

a. H

ow lo

ng a

fter b

irth?

< 1

min

/ 1–

10 m

in /

11–5

9 m

in /

≥ 60

min

n (<

1 m

in) =

b. H

ow lo

ng d

id th

e ba

by re

mai

n in

uni

nter

rupt

ed S

TS c

onta

ct b

efor

e be

ing

sepa

rate

d fro

m th

e m

othe

r for

any

reas

on?

<

10

min

/ 10

–29

min

/ 30

–59

min

/ 60

–89

min

/ ≥ 9

0 m

inn

(≥ 9

0 m

in) =

c. Ha

d th

e ba

by c

ompl

eted

the

first

bre

astfe

ed (a

ttach

ed, d

eep

suck

ing)

bef

ore

sepa

ratio

n fro

m th

e m

othe

r?

d. W

hy w

as th

e ba

by se

para

ted

from

the

mot

her?

Reas

ons:

e. Di

d th

e ba

by re

ceive

imm

edia

te S

TS c

onta

ct, w

ith n

o se

para

tion

for a

t lea

st 9

0 m

in a

nd u

ntil

the

first

bre

astfe

ed w

as c

ompl

eted

? An

swer

Y o

nly

if: a

. < 1

min

, b. ≥

90

min

and

c. =

Yn

(# Y

es) =

3.Is

the

mot

her g

ivin

g an

y br

east

milk

(eith

er d

irect

ly fr

om th

e br

east

or

exp

ress

ed b

reas

t milk

or b

oth)

?

4.Is

the

mot

her b

reas

tfeed

ing

dire

ctly

from

the

brea

st?

If ye

s:

a. H

ow lo

ng a

fter b

irth

did

the

baby

firs

t bre

astfe

ed?

(T

he b

aby

mus

t hav

e be

en a

ttach

ed w

ith d

eep

suck

ing.

) An

swer

: < 1

5 m

in /

15–8

9 m

in /

90 m

in–2

4 h

/ 1–2

day

sn

(15–

89 m

in) =

b. H

ow m

any

min

utes

did

the

baby

bre

astfe

ed th

e fir

st ti

me?

n

(≥ 1

5 m

in) =

c. Si

nce

birth

, was

the

baby

fed

anyt

hing

oth

er th

an b

reas

t milk

?n

(# N

o) =

d. D

id th

e ba

by re

ceive

ear

ly (w

ithin

15–

89 m

in) a

nd e

xclu

sive

brea

st-

feed

ing?

Ans

wer

Y o

nly

if bo

th a

. and

b. =

15–

89 m

in a

nd c

. = N

o

n (#

Yes

) =

e. In

the

last

24

hour

s, ho

w m

any

times

was

bre

ast m

ilk g

iven?

n (≥

8 ti

mes

) =

CHECKLIST 1

Preterm and LBW practices: Interview of mothers of babies in postnatal wards and the neonatal care units (NCU)

13

Que

stio

n M

othe

r nu

mbe

rSu

mm

ary

Ans

wer

the

que

stio

ns w

ith:

Y

(Yes

) or N

(No)

unl

ess

othe

rwise

spe

cified

Post

nat

al r

egis

ter

NC

U r

egis

ter

n* /

N**

(%)

12

34

56

78

910

5.Is

the

mot

her g

ivin

g br

east

milk

by

mea

ns o

ther

than

dire

ctly

fro

m th

e br

east

(e.g

. by

expr

essin

g br

east

milk

and

feed

ing

by

othe

r mea

ns)?

If y

es:

a. H

ow is

the

brea

st m

ilk b

eing

give

n? (c

up, s

poon

, syr

inge

, sto

mac

h tu

be o

r bot

tle) –

Not

e: if

give

n by

bot

tle th

is sh

ould

be

mar

ked

as

an a

rea

for i

mpr

ovem

ent

n

(# Y

es) c

up, s

poon

, sy

ringe

tube

=

b. I

n th

e pa

st 2

4 ho

urs,

how

ofte

n di

d sh

e ex

pres

s bre

ast m

ilk?

n (≥

8 tim

es) =

c. Si

nce

birth

, was

the

baby

fed

anyt

hing

oth

er th

an b

reas

t milk

?

d. I

s the

bab

y ov

er 3

2 w

eeks

ges

tatio

nal a

ge n

ow?

e. If

yes,

does

the

mot

her a

ttem

pt b

reas

tfeed

ing

befo

re g

iving

br

east

milk

not

by

brea

st?

6.If

the

mot

her f

ed th

e ba

by a

nyth

ing

othe

r tha

n br

east

milk

:

a. W

hat w

as g

iven?

Flui

ds g

iven

:

b. W

as a

nyth

ing

give

n be

fore

the

first

bre

astfe

ed o

r firs

t exp

ress

ed

brea

st m

ilk?

7.Ha

s th

e ba

by b

een

fed

anyt

hing

from

a b

ottle

?

Not

e: if

yes

, thi

s sh

ould

be

flagg

ed a

s an

are

a fo

r im

prov

emen

t, ev

en if

it is

bre

ast m

ilk.

8.Do

es th

e ba

by w

eigh

< 2

000

g? If

yes

:

a. D

id th

e ba

by re

ceive

any

KM

C in

the

past

24

hour

s?

b. F

or h

ow m

any

hour

s was

KM

C ap

plie

d?

0 / <

1 h

/ 1–

4 h

/ 5–1

9 h,

/ ≥

20 h

n (≥

20 h

) =

c. Ho

w lo

ng w

as th

e lo

nges

t sep

arat

ion?

n (<

30 m

in) =

d. W

as th

e ba

by k

ept i

n KM

C po

sitio

n (i.

e. ST

S co

ntac

t) w

hile

br

east

feed

ing?

CHECKLIST 1

Preterm and LBW practices: Interview of mothers of babies in postnatal wards and the neo-natal care units (NCU) (continued)

* n =

tota

l num

ber o

f “Y”

(Yes

resp

onse

s), u

nles

s oth

erw

ise sp

ecifi

ed**

N =

tota

l num

ber o

f mot

hers

inte

rvie

wed

14


Chec

klis

t 2.

Pre

term

and

LBW

pra

ctic

es: C

hart

revi

ews

of p

ostp

artu

m m

othe

rs in

terv

iew

ed

Use

the

iden

tifica

tion

num

bers

of t

he m

othe

r and

bab

y to

iden

tify

the

char

ts o

f wom

en w

ho a

lread

y re

ceiv

ed a

n in

terv

iew

. If

the

mot

her’s

cha

rt is

sep

arat

e fr

om th

at o

f the

bab

y, it

may

be

nece

ssar

y to

revi

ew b

oth

char

ts to

com

plet

e th

e ch

art r

evie

w.

Que

stio

n M

othe

r nu

mbe

rSu

mm

ary

Ans

wer

the

que

stio

ns w

ith:

Y

(Yes

), N

(No)

, or N

R (N

ot R

ecor

ded)

unl

ess

othe

rwise

spe

cified

Post

nata

l reg

iste

rN

CU r

egis

ter

n* /

N**

(%)

12

34

56

78

910

1.Di

d th

e m

othe

r del

iver

at 2

4–34

wee

ks o

f ges

tatio

n? If

yes

:

a. W

ere

mat

erna

l crit

eria

for u

se o

f ant

enat

al st

eroi

ds m

et?1

b. W

as a

full

cour

se o

f ant

enat

al st

eroi

ds g

iven

to th

e m

othe

r? 2

c. W

as th

e fir

st d

ose

give

n w

ithin

1 h

our o

f her

arri

val a

t the

ho

spita

l? 3

,4

2.Di

d th

e m

othe

r del

iver

bef

ore

32 w

eeks

of g

esta

tion?

If y

es:

a. W

as m

agne

sium

sulfa

te g

iven

to th

e m

othe

r for

feta

l ne

urop

rote

ctio

n?

b. W

as m

agne

sium

sulfa

te g

iven

with

in 1

hou

r of h

er a

rriva

l at

the

hosp

ital?

3,4

3.W

ere

syph

ilis

test

resu

lts fr

om a

nten

atal

car

e (A

NC)

reco

rded

in

the

mot

her’s

cha

rt? If

yes

:

a. W

as th

e te

st p

ositi

ve?

b. W

ere

actio

ns ta

ken

in th

e an

tena

tal p

erio

d to

add

ress

the

posit

ive

syph

ilis t

est?

4.W

as p

oint

-of-c

are

rapi

d HI

V te

stin

g do

ne o

r HIV

test

resu

lts

from

AN

C w

ritte

n in

the

reco

rd?

5.W

as a

rtific

ial r

uptu

re o

f mem

bran

es (a

mni

otom

y) d

one?

6.W

as th

e m

othe

r’s la

bour

indu

ced/

augm

ente

d w

ith o

xyto

cin?

a. I

f yes

, wha

t wer

e th

e in

dica

tions

? 5

CHECKLIST 2

Preterm and LBW practices: Chart reviews of postpartum mothers interviewed

15

Que

stio

n M

othe

r nu

mbe

rSu

mm

ary

Ans

wer

the

que

stio

ns w

ith:

Y

(Yes

), N

(No)

, or N

R (N

ot R

ecor

ded)

unl

ess

othe

rwise

spe

cified

Post

nata

l reg

iste

rN

CU r

egis

ter

n* /

N**

(%)

12

34

56

78

910

7.W

as th

e ba

by d

eliv

ered

by

caes

area

n se

ctio

n?

a. I

f yes

, wha

t wer

e th

e in

dica

tions

? 5 Re

ason

s:

8.W

ere

baby

vita

l sig

ns m

easu

red

at le

ast 4

tim

es in

the

last

24

h?

a. T

empe

ratu

re

b. P

ulse

c. Re

spira

tory

rate

d. O

xyge

n sa

tura

tion

CHECKLIST 2

Preterm and LBW practices: chart reviews of postpartum mothers interviewed (continued)

* n =

tota

l num

ber o

f “Y”

(Yes

resp

onse

s), u

nles

s oth

erw

ise sp

ecifi

ed**

N =

tota

l num

ber o

f mot

hers

inte

rvie

wed

1. G

esta

tiona

l age

can

be

accu

rate

ly a

sses

sed;

pre

term

birt

h is

imm

inen

t; no

clin

ical

evi

denc

e of

mat

erna

l inf

ectio

n. If

ther

e is

no re

cord

of t

hese

crit

eria

, ind

icat

e “N

” (N

o).

2. T

wo

12 m

g do

ses

of b

etam

etha

sone

giv

en in

tram

uscu

larly

24

hour

s ap

art o

r fou

r 6 m

g do

ses

of d

exam

etha

sone

adm

inis

tere

d in

tram

uscu

larly

eve

ry 1

2 ho

urs.

3. I

f tim

ing

of a

dmin

istr

atio

n is

not s

peci

fied,

indi

cate

“N

” (N

o).

4. I

f the

wom

an re

ceiv

ed c

ortic

oste

roid

s be

fore

arr

ival

, the

n tim

ely

adm

inis

trat

ion

shou

ld b

e as

sess

ed a

ccor

ding

to ti

min

g of

pre

viou

s do

se (a

t 6 h

ours

aft

er p

revi

ous

dose

of d

exam

etha

sone

or 1

2 ho

urs

of b

etam

etha

sone

).

5. I

f ind

icat

ions

for t

he p

roce

dure

wer

e no

t rec

orde

d in

the

char

t, w

rite

NR

(Not

Rec

orde

d).

16


Chec

klis

t 3.

Pre

term

and

LBW

pra

ctic

es: O

bser

vatio

ns o

f env

ironm

ents

in P

NC

area

s an

d N

CURe

view

all

room

s w

here

pre

term

and

LBW

bab

ies

are

stay

ing.

The

se m

ay in

clud

e po

stna

tal c

are

(PN

C) a

reas

, KM

C ar

eas,

and

room

s in

the

neon

atal

car

e un

its (N

CU)

allo

cate

d fo

r pre

term

and

LBW

bab

ies.

Obs

erve

room

env

ironm

ents

and

ent

er fi

ndin

gs in

to q

uest

ions

1–1

0 of

Che

cklis

ts 1

–14.

Tak

e ph

otog

raph

s of

pro

blem

s su

ch a

s m

ultip

le b

abie

s in

one

bed

-spa

ce, u

se o

f inf

ant f

orm

ula

or o

ther

laps

es in

infe

ctio

n co

ntro

l.

Indi

cato

rPN

C ro

om(s

)KM

C ro

om(s

)N

CUro

om(s

)TO

TAL

Com

men

ts

For q

uest

ions

1–1

0, e

nter

a n

umbe

r

1.

Num

ber o

f pre

term

/LBW

bab

ies i

n th

e ro

om(s

) (N

P)

2.N

umbe

r of b

eds

avai

labl

e in

the

room

(s) (

NB)

3.

Ratio

of n

umbe

r of b

abie

s to

num

ber o

f bed

s in

the

room

(s) (

NP/

NB)

Take

a p

hoto

if b

abie

s ar

e sh

arin

g be

ds

4.N

umbe

r of b

ottle

s of

alc

ohol

han

d ge

l ava

ilabl

e in

the

room

(s) (

NHG

)

5.Ra

tio o

f the

num

ber o

f bot

tles

of a

lcoh

ol h

and

gel t

o th

e nu

mbe

r of b

eds

in th

e ro

om(s

) (N

HG/N

B)

6.N

umbe

r of b

abie

s se

para

ted

from

the

mot

her

7.N

umbe

r of b

abie

s se

para

ted

from

the

mot

her f

or c

aesa

rean

sec

tion

(CS)

8.N

umbe

r of b

abie

s se

para

ted

from

the

mot

her f

or p

rem

atur

ity/L

BW

9.N

umbe

r of b

abie

s re

ceiv

ing

phot

othe

rapy

a. N

umbe

r of b

abie

s rec

eivin

g ph

otot

hera

py in

the

KMC

posit

ion

10.

Num

ber o

f inf

ant f

orm

ula

prod

ucts

visi

ble

in th

e ro

om(s

) (tin

s, pa

cket

s bot

tles)

For q

uest

ions

11–

14, a

nsw

er w

ith Y

(Yes

), N

(No)

or N

A (N

ot A

pplic

able

)

11.

Did

any

heal

th w

orke

r han

dle

any

baby

with

out w

ashi

ng h

ands

with

soa

p/w

ater

or a

lcoh

ol h

and

gel b

efor

e to

uchi

ng a

ny b

aby?

1

12.

Did

any

heal

th w

orke

r tak

e an

y ba

by’s

tem

pera

ture

with

out d

isinf

ectin

g

the

ther

mom

eter

with

alc

ohol

bef

ore

use?

1 13

.Di

d an

y he

alth

wor

ker u

se a

ste

thos

cope

on

any

baby

with

out s

teril

izin

g w

ith a

lcoh

ol b

efor

e us

e? 1

14.

Did

the

heal

th w

orke

r in

the

room

use

a c

ell p

hone

bef

ore

or d

urin

g pa

tient

ca

re w

ithou

t was

hing

han

ds b

efor

e to

uchi

ng a

ny b

aby?

CHECKLIST 3

Preterm and LBW practices: Observations of environments in PNC areas and NCU

1. H

ealth

-wor

ker p

ract

ices

can

be

obse

rved

for a

ny b

aby

in th

e ro

om.

17

Chec

klis

t 4.

NCU

adm

issio

ns fo

r pre

term

and

LBW

bab

ies

Iden

tify

the

med

ical

reco

rds

of th

e la

st 2

0 pr

eter

m o

r LBW

adm

issi

ons

to th

e N

CU.1 U

se m

edic

al re

cord

s to

com

plet

e th

e ta

ble.

For

ques

tion

s 3–

6, a

nsw

er w

ith:

Y

(Yes

) or N

(No)

Med

ical

rec

ord

num

ber

Sum

mar

y/Re

mar

ks1

23

45

67

89

1011

1213

1415

1617

1819

20

1.

Mod

e of

birt

h: v

agin

al (V

) or

caes

area

n se

ctio

n (C

S)

2.In

dica

te m

onth

and

day

of b

irth

(mm

/dd)

3.

Ges

tatio

nal a

ge

a. ≥

37

wee

ks

b. 3

2 to

< 3

7 w

eeks

c. 28

to

< 3

2 w

eeks

d. <

28

wee

ks

4.Bi

rthw

eigh

t

a. >

250

0 g

b. 2

000

– 24

99 g

c. 1

500

–199

9 g

d. 1

000

–149

9 g

e. <

100

0 g

5.Di

d th

e ba

by re

ceiv

e an

y KM

C

at a

ny ti

me?

CHECKLIST 4

NCU admissions for preterm and LBW babies

1. I

nclu

des

NCU

bed

s, N

CU s

tep-

dow

n ar

eas

and

NCU

obs

erva

tion

area

s.

18


For

ques

tion

s 5–

6, a

nsw

er w

ith:

Y

(Yes

) or N

(No)

Med

ical

rec

ord

num

ber

Sum

mar

y/Re

mar

ks1

23

45

67

89

1011

1213

1415

1617

1819

20

6.W

as th

e ba

by s

epar

ated

from

ca

regi

vers

for a

dmiss

ion

to N

CU?

If ye

s: a.

Di

d th

e ba

by re

ceive

any

KM

C be

fore

se

para

tion?

b.

Whi

ch o

f the

follo

win

g sig

ns w

ere

pres

ent a

t the

tim

e of

adm

issio

n?

i.

Resp

irato

ry d

istre

ss n

ot re

spon

ding

to

cont

inuo

us p

ositi

ve a

irway

pre

ssur

e (C

PAP)

ii.

Apno

ea m

ore

than

3 ti

mes

per

h

(

stop

ped

brea

thin

g >

20

s)

iii

. Se

vere

hyp

othe

rmia

< 3

5 °C

tha

t doe

s not

resp

ond

to K

MC

iv.

Con

vulsi

ons

v.

No

spon

tane

ous m

ovem

ent

vi.

Neo

nata

l tet

anus

vii

. Bl

ood

in st

ool w

ith a

bdom

inal

dist

entio

n

viii

. Se

vere

con

geni

tal a

bnor

mal

ity

ix

. W

as a

t lea

st o

ne s

ign

abov

e pr

esen

t?

(

at le

ast o

ne Q

6.b

i–vii

i = Y

)

c. W

as th

e ba

by p

lace

d in

KM

C at

any

tim

e af

ter a

dmiss

ion

to th

e N

CU?

CHECKLIST 4

Preterm and LBW practices: chart reviews of postpartum mothers interviewed (continued)

19

Review by direct observation.

Indicate with: Y (Yes) or N (No) Available on the day of the review?

Indicator Delivery room

Operating room NCU KMC area(s)

(if available) 1

1. Antenatal steroids

2. Magnesium sulfate

3. Flat, dry, warm and clean resuscitation areas – one within 2 m of each delivery bed; at least one in each NCU and KMC area

4. Functional neonatal bag with term and preterm mask at every resuscitation area

5. Oxygen and delivery system (including nasal cannula and oxygen concentrators)

6. Oxygen saturation monitor

7. KMC wraps or binders

8. Small baby hats

9. Continuous positive airway pressure (CPAP)

10. Alcohol hand gel (at least one bottle in delivery, operating rooms and KMC areas; one bottle for each NCU bed)

11. Vitamin K1

12. Routine eye prophylaxis

13. Hepatitis B vaccines

14. Injectable antibiotics for neonatal sepsis

15. Vitamin D, calcium, phosphorus and iron supplements

16. Phototherapy equipment

1. If more than one room or KMC area is used for preterm and LBW babies, medicines, supplies and equipment must be avail-able for use in all rooms or areas to score Y.

CHECKLIST 5

Review of availability of key medicines, supplies and equipment for management of preterm and LBW babies

20


Review the most recent EENC review or consult senior staff to obtain available written policies.

Indicate with: Y (Yes) or N (No) Written policy?

Have staff been oriented on the policy?Policy, protocol or standard 1

1. Continuous KMC for preterm and LBW babies including STS contact, feeding with mother’s breast milk, monitoring and management of complications

2. Exclusive breastfeeding for all preterm and LBW babies, including giving expressed breast milk by cup, spoon or stomach tube until the baby has a suck-and-swallow reflex

3. Prevention and stabilization of hypothermia, hypoglycaemia, hypoxemia, apnoea/respiratory distress and infection prior to timely referral

4. Care of respiratory distress for preterm including

a. Oxygen

b. Continuous positive airway pressure (CPAP)

5. Care of sick preterm babies

6. Patient and bed to staff ratios for:

a. Delivery room

b. Postpartum ward(s) practising KMC

c. NCU practising KMC

7. Guidelines on identification and treatment of hypoglycaemia, including:

a. Symptomatic newborns

b. Asymptomatic high-risk newborns requiring glucose monitoring8. Restricted NCU admission criteria requiring separation from the mother, 2

including: a. Respiratory distress not responding to CPAP

b. Severe hypothermia < 35 °C not responding to KMC

c. Frequent apnoea more than 3 times per hour (stopped breathing > 20 s)

d. Convulsions

e. No spontaneous movement

f. Neonatal tetanus

g. Blood in stool with abdominal distention

h. Severe congenital malformation

9. Daily assessments of preterm infants

10. Criteria for discharge home – including mother confident to be able to practise KMC at home

11. Timing and content of follow-up visits of preterm infants and community follow-up if available

1. Including hospital-specific policies or standards or national policies intended for hospital use.2. Weight should not be an indication for admission to NCUs. Instead, admission should be based on the presence of one of

the signs in Q8.

CHECKLIST 6

Review of hospital policies, protocols and standards to support management of preterm and LBW babies

21

STAFF COACHING SUMMARY FORM: KMC

Type of health professional

Total, #

Coached, #

Remaining to be coached,

#

KMC facilitator(s) available for coaching? 1

Timeline for conducting coaching

Other resources needed 2

1. Facilitators may be staff in the hospital or may be from other hospitals.2. Other resources may include: coaching materials, KMC binders, manikins for demonstrating childbirth for premature delivery,

artificial breasts, fluorescent gel for demonstrating handwashing effectiveness, available space, etc.

STAFF COACHING SUMMARY FORM: EENC

Type of health professional

Total, #

Coached, #

Remaining to be coached,

#

EENC facilitator(s) available for coaching? 1

Timeline for conducting coaching

Other resources needed˚2

1. Facilitators may be staff in the hospital or may be from other hospitals.2. Other resources may include: manikins for demonstrating childbirth for normal delivery, fluorescent gel for demonstrating

handwashing effectiveness, full delivery kits, cloths and baby hats, delivery trolleys and resuscitation tables, available space in delivery rooms or other rooms, EENC materials including pre-and post-tests, and clinical checklists.

CHECKLIST 7

Staff coaching summary: KMC and EENCReview the most recent EENC review or consult senior staff to obtain available written policies.

22


MonthTotal live

births,#

Inborn preterm births by gestational age (in weeks)

#

Inborn term births < 2500 g, 2

(B)#

< 28 28 to < 32 32 to < 37 Total (A) 1

1

2

3

4

5

6

7

8

9

10

11

12

TOTAL(%) N n (n/NP) n (n/NP) n (n/NP) NP 1 (NP/N) NLBW 2 (NLBW/N)

1. Total number of preterm births (< 37 weeks).2. Total number of term (≥ 37 weeks) and LBW births (< 2500 g).

CHECKLIST 8

Hospital register data on preterm and LBW babiesReview hospital delivery register, NCU registers or KMC registers for the previous 12 months to complete the table on hospital data.

23

Month

Inborn and outborn (born outside the facility) preterm and LBW babies4

Total inborn (C = A+B) 3

#

Admitted to NCU(D)#

Admitted to NCU receiving continuous 4

KMC (E)#

Admitted to PNC ward or KMC areas

(F)#

Admitted to PNC ward or KMC areas

receiving continuous 5 KMC (G)

#

Inborn Outborn Inborn Outborn

1

2

3

4

5

6

7

8

9

10

11

12

TOTAL (%) NN

In–N–NCU(n/NN)

Out–N–NCU

N–NCUKMC

(n/Total–N–NCU)In–N–PNC

(n/NN)Out–N–

PNCN–PNCKMC

(n/Total–N–PNC)Total–N–NCU Total–N–PNC

3. Total number of inborn preterm births (< 37 weeks) and term LBW births (< 2500 g).4. If the hospital admits outborn newborns to rooms that are separate from inborn newborns, then outborn babies should not

be included in the calculations. 5. Continuous KMC is defined as uninterrupted STS contact with the mother or a family member for at least 20 hours of each

24-hour period.

CHECKLIST 8

Hospital register data on preterm and LBW babies (continued)

24


This checklist determines changes that can be expected if 70% of preterm or LBW babies were moved from NCU to KMC areas.i Review Checklist 8 to complete questions a.–d. Consult staff to obtain information on the number of staff, beds and physical space available. If necessary, visit NCU and KMC areas to assess availability of beds and space.

Preterm and LBW admissionsa. Current annual NCU admissions (Inborn and outborn, excluding those with continuous KMC)

before letter C, Checklist 8: Db. Expected NCU admissions (Annual total preterm and LBW babies < 2500 g): Checklist 8: C x 0.3c. Current annual KMC admissions (Inborn and outborn, including those in the NCU who are kept

in continuous KMC): Checklist 8: E + Gd. Expected KMC: (Annual total preterm and LBW babies < 2500 g) – Checklist 8: C x 0.7

Beds needed for preterm and LBW babies (and caregivers)e. Current NCU beds

f. Total NCU beds ii needed: Expected NCU admissions (b) x (Average length of stay / 365) x 1.5 iii

g. Current KMC beds

h. Total KMC beds needed: Expected KMC (d) x (Average length of stay / 365) x 1.5

Space needed for preterm and LBW babies (and caregivers)i. Current NCU space (in m2)

j. Total NCU space needed: Total bed spaces needed (f) x 9 m2, iv

k. Current KMC space (in m2)

l. Total KMC space needed: Total beds needed (h) x Space per bed (6 m2) v

Staff needed for preterm and LBW babiesm. Current NCU staff

n. Number of NCU staff needed: (Total beds needed (f) / 4) x (# shifts/day) vi x (7 / # days worked/week)

o. Current KMC staff

p. Number staff needed for KMC: (Total beds needed (h) / 8 )vii x (# shifts/day) x (7 / # days worked/week)q. Total staff needing coaching on KMC: based on the total number of health-care providers

in NCU and KMC ward(s)Facility support for KMC

r. Is additional facility support needed for mothers and families in the area(s) being used for KMC or being considered for KMC? Specify needs.

s. Toilet(s)

t. Washing space(s) for hand hygiene

u. Cooking facilities

v. Beds

w. Systems to support delivery of oxygen or CPAP

i. 70% of preterm and low-birthweight babies are estimated to be suitable for KMC.ii. Beds here refer to bassinettes, incubators or other places where babies are kept.iii. A factor of 1.5 is to account for fluctuations in bed occupancy.iv. Assumes each bed is 1 x 1 m, with 2 m between each bed.v. Beds include cots or other places the family will stay with the preterm baby. These are typically 1 x 2 m in size. For infection

control purposes, each bed space should be separated by at least 1 m. Total space allocated per bed space is 3 x 2 m, or 6 m2.vi. Assumes only neonates requiring intensive care are admitted with 1 staff member for 2 (ventilated); for 4 (on CPAP) or for 5

(no respiratory support) newborns in the NCU. This ratio can be modified depending on local hospital policy and resources.vii. For a basic KMC ward assume 1 nurse or equivalent staff for 8–10 beds; if the KMC ward includes CPAP, phototherapy or

palliative care, assume at least 2 nurses for 8–10 beds. At least one staff member should be present at all times. These ratios should be modified according to national or hospital standards and resources.

CHECKLIST 9

Staff, space and bed requirements for preterm and LBW babies

25

Checklist for developing the Kangaroo Mother Care (KMC) action framework

Checklist 10. KMC action framework

Review findings from Checklists 1–9

1. Draw the checklists on flip charts and enter data from the review. Additional prob-lems identified that were not on the checklists can also be listed.

2. Post completed flip charts around the room in order (Checklists 1–9).

3. Discuss and highlight the 2–3 most important gaps or problems identified (marked with a different colour pen).

Complete the KMC action framework

1. Draw the KMC action framework column headings on a flip chart.

2. Enter the 2–3 most important gaps or problems identified from the checklists as “priority issues”. Use the exact language from the checklists.

3. Post completed flip charts for priority issues around the room in order next to Checklists 1–9.

4. Discuss findings and reach consensus on the most important underlying issues, actions, responsibilities and timing. Summarize these on KMC action framework.

ANNEX 2

26


Priority issue Underlying

reasons for issue

Priority actions Person responsible Timing Status / Date

Policies, standards and guidelines

Space for KMC in neonatal care unit (NCU) or postnatal care (PNC) areas (see Considerations for location of KMC areas below)

Staff to support KMC

Medicines, supplies and equipment

Clinical coaching for staff

Communications and counselling materials and support (see Annexes 5.2 and 5.3)

CHECKLIST 10

KMC action framework

27

Considerations for location of KMC areas

KMC wards can be established in any PNC ward, provided it has adequate space, supplies and staff available to coach and assist mothers. In most facilities, existing spaces can be reorgan-ized to allow KMC to be practised.

Issue Factors to consider

1. Location of ward

Near NCU (for facilities with one ward): a. Allows NCU staff to support KMC and rotate easily in and out of NCU.

b. Ensures that sick babies receive immediate attention when needed and can be easily transferred to NCU.

Near delivery room: a. More convenient for immediate transfer for the majority of stable babies.

b. Mothers who require treatment for complications also will have easier access.

2. KMC with respiratory support

Wall oxygen and medical air (or oxygen cylinder and concentrator) is needed at each bed dedicated to receive respiratory support.

3. KMC for babies not needing respiratory support

One area with wall oxygen and medical air (or oxygen cylinder and concentrator) is required for the rare cases requiring resuscitation.

4. Availability of staff

For basic KMC: at least 1 staff member is needed for 8–10 beds.For KMC with CPAP or phototherapy: at least 2 staff members are needed for 8–10 beds.

Ensure nurses and midwives have mix of skills to manage both mothers and newborns. There should be at least one nurse or midwife available at all times to cover allocate KMC beds.

5. Physical space and amenities

There should be 1 metre between each bed; and an adequate number of sinks with soap and water or alcohol hand gel for handwashing, functional toilets and adequate space and privacy for mothers and families.

28

Facilitator’s guide for Kangaroo Mother Care (KMC) clinical coaching

Agenda for two-day KMC clinical coaching

DAY 1

Time Steps Documents

SESSION 1. Opening and assessment

DAY

1

1. Review of objectives

2. Brief introduction of facilitators and participants

3. Pre-coaching assessment

a. Pre-coaching written assessment* Pre- and post-test Participant's Recording Form

SESSION 2. KMC Role play and supervised practice

DAY

1

4. Help the mother position her baby correctly for KMC (use of binder, positioning, clothing)

Checklist 11

a. Baseline scenario of preterm management: health-care providers do their usual practice (plenary)

b. Re-enactment based on current practices and sequence of events – facilitated dialogue on current and evidence-based practice (plenary)

c. Role play with coaching and incremental correcting of gaps and malpractices (plenary)

d. Supervised role-play practice (small group) – participants all demonstrate correct practice.

5. Steps 4 a–d are repeated for the following scenarios – Helping the mother breastfeed in KMC– Helping the mother express breast milk in KMC– Helping mothers and families prevent infection and monitor progress

Checklists:– 12– 13– 14

6. Return written pretest to participants for review (10 minutes) Pre- and post-test

7. Discussion and distribution of handouts

1.

ANNEX 3

29

DAY 2

Time Steps Documents

SESSION 3. Review and practice

DAY

2

8. Facilitated Q&A on KMC clinical practice (10 minutes)

9. Visit to preterm areas to practise four clinical checklists with mothers and preterm babies

Checklists 11–14

10. Facilitated discussion: Immediate newborn care of preterm/ low-birthweight (LBW) babies

Preterm delivery checklist

SESSION 4. Assessment

DAY

2

11. Final assessments

a. Post-coaching skills assessment – each participant performs skills observed by facilitator

Checklists 11–14

b. Post-coaching written assessment Pre- and post-test Participant's Recording Form

SESSION 5. Review of KMC action plan

DAY

2

12. Review and plan next steps for KMC introduction

a. Review KMC action framework (actions for introducing and sustaining KMC in hospitals), status of current actions and next steps towards taking further action

Annex 5KMC action framework

b. Discuss planned actions with senior hospital staff and managers

13. Closing

* It is expected that all participants have completed EENC coaching prior to beginning KMC clinical coaching. If participants have not completed EENC coaching, consider adding pre- and post-test handwashing assessments using fluorescent gel (see Module 2: Coaching for the First Embrace – Facilitator’s guide. Manila: World Health Organization Regional Office for the Western Pacific; 2016).

30


Annotated facilitator’s guide: KMC clinical coaching

DAY 1 ACTIVITIES

1. Review of objectives

Read the following objectives aloud:

a. To give health workers a venue to practise until they master sequential steps to provide KMC care to preterm and LBW babies.

b. To help health workers value these skills so that they will practise them for all preterm and LBW babies.

2. Brief introduction of participants and facilitators

Briefly ask participants to introduce themselves, where they are from, their primary respon-sibility, training – i.e. neonatal care unit (NCU) or paediatric doctor, NCU or postnatal care (PNC) nurse – if they have received EENC coaching, and if they currently provide any KMC. A designated facilitator will record and update the Participant's Attendance Form (obtaining missing information, if any, during the break). The facilitators introduce themselves and, lastly, the organizers introduce themselves. Distribute the agenda and briefly discuss it.

3. Pre-coaching written assessment

Participants write their names at the top of the page and are given 15–20 minutes to complete the written pre-coaching assessment. Facilitators will collect the forms, grade the assessments and enter the results into the Participant's Recording Form at the end of Day 1.

4. First role play: putting the baby into the KMC position

a. Health-care providers demonstrate their usual practice (to be done in a large group) Facilitators use Checklist 11 to assess action by the demonstrator. This will be used as a

baseline performance score of the demonstration.

– Ask for three participants – one participant each to play: (1) the woman with a preterm/LBW baby; (2) the attending health worker; and (3) the note taker.

2.

31

– Ask the “mother” to sit on the bed or on a chair with the baby wrapped up in a blanket.

– Explain to the attending health worker: “This baby is 33 weeks of gestational age and weighs 1900 grams. The baby is stable and requires no medical treatment. Please show how you would normally put the baby into the KMC position. Please do not explain to us what you are doing. However, please do speak to the mother as you would normally and request the mother or other health workers to perform actions as needed. You may use any of the materials and supplies on the table.” Ask if there is anything that needs further clarification.

– Explain to the note taker: “You will write down the exact actions you observe.”

– Ask the other participants to pay close attention to what the health worker is doing, and take notes, as they will be asked to comment later. During the demonstration, they should not tell the demonstrator what to do or how to do it.

– Ask the health worker to start the role play. Note: Participants doing the role play may describe what they do in their practice instead of actually doing it. In this case, ask them to do what they are describing.

b. Re-enactment based on current practices and sequence of events

Facilitators generate participatory agreement or disagreement with every stage of practice and encourage discussion on the evidence base for the correct practice (done in a large group).

– Give the health worker a chance to discuss his or her thoughts on putting the baby into the KMC position, then ask the participants to give their thoughts. If interesting points are raised that will be covered during re-enactment, take note of them and state: “We will come back to this point shortly.”

– Ask the note taker to read aloud his or her record of only the first action that the health worker has performed. Ask the health worker to do the action again; ask the participants if this is correct or needs improvement. Facilitate a discussion around the: (1) order of actions; (2) quality of the action; and (3) the evidence base for the recommendation (see Section 5, Facilitator’s notes).

– Repeat steps until all the practice steps have been reviewed and discussed.

c. Supervised role-play practice with involvement of all participants

This is done in groups with five or six participants per station. Break into groups, one per practice station. Each group should have one facilitator. Participants should repeat the practice until all demonstrate it perfectly. Remind participants that there is a demonstration assessment on Day 2 where they will need to perform perfect KMC care.

32


5. Repeat role plays for other clinical practice tasks

Steps 4–6 are repeated for other clinical skills practice tasks using:

– Checklist 12 (helping the mother breastfeed in KMC);

– Checklist 13 (helping the mother express breast milk herself while practising KMC);

– Checklist 14 (helping mothers and families prevent infection and monitor progress).

Following each large group role play, trainees return to small groups and each person practises the task with feedback from the facilitator.

6. Return written pretests for participants to review

Scored pretests are returned to participants. They are given about 10 minutes to review. They may discuss responses with each other and ask questions to facilitators if necessary. Tests are then returned.

7. Discussion followed by dissemination of handouts to participants

Distribute the clinical skills checklists (Checklists 11–14) to trainees and explain that they pro-vide information as a reminder of what they learnt on Day 1. Agree on the starting time for the following morning and give any instructions needed.

DAY 2 ACTIVITIES

8. Facilitated brief Q&A on KMC clinical practice (10 minutes)

Facilitators ask questions to participants to recall the steps for KMC for preterm/LBW babies (KMC positioning, breastfeeding, expressing breast milk and counselling). See Annex 3.6, Facilitator’s notes.

9. Visit to preterm areas to practise four clinical checklists with mothers and preterm babies

Arrange in advance with clinical staff for participants to practise skills with mothers and babies in preterm areas.

33

Ideally mothers and preterm babies in KMC areas or postnatal wards will be selected. If an adequate number of mother–baby pairs are available, participants each complete all four clinical skills checklists (Checklists 11–14) with one mother–baby pair. If lower numbers are available, participants work in groups of 2–4 with each participant completing 1–3 checklists for each mother–baby pair. After clinical practice participants return to the coaching area. Facilitators ask for feedback on the clinical practice, identify any problems and discuss solutions.

It is important to:

– obtain consent from mothers for clinical practice;

– minimize touching of babies by ensuring that mothers are taught to perform as many tasks as possible themselves; and

– ensure that all participants follow strict hygiene practices and that mothers are taught to do the same.

10. Facilitated discussion: Immediate newborn care of preterm/LBW babies

In plenary, facilitators distribute and review with the staff the Preterm Clinical Skills Checklist: Immediate Care of a Preterm Baby for the breathing baby and asks, “What are the differences in how we manage mothers and preterm babies?”

Facilitators discuss the following:

– when it is appropriate for mothers to receive antenatal steroids and magnesium sulfate, and they review criteria for using these drugs;

– Step 5 (two extra towels are placed on the mother);

– Step 7 (ensure that both preterm and term resuscitation masks are available); and

– Step 17 (baby is covered with extra two cloths and has a preterm cap applied)

11. Final assessments

a. Skills assessment: This is done in small groups. Each participant needs to demonstrate the four KMC clinical practice tasks (Checklists 11–14) to a high degree of proficiency (at least 90% of tasks completed correctly). Facilitators observe each participant and assign a total score for each checklist based on tasks completed. The group observes and notes gaps. If the score is below 90%, the participant goes to the end of the queue for the next round and repeats the demonstration until they score at least 90%.

34


b. Written assessment: Participants write their names at the top of the form and are given 15–20 minutes to complete the written post-coaching assessment. Facilitators collect the forms at the end of the 15–20 minutes, grade the assessments, and enter the results into the Participant's Recording Form. All participants’ recording forms, with final scores for written and clinical tests, should be completed with a copy kept by the EENC hospital team.

12. Review and plan next steps for KMC introduction

The KMC action framework developed previously, as part of Action Steps 1–4, is reviewed. Progress with planned actions is discussed and used to identify next steps to complete ac-tions or further develop the plan. Findings should be presented and discussed with hospital directors and managers and commitments for next steps obtained.

13. Closing

The closing can be adapted locally; there is no prescribed closing suggested here. Presentation of findings and notes of congratulations are often presented in the presence of senior-level management prior to closing remarks the senior manager might deliver.

List of materials and handouts

TO BE PREPARED BY FACILITATOR(S) AND COACHING VENUE

Determine in advance the number of facilitators attending. The ideal facilitator-to-participant ratio is 1:5 or 1:6 to ensure adequate supervised practice. Rooms should be in the hospital. Enough space should be available to allow small groups to practise clinical tasks at separate beds or tables. If necessary, more than one room may be used. Each facilitator requires a bed or chair and table with all KMC supplies.

KMC binders

A binder is a loop of fabric that fits around the mother’s chest. The preterm baby is placed in

the loop of cloth and supported against the mother. Binders should be tight enough to provide

support, but not so tight that the baby is compressed and cannot be moved for breastfeeding.

Binders can be made by hospitals or families. See Annex 5.3 for binder photographs.

3.

35

General guidelines for making KMC binders:

– Choose a locally available, reasonably priced fabric or cloth.

– Cloth should have some elasticity so that it will snuggly hold the baby.

– Cut cloth into strips 0.8–0.9 metres long and 0.5 metres wide.

– Sew the ends of each cloth strip together to form a loop.

– Test binders with mothers and preterm babies to establish correct average size – adjust the fabric and length to ensure an adequate fit for the average mother.

Supplies

One set of the following items for each group of five or six participants

» Preterm baby caps and socks (2 pairs)

» Preterm diapers (2)

» KMC binder (see above for binder guidelines) (2)

» Cups for cup feeding demonstration (2)

» Spoons for spoon-feeding demonstrations (2)

» Extra pillows to support mother giving KMC

» Large-size, open-front shirts for use giving KMC (2)

» Preterm manikins for KMC practice (2)

» Alcohol hand gel for handwashing practice (1)

36


WRITTEN MATERIALS AND FORMS Facilitators Participants

» Facilitator’s guide (Annex 3) 1 each 0

» Participant's Attendance Form 1 per coaching 0

» Agenda for two-day clinical KMC coaching (Annex 3.1) 0 1 each

» Written pre- and post-coaching assessments and answer sheet (Annex 3.4)

1 answer sheet per coaching

2 assessments for each

» Skills Checklists 11–14 for KMC (Annex 4) 2 sets each (one for coaching; one for final assessments)

2 sets each for use in coaching

» EENC frequently asked questions (FAQs) summary sheet (Annex 5)

0 1 each

» Preterm clinical skills checklist: immediate care of a preterm baby (Annex 3.6)

0 1 each

» National or regional Early Essential Newborn Care: Clinical Practice Pocket Guide

0 1 each

» Certificate of attendance and completion (made locally)

0 1 each

TO BE GIVEN TO EACH PARTICIPANT

At the beginning of Day 1

– Agenda of coaching sessions

– Folder with notebook and pen

At the end of Day 1

– KMC clinical checklists (11–14)

– KMC FAQ

– Preterm clinical skills checklist

At the end of Day 2

– Facilitator’s guide (for those who will be coached to be KMC facilitators)

37

Written pre- and post-tests: Care of the preterm baby Except where otherwise stated, choose the best answer.

1. List three criteria that must be met to give antenatal steroids to a woman in preterm labour:

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

2. The primary purpose of giving antenatal steroids to the pregnant women is to:

a. Stop preterm labour

b. Prevent infection

c. Reduce the risk of hypoglycaemia

d. Mature the baby’s lungs to reduce risk of breathing difficulties

3. The purpose of giving magnesium sulfate to the pregnant women at risk of imminent early preterm birth is to:

a. Stop bleeding

b. Prevent infection

c. Prevent cerebral palsy in the infant and child

d. Mature the baby’s lungs to reduce risk of breathing difficulties

4. List three ways you can prevent nosocomial infections when looking after mothers and preterm babies:

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

4.

38


5. When a preterm baby is born, you should call out the time of birth (accurate to the min-ute and second). What do you do next?

a. Clamp and cut the cord

b. Suction the baby’s mouth and nose

c. Thoroughly dry the baby

d. Hold the baby upside-down to remove the secretions

6. When a preterm baby is born, when should the baby’s mouth and nose be suctioned?

a. At all deliveries to remove secretions

b. When the non-breathing baby is covered in thick meconium

c. When after thorough vigorous drying, the baby is not breathing and not vigorous

d. All of the above

7. When does a preterm baby need bag and mask ventilation? After thorough drying for 30 seconds, give bag and mask ventilation if the baby is:

a. Not breathing

b. Having difficulty breathing (gasping respirations)

c. Limp and very pale or blue in colour

d. All of the above

8. You are giving a preterm baby bag and mask ventilation. You note the chest does not rise when you squeeze the bag. List three things you can do to improve bag and mask ventilation to achieve good chest rise:

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

39

9. List three benefits of immediate skin-to-skin (STS) contact for all newborns including pre-terms:

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

10. What are the three main components of Kangaroo Mother Care (KMC)?

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

11. Which is incorrect about the position of the baby in KMC?

a. Baby’s head is slightly extended and turned to one side

b. Mother placed baby between breasts, vertically with legs in the frog position

c. Upper edge of wrap is under baby’s neck

d. Lower edge of wrap is under baby’s buttocks and contains the feet

12. List three factors related to prematurity that make preterms more likely to become hypo-thermic:

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

13. List three discharge criteria for babies managed with KMC:

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

40


14. List three breastfeeding cues:

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

15. List three signs of good positioning for breastfeeding:

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

16. List three signs of good attachment for breastfeeding:

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

17. If a preterm baby is over 32 weeks and unable to breastfeed, what three actions could you take to assess the mother’s breastfeeding practice?

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

....................................................................................................................................................................................................................................

Circle true or false for the following statements?

18. KMC is the same as the STS contact given to all babies immediately at birth.

True / False

19. KMC can help to reduce newborn sickness. True / False

20. Incubator/warmer care is better than KMC for small babies. True / False

41

21. KMC helps to improve infant nutrition. True / False

22. Only the mother can give KMC to her baby. True / False

23. KMC helps to keep a baby warm. True / False

24. KMC helps to reduce newborn infection. True / False

25. While a baby is in the kangaroo position, the mother can move around and do tasks.

True / False

26. KMC enables earlier discharge of small babies. True / False

27. KMC can help to reduce preterm deaths. True / False

28. There is scientific evidence that at least 20 hours of KMC can reduce preterm deaths without using incubators.

True / False

Scoring:

• 1 point is given for every correct answer.

• 0 points if more than one answer is given for a multiple-choice question.

• The maximum possible score is 50 (each multiple-choice question with one answer is scored 1 and each 3-part written question is scored 3).

• Participants must score 40 or above to pass (at least 80%).

42


Answer sheet for written pre- and post-tests: Care of the preterm baby

FOR FACILITATORS ONLY

1. List three criteria that must be met to give antenatal steroids to a woman in preterm labour:

a. Woman is at 24–34 weeks of gestation

b. Preterm birth is considered imminent (within 7 days of starting treatment)

c. A gestational age assessment can be accurately undertaken

d. There is no clinical evidence of maternal infection

e. Adequate childbirth care is available (including the capacity to recognize and safely manage preterm labour and birth)

f. The preterm newborn can receive adequate care if needed, including resuscitation, thermal care, feeding support, infection treatment and safe oxygen use

2. The primary purpose of giving antenatal steroids to the pregnant women is to:

a. Mature the baby’s lungs to reduce risk of breathing difficulties

3. The purpose of giving magnesium sulfate to the pregnant women at risk of imminent early preterm birth is to:

a. Prevent cerebral palsy in the infant and child

4. List three ways you can prevent nosocomial infections when looking after mothers and preterm babies:

a. Perform handwashing before touching babies

b. Sterilize all equipment before using on babies (thermometers, stethoscopes)

c. Avoid touching babies by staff or by other people other than the mother and family

d. Ensure continuous KMC and exclusive breastfeeding

e. Avoid placing the baby on facility surfaces

5.

43

5. When a preterm baby is born, you should call out the time of birth (accurate to the minute and the second). What do you do next?

a. Thoroughly dry the baby

6. When a preterm baby is born, when should the baby’s mouth and nose be suctioned?

a. When the non-breathing baby is covered in thick meconium

7. When does a preterm baby need bag and mask ventilation? After thorough drying for 30 seconds, give bag and mask ventilation if the baby is:

a. All of the above

8. You are giving a preterm baby bag and mask ventilation. You note the chest does not rise when you squeeze the bag. List three things you can do to improve bag and mask ventilation to achieve good chest rise:

a. Reposition the neck and head, ensure chin is pulled upwards

b. Check the seal of mask around mouth and nose

c. Squeeze the bag harder

9. List three benefits of immediate STS contact for all newborns including preterms:

a. Keeps warm and prevents hypothermia

b. Promotes bonding

c. Contributes to overall success of breastfeeding and colostrum feeding

d. Stimulates the immune system (mucosa-associated lymphoid tissue)

e. Protects from hypoglycaemia

f. Helps colonization with maternal skin flora (friendly family bacteria)

10. What are the three main components of KMC?

a. Continuous STS contact (at least 20 hours in each 24-hour period)

b. Exclusive breastfeeding

c. Monitoring for illness

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11. Which is incorrect about the position of the baby in KMC?

a. Upper edge of wrap is under baby’s neck

12. List three factors related to prematurity that make preterms more likely to become hypo-thermic:

a. High surface-area-to-volume ratioless fat reserves

b. Less developed muscle mass

c. Liver less efficient at storing glycogen and converting glycogen to glucose for energy

13. List three discharge criteria for babies managed with KMC:

a. No apnoea

b. Gaining weight

c. Temperature stable

d. Feeding well

e. Other comfortable giving KMC, understands danger signs for seeking care and has adequate family support at home

14. List three breastfeeding cues:

a. Drooling

b. Mouth opening

c. Tonguing

d. Licking

e. Rooting

f. Biting of fingers or hand

g. Crawling

15. List three signs of good positioning for breastfeeding:

a. The baby’s head and body are in a straight line (neck is not twisted or flexed)

b. The baby is facing the breast, with nose opposite nipple

c. The mother is holding the baby’s body close to her body and supporting the baby’s whole body (not just neck and shoulders)

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16. List three signs of good attachment for breastfeeding:

a. More areola is visible above the baby’s mouth than below

b. The mouth is wide open with the lower lip turned outwards

c. The baby’s chin is touching the breast

d. Sucking is slow and deep with occasional pauses

17. If a preterm baby is over 32 weeks and unable to breastfeed, what three actions could you take to assess the mother’s breastfeeding practice?

a. Review mother’s understanding of feeding cues

b. Review baby’s position for breastfeeding

c. Review signs of good attachment for breastfeeding

d. Review number of times per day the mother is breastfeeding

e. Review the duration of breastfeed each time and whether both breasts are used

Circle true or false for the following statements

18. KMC is the same as the STS contact given to all babies immediately at birth.

False

19. KMC can help to reduce newborn sickness. True

20. Incubator/warmer care is better than KMC for small babies. False

21. KMC helps to improve infant nutrition. True

22. Only the mother can give KMC to her baby. False

23. KMC helps to keep a baby warm. True

24. KMC helps to reduce newborn infection. True

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25. While a baby is in the kangaroo position, the mother can move around and do tasks.

True

26. KMC enables earlier discharge of small babies. True

27. KMC can help to reduce preterm deaths. True

28. There is scientific evidence that at least 20 hours of KMC can reduce preterm deaths without using incubators.

True

Summary of participant’s scores: KMC clinical coaching

Participants Written Clinical practice

Pretest Post-test11 12 13 14

n/28 n/40 n/42 n/40

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Facilitator’s notes Note: The facilitator’s notes are not designed for use with the Q&A, but provide typical ques-tions and answers that can help the facilitator guide the questions.

Possible questions to ask to participants during supervised role plays of KMC clini-cal practice tasks (Checklists 11–14)

Preterm / LBW baby deaths

What are the common causes of preterm/LBW deaths?

Respiratory failure (respiratory distress syndrome, apnoea), infections (all causes and nosocomial), hypothermia, necrotizing enterocolitis, brain haemorrhage.

Why are preterm/LBW babies at higher risk of hypothermia?

High surface-area-to-volume ratio, less fat reserves, less-developed muscle mass, liver less efficient

at storing glycogen and converting glycogen to glucose for energy.

Why is hypothermia dangerous to preterm/LBW babies?

Hypothermia can cause newborns to have infections, coagulation defects, acidosis, delayed fetal-to-newborn circulatory adjustment, hyaline membrane disease (respiratory distress syndrome)

and brain haemorrhage.

Kangaroo Mother Care (KMC)

What are the three core components of KMC?

Continuous skin-to-skin (STS) contact (at least 20 hours in each 24-hour period), exclusive breast-feeding and monitoring for illness.

What are the benefits of KMC?

Compared with conventional neonatal care, continuous KMC reduces mortality, severe infection, sepsis, nosocomial infection, hypothermia, severe illness, and lower respiratory tract disease. In addition, KMC increases gain in weight, length and head circumference, breastfeeding rates, mother’s satisfaction with infant care and attachment.

6.

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Why is STS contact so effective?

It keeps vulnerable preterm and LBW babies warm, promotes bonding, contributes to overall suc-cess of breastfeeding and colostrum feeding, stimulates the immune system (mucosa-associated lymphoid tissue), protects from hypoglycaemia, and helps colonization with maternal skin flora (friendly family bacteria).

Who can provide KMC?

Fathers and grandparents who do not have a cough, cold, fever, transmissible systemic infectious disease (e.g. hepatitis A or E), skin infection on the chest or arms (boils, abscesses, furuncles) or mental impairment (e.g. mental illness, intoxication with alcohol or illicit or prescription drugs).

What is the maximum time KMC can be interrupted during any time?

To maximize benefits of KMC, breaks should be limited to less than 30 minutes.

Why is a KMC binder the preferred method of providing KMC?

A KMC binder holds the baby firmly against the mother’s chest and increases mobility by allowing the mother to stand and walk with the baby in place. A binder allows the baby to be easily shifted for breastfeeding and expressing breast milk while keeping the baby in STS contact. Conventional wraps are more cumbersome and make it more difficult to move the baby for feeding in the KMC position. The use of a shirt only is less effective at maintaining the baby in STS contact and does

not provide enough support to allow the mother to move around with free hands.

How many staff members are required to support mothers practising KMC?

For a basic KMC area, assume one nurse or equivalent staff for 8–10 beds. If the KMC area includes continuous positive airway pressure (CPAP), phototherapy or palliative care, assume at least two nurses for 8–10 beds. At least one staff member should be present at all times. These ratios should be modified according to the hospital policies and resources.

Delivery care

When are antenatal steroids recommended?

Antenatal corticosteroids are recommended for women from 24–34 weeks of gestation when the following conditions are met:

• preterm birth is considered imminent (within seven days of starting treatment);

• a gestational age assessment can be accurately undertaken;

• there is no clinical evidence of maternal infection;

• adequate childbirth care is available (including the capacity to recognize and safely manage preterm labour and birth); and

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• the preterm newborn can receive adequate care if needed (including resuscitation, thermal

care, feeding support, infection treatment and safe oxygen use).

What is the impact of antenatal steroids?

A reduction in neonatal deaths (32%), respiratory distress syndrome, or RDS, (35%), cerebro-ventricular haemorrhage, infant systemic infection in the first 48 hours of life and necrotizing enterocolitis. In childhood, reductions in the number of children treated for cerebral palsy and developmental delay.

Which antenatal steroids should be used?

Betamethasone and dexamethasone have comparable efficacy. Dexamethasone has an advantage over betamethasone because it is lower cost and more widely available. Dexamethasone is currently listed for use in pregnant women on the WHO Essential Medicine List and in WHO’s Managing complications in pregnancy and childbirth: a guide for midwives and doctors.

Why shouldn’t all preterm babies get antenatal steroids?

If antenatal steroids are given to women with late preterm or term deliveries, the risks of newborn mortality and of maternal infection are higher. This is because steroids can have a detrimental effect on immunity. Thus, steroids should not be used if gestational age cannot be accurately determined. If diagnosed with clinical chorioamnionitis or systemic infection (e.g. septicaemia or tuberculosis), antenatal steroids can exacerbate the problem and are also not recommended. Since mothers and babies delivering preterm are more likely to have other problems, close monitoring of the mother and fetus to identify and appropriately manage complications, such as maternal infection and fetal hypoxia and to deliver high-quality delivery and post-delivery care must be

available. If not available, these mothers and babies are placed at higher risk.

What dose and interval of antenatal steroids are recommended?

Four 6 mg intramuscular (IM) doses of dexamethasone should be given 12 hours apart. Two 12 mg IM doses of betamethasone should be given 24 hours apart.

What are the benefits of magnesium sulfate?

Infants exposed to magnesium sulfate have a reduced risk (39%) of gross motor dysfunction and

of cerebral palsy (30%).

Who should receive magnesium sulfate?

Women at risk of imminent preterm birth before 32 weeks of gestation. Magnesium sulfate for

neuroprotection should only be given if preterm birth is likely within the next 24 hours.

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Why is early separation of preterm and LBW babies dangerous?

Early separation increases the risks of hypothermia, hypoglycaemia and acidosis; exposure to harmful bacteria on hospital surfaces; reduced likelihood of early and exclusive breastfeeding; and increased risks of infection from medical staff and instruments.

What delivery preparations are needed for preterm/LBW babies receiving EENC?

Preterm and LBW babies receive all standard preparations required for EENC. Additional prepara-tions include: • laying out an additional two cloths for covering the baby after birth on the mother’s chest,• laying out a preterm baby cap, and

• ensuring that a preterm resuscitation mask (size 0) is available for resuscitation.

Breastfeeding

Why is breastfeeding beneficial?

Breastfeeding is one of the most life-saving interventions we have. Delays in initiation of breast-feeding are associated with dramatic increase in death and illness. Babies who are fed formula have 4–6 times the risk of dying compared with exclusively breastfed babies. Formula is more dangerous to a newborn than is smoking to an adult.

When is a baby ready to breastfeed?

Babies will develop a suck-and-swallow reflex and be able to successfully breastfeed between 32 and 36 weeks. Each baby is different. Babies < 28 weeks usually require tube feeding because they do not have a swallow reflex. From 28 to 32 weeks, babies may require tube feeding during their earlier ages but can shift to cup-and-spoon-feeding at higher ages and begin to practise breastfeeding. All babies > 32 weeks should attempt breastfeeding every day with cup-and-spoon-feeding added if required. To initiate breastfeeding, mothers should look for feeding cues, express drops of milk directly onto the mouth of the baby and encourage attachment. The baby may initially suck for brief periods, but with repeated attempts, will feed longer until normal

breastfeeding is initiated.

What are the feeding cues that a baby is ready to breastfeed?

The earliest sign is drooling, followed by mouth opening, tonguing, licking, rooting and biting of fingers or hand. Eventually, the baby will crawl towards the breast and open his or her mouth widely to attach to the breast.

Do mothers of preterm and LBW babies have enough milk?

The vast majority of mothers have an adequate supply of breast milk. If the baby is not yet able to breastfeed, expressed breast milk can be given to the baby by tube, cup or spoon, and stored

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if necessary (mothers should express breast milk 8–12 times over the day and night until the baby begins breastfeeding). Stimulation of the breast sends messages to the mother’s brain and back to the breast to produce more milk. Once the baby is around 32 weeks of age, the mother can introduce normal breastfeeding. A full-term newborn’s stomach is only the size of a thumbnail (and a preterm is smaller). Provided that the mother’s breastfeeding technique is effective (posi-tioning and attachment), most babies can get enough milk from the mother.

What are the signs of good feeding position?

• The baby’s head and body are in a straight line (neck is not twisted or flexed).

• The baby is facing the breast, with nose opposite the nipple.

• The mother is holding the baby’s body close to her body and supporting the baby’s whole body, not just neck and shoulders.

What are the signs of good attachment?

More areola is visible above the baby’s mouth than below; the mouth is wide open with the lower lip turned outward, the baby’s chin touching the breast; and sucking is slow and deep with occa-sional pauses. Note: Signs of ineffective attachment include indrawing of the newborn’s cheeks, lip-smacking sounds or mother’s nipple pain.

How can we improve attachment?

By touching the baby’s lips with the nipple, waiting until the mouth is opened wide, moving baby quickly onto the breast, aiming the baby’s lower lip well below nipple; also, by trying different positions, e.g. sitting upright or lying on her side.

Why should preterm babies not be given a bottle?

Bottle-feeding reduces the likelihood that the baby will develop an effective suck-and-swallow reflex and begin to breastfeed normally (nipple confusion), and it increases the risk of aspiration and of infection. Feeding with a cup and spoon reduces these risks. Cup-and-spoon-feeding may be slightly slower than bottle-feeding, but this is outweighed by the benefits to the baby for long-term breastfeeding success. Cup-and-spoon-feeding of expressed breast milk can be carried out effectively by mothers and family members.

How long should expressed breast milk be stored? 6

Room temperature:

• 15–25 °C: breast milk in a covered container can be kept for 8 hours. • 25–37 °C: breast milk in a covered container can be kept for 4 hours. • Breast milk should not be stored above 37 °C.

6. WHO, UNICEF, Wellstart International. Baby-friendly hospital initiative: revised, updated and expanded for integrated care. Section 3, Breastfeeding promotion and support in a baby-friendly hospital, a 20-hour course for maternity staff. Geneva: World Health Organization; 2009.

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In a refrigerator (4 °C):

• Breast milk can be stored at the back of the refrigerator for 5 days. • In the freezer compartment of a refrigerator with separate doors (– 18 °C): breast milk can

be stored at the back of the freezer for 3 months. • In a chest or upright deep freezer (– 20 °C): breast milk can be stored for 6 months. Shorter

freezer storage times are preferred to limit degradation of some lipids in the milk. • Frozen milk should be thawed by placing in a refrigerator for 24 hours; or by gentle heat

in warm water. Frozen breast milk should not be boiled or thawed in a microwave, which generates high and uneven heat – and degrades proteins.

What is the difference between foremilk and hindmilk?

The term foremilk refers to the milk at the beginning of a feed and hindmilk refers to milk at the end of a feed. Hindmilk has a higher fat content than foremilk. If a preterm/LBW baby is not growing adequately, mothers may be instructed to express the foremilk and hindmilk into separate containers and to give the hindmilk first because of its higher fat content and increased nutrient density.

How much weight do preterm babies lose after birth?

All babies normally lose weight in the first week after birth. This is because babies have an exces-sive amount of fluid in their bodies at birth, which is then lost. The demands of extra uterine life also increase metabolic demands and require more energy. It is normal for preterm newborns to lose 10% of their body weight in the first 7–10 days of life. This means that a baby who weighs 1000 g at birth can be expected to lose about 100 g in the first 7–10 days. LBW babies usually regain their birth weight by 10–14 days. Babies born by caesarean section may lose a higher percentage of their birth weight because they do not pass through the birth canal and therefore have more retained fluid at birth.

How much breast milk should preterm babies receiving expressed breast milk require?

Preterm babies should consume 60 ml/kg on Day 1, increasing by 10 or 20 ml per day over 7 days up to 160 ml/kg per day. If the baby is still having exclusive breast milk by cup or gastric tube after 7 days, increase the quantity given by 20 ml/kg each day until the baby is receiving 180 ml/kg per day. Milk is given at least 8 times in each 24-hour period. If a baby has more than 8 feeds in 24 hours, the amount per feed must be reduced accordingly, to achieve the same total volume in 24 hours. Cup fed babies need to be offered 5 ml extra at each feed to accommodate for spillage. A record of the 24-hour total breast-milk consumed should be kept to ensure the daily intake is sufficient.7

7. Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals. Geneva: World Health Organization; 2009.

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Recommended fluid intake for LBW infants 8

Day of lifeFluid requirements (in ml/kg per day)

2000–2500 g 1500–1999 g 1000–1499 gDAY 1 60 60 60DAY 2 80 75 70DAY 3 100 90 80DAY 4 120 115 90DAY 5 140 130 110DAY 6 150 145 130DAY 7 160 160 150

How much weight are preterm babies expected to gain over time?

After 10–14 days of life a weight gain of at least 10 g/kg per day is expected (averaged over 3 days).8

Minimum expected weight gain is 10 g/kg per day

– birth weight 1–1.9 kg: Expected weight gain is at least 10 g/day, or 70–150 g/week

– birth weight 2–2.9 kg: Expected weight gain is at least 20 g/day, or 150–200+ g/week

– birth weight 3+ kg: Expected weight gain is at least 30 g/day, or > 200+ g/week

What should be done if the baby is not gaining enough weight?

If the baby has inadequate weight gain, determine and classify the cause. A baby with inad-equate weight gain usually has: 1) insufficient feeds; 2) incorrect feeding method; 3) incorrect temperature control; or 4) illness. Signs of illness must be assessed and baby referred, if present (see Checklist 14).

To assess adequacy of feed volumes, ask about and observe the mother in these areas:• expressing and giving expressed breast milk (volume, technique, frequency of feeds);

• breastfeeding (positioning, attachment, sucking adequacy, duration, and frequency); and

• inappropriate use of other methods, including giving formula between feeds and the use of

bottle-feeding.

To assess temperature control, ask about and observe KMC technique including positioning, adequacy of STS contact, duration of separations, total time in STS contact each 24-hour period, and whether the baby is adequately covered. Ensure that the environmental temperature is adequate (at least 25–28 °C).

If no obvious cause is found or if feeding problems cannot be adequately addressed, refer for further review by a paediatrician.

8. Save the Children, Limpopo Provincial Government of South Africa, University of Limpopo, UNICEF. Management of sick and small newborns in district hospitals: trainee manual. Polokwane, South Africa: Limpopo Initiative for Newborn Care; 2015.

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Preterm clinical skills checklist – Immediate care of a preterm baby (facilitated discussion sheet)

ACTIVITY: Prebirth preparations

1. Is the mother’s gestational age 24–34 weeks? If yes, are the following true? a. Preterm birth is considered imminent (within 7 days of starting treatment).

b. A gestational age assessment can be accurately undertaken.

c. There is no clinical evidence of maternal infection.

d. Adequate childbirth care is available, including the capacity to recognize and safely manage preterm labour and birth.

e. The preterm newborn can receive adequate care if needed, including resuscitation, thermal care, feeding support, infection treatment and safe oxygen use.

If a.–d. are all “Yes”: give steroids according to the national protocol

2. Is the mother’s gestational age < 32 weeks?If yes, give magnesium sulfate according to the national protocol

3. Checked room temperature; turned off fans

4. Washed hands (first of two handwashings)

5. Two extra dry cloths are available and placed in reach of the attendant

6. Placed dry cloth on mother’s abdomen

7. Prepared the newborn resuscitation area

8. Checked that bag and mask are functional – a preterm mask is fitted (size 0) and term mask (size 1) is available for large preterms

9. Washed hands (second of two handwashings)

10. Put on two pairs of clean gloves, if the same attendant handles the cord

11. Put forceps, cord clamp/ties in easy-to-use order

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ACTIVITY: Immediate postpartum/newborn care*

12. Called out time of birth: ........ hour ........ minute ........ second

13. Drying started within 5 seconds of birth?

14. Dried the baby thoroughly (eyes, face, head, front, back, arms and legs)

15. Removed the wet cloth

16. Put baby in direct STS contact with mother

17. Covered baby’s body with 2 cloths for extra warmth and the head with a preterm hat

18. Checked for a second baby

19. Gave oxytocin to mother within 1 minute of delivery

20. Removed outer pair of gloves

21. Checked cord pulsations, clamped after cord pulsations stopped (usually 1–3 min)

22. Placed clamp/ties at 2 cm, forceps at 5 cm, from umbilical base

23. Cut cord close to the first clamp with sterile pair of scissors

24. Delivered placenta

25. Counselled mother on feeding cues (drooling, mouth opening, etc.)

26. Reviewed the status of the newborn, including whether the baby becomes pink, is breathing normally, or has grunting or respiratory distress, or any other concerns

* In the rare event of a non-breathing baby, the health worker should shift to the EENC non-breathing baby protocol – begin-ning with immediate cutting of the cord and transfer for bag and mask resuscitation.

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Checklists for reviewing KMC skills of health workers

Checklists 11–14. Review of KMC skills of health workers

When conducting KMC, coaching checklists are used by facilitators and staff to:

1. Review practices during role plays and provide feedback on correct practices

2. Review and reinforce practice skills in small groups

3. Conduct final assessments and calculate practice scores of participants

When conducting periodic monitoring in hospital wards or KMC areas, checklists are used by more experienced staff to:

1. Observe and score key clinical management tasks for less experienced staff, begin-ning with management of at least 10 consecutive preterm babies

2. Provide immediate feedback and corrections to practise

3. Repeat observations and feedback periodically on five cases quarterly or biannually

ANNEX 4

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Mark Y (“Yes”), P (“Partial”) or N (“No”) for each step. Repeat until a pass score is achieved

STEPAttempt

1 2 3Discusses KMC with the mother

1. Three components of KMC

2. At least three benefits of continuous KMC

Shows mother how to prepare for KMC

3. Wash hands before baby care

4. Prepare clothes for the mother, the baby and the KMC binder

5. Put clothes on the mother that can be opened at front

6. Remove clothes from the baby, and ensure that the baby is wearing cap, socks and diaper

7. Repeat handwashing after touching baby, clothes and diaper

Shows mother how to prepare for KMC

8. Hold the baby – one hand on head, one hand on bottom, and place between the breasts, chest to chest vertically with legs and arms flexed

9. Ensure the baby’s head is slightly extended, with head turned to one side and arms flexed

10. Pull the binder over the baby’s feet, upper edge of wrap placed at the level of the baby’s ears and then the lower edge pulled under baby’s buttocks with the feet inside the binder in the frog position

11. Adjust the binder to hold the baby securely so when the mother moves around, the baby will not fall

12. Check that the baby can breathe easily and that the tight edge of the binder is not over the baby’s chest

13. Button clothes over the baby and cover with a blanket; ensure that the mother is comfortable

14. Wash hands after baby care

Total: (Y x 2) + (P x 1) maximum: 28 – Pass > 25

Staff signature (over printed name) Observer signature (over printed name)

CHECKLIST 11

Helping mother position her baby correctly for KMC

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ACTIVITYAttempt

1 2 3Discusses how to breastfeed with the mother

1. Recognize feeding cues that indicate the baby is ready to feed

2. Breastfeed 8–12 times in 24 hours

Shows the mother how to position the baby

3. Wash hands before baby care

4. Loosen or move binder so baby is covered but in correct position to breastfeed

5. Hold baby close with as much STS contact as possible

6. Support the baby’s body, not just neck and shoulders

7. Ensure baby’s ear, shoulder and hip are in a straight line to midline of body

8. Ensure that baby’s face looks towards breast, nose opposite nipple

Shows the mother how to help baby attach to the breast

9. Touch baby’s lips with her nipples

10. Wait for baby’s mouth to open wide

11. Move baby onto breast with lower lip well below the nipple, as the mouth is closing

Shows the mother how to help baby attach to the breast

12. Baby’s chin is touching the breast

13. Baby’s mouth is wide open

14. Baby’s lower lip is curled out/downwards

15. More areola is visible above the baby’s mouth than below

16. Baby feeds with slow deep sucks

Discusses with the mother signs of good breastfeeding

17. Occasional short pauses in sucking are normal; no sucking sounds should be heard

18. Feed on both sides until breasts feel empty after feeding (may need to feed twice from each side)

CHECKLIST 12

Helping mother breastfeed in KMC

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ACTIVITYAttempt

1 2 3

Shows the mother how to return the baby to KMC

19. Move the baby back into the KMC position, adjust the binder

20. Wash hands after baby care



CHECKLIST 12

Helping mother breastfeed in KMC (continued)


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ACTIVITYAttempt

1 2 3Discusses with the mother

1. Expressed breast milk is given to preterm babies who cannot suck or swallow or who tire easily. It can also be used for term babies so the baby can be fed breast milk when the mother is away.

2. Breast milk is made deep in the breast and flows to the nipple – no milk will come if only the nipple is squeezed

3. Express on average 8–12 times in 24 hours

4. Hand expressing should not hurt but if you get sore, there is a problem with technique that needs to be corrected

5. Clean cup with lid in soap and water, then fill with boiling water, wait until cool and empty to be ready for the expressed milk

Shows mother breast massage before expressing breast milk

6. Wash hands with baby in KMC position

7. Loosen the binder and move the baby away from one breast

8. Run fingers from the chest wall down the upper edge of the breast

9. Use both knuckles to massage the breast from top to bottom and around sides in a circular motion

10. Use both thumbs to massage the breast from top to bottom and around the sides in a circular motion

11. Use thumb and forefinger to move around the areola

12. Use thumb and forefinger to move around the nipple

13. Continue massage for 3–5 minutes

Shows and discusses how to express breast milk

14. Form the hand into a “C” on the area behind the areola, about 2–4 cm from the center of the nipple

15. Press back towards the chest wall and compress the breast rhythmically between the thumb and fingers until milk expresses

16. When the flow slows, move the fingers and thumb to a new position gradually moving all around the areola; continue until the milk flow stops

17. Repeat on the second side until both breasts feel empty

18. Put a lid on the container and store in a cool place or fridge until ready to feed to baby; explain how long milk can be stored (room, fridge, freezer)

CHECKLIST 13

Helping mother express breast milk herself while practising KMC skills

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ACTIVITYAttempt

1 2 3Shows how to feed using expressed breast milk19. Feed small volumes with cup and spoon from the center of the nipple20. Return baby to KMC position21. Wash hands after patient care



CHECKLIST 13

Helping mother express breast milk herself while practising KMC skills (continued)


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ACTIVITYAttempt

1 2 3Explains and discusses how and when to wash hands

1. Use soap and clean water or alcohol hand gel; dry hands with disposable towel

2. Before and after breastfeeding or expressing

3. Before and after baby care, e.g. bathing or changing diaper

4. After using the toilet

5. Before and after handling food and cooking

6. After using cell phone

7. All family members wash hands before touching the baby

Explains and discusses how to recognize danger signs

8. Breathing is: fast (> 60 breaths per minute), irregular (gasping) or noisy

9. Severe chest indrawing

10. Stops breathing > 20 seconds (apnoeic episode)

11. Pale or blue colour on lips and around mouth

12. Yellow skin (jaundice) in the first 24 hours or on the palms or soles at any age

13. Baby feels cold or hot

14. Stops feeding well, difficulty feeding, abdominal distension, recurrent vomiting, diarrhoea

15. Convulsions

Explains and discusses discharge criteria

16. No apnoea

17. Feeding well

18. Gaining weight 9

19. Temperature is stable

20. Mother is confident of taking care of her baby using KMC, knows danger signs and actions and has adequate support at home



CHECKLIST 14

Helping mothers and families prevent infection and monitor progress

9. Many babies lose up to 10% of their birthweight after birth, but should have returned to their birthweight 10 days after birth. After 7–10 days of life a weight gain of at least 10/g/kg/day is expected (averaged over 3 days). After birthweight is regained, weight gain over the first 3 months should be: birthweight 1000–1999 g: 70–149 g per week; birthweight 2000–2999 g: 150–250 g per week.

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KMC SKILLS CHECKLIST: SUMMARY SHEET

Observe staff managing 10 preterm babies using Checklists 11–14. Record clinical scores in the table.

Month .............................. Year .........................

Staff name ................................................................ Observer name ....................................................................

ID

Skills checklists scoresBaby

outcome10 11 12 13 14

Positionn/28

Breastfeedingn/40

Express breast milkn/42

Monitorn/40

10. W = discharged well, U = discharged unwell, N = admitted to neonatal care unit (NCU), R = referred, D = died

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Family support for KMC

Frequently asked questions

What are the benefits of Kangaroo Mother Care (KMC)?

KMC has been shown to increase breastfeeding rates; decrease the risk of apnoea, irregular

breathing, hypothermia and infection; improve growth; and importantly promote bonding be-

tween mothers and their babies. KMC has been shown to halve preterm deaths.

Which babies benefit from KMC?

KMC is currently recommended for all stable babies < 37 weeks and weighing < 2.0 kg. Babies

2.0–2.5 kg may also benefit from KMC.

Can I take care of my tiny baby as well or better than a health professional?

Small babies need constant warming and frequent feeding with breast milk. KMC care by you or

a family member provides this better than modern technology and formula milk and reduces the

risk of illness and death. With support, you and your family can do this very well.

Who can give skin-to-skin (STS) contact for my baby?

STS care can be provided by the mother, the father or healthy grandparents.

What do family members need to know to support KMC?

Howto: • positionthebabycorrectlyandsafelyagainstthechest• breastfeedproperly

• express breast milk and give it to the baby if the baby cannot suck

• recognize when the baby is sick or needs help.

These can be demonstrated by a health worker, another mother, or family practising KMC.

How long each day do we put our baby in the KMC position?

KMC is initiated right after birth and practised all day and night, every day. WHO recommends

the baby to spend at least 20 hours each day in direct STS contact. Breaks should not last more

than 30 minutes.

1.

ANNEX 5

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How long should I continue KMC?

KMC is continued until the baby does not want to be in the position any longer. This usually

happens when the baby has reached an adequate weight and is able to suck and breastfeed on

its own. Most babies will stay in KMC for a few weeks. Babies who are born small may stay in

KMC for up to 2 months.

Our little baby does not want to lie on my chest, and seems to be more comfortable on the bed. Should I stop KMC?

No. KMC should be continued. Babies usually get used to the KMC position quite quickly. If the

baby seems restless, check that she or he has been secured in the correct position, that she or he

is being fed adequately and frequently enough and that there are no signs of illness.

Should I continue doing KMC if my baby is cold or has a fever?

Babies who are cold or have fever should be kept in KMC and evaluated by a health professional.

They may be sick, but will benefit from being kept warm by STS contact.

What should I do if my baby is in the KMC position and occasionally stops breathing or turns blue?

This is called apnoea. The baby should be kept in the KMC position and a health professional

should be called immediately to examine the baby. The KMC position reduces apnoea and ir-

regular breathing.

If I have a cold and cough, can I do KMC?

People with a cough, cold or fever should not provide KMC to the baby, since they may transmit

the infection. A healthy family member should provide KMC instead. However, you should continue

expressing breast milk as this will help protect the baby from the mother’s infection.

My baby is on CPAP (continuous positive airway pressure). Can I do KMC?

KMC can be practised when the baby is on CPAP. KMC will continue to benefit the baby. You are

more restricted in where you can go, however, when the baby is on CPAP.

My baby has jaundice. Can she or he have phototherapy while receiving KMC?

Certain types of phototherapy can be done while the baby is in the KMC position.

Who should feed my baby when I do KMC? How often should I feed my baby?

You should feed the baby yourself with the baby in the KMC position. If the baby is able to suck

then you can feed them directly from the breast. This can be done either sitting up or lying down.

You should try to feed the baby every 2 hours on average, 8–12 times a day.

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My baby is very small and not able to breastfeed. How can I feed her or him?

If your baby is not able to suck, then she or he can be fed your own expressed breast milk. This

can be given to the baby in a cup or a spoon. In small babies who cannot swallow (usually babies

less than 28 weeks) breast milk can be given through a stomach tube.

When should I start breastfeeding my baby? She or he is still very small now and on a stomach tube.

Your baby will develop a suck and swallow reflex and be able to successfully breastfeed between

32–36 weeks. Each baby is different. Babies < 28 weeks usually require tube feeding because they

do not have a swallow reflex. From 28–32 weeks babies can shift to cup-and-spoon-feeding and

begin to practise breastfeeding. All babies > 32 weeks should attempt breastfeeding every day

with cup-and-spoon-feeding added if required. Once your baby starts showing feeding cues, she

or he should be exposed to your breasts to learn the smell, shape and texture of your nipple and

areola. The baby may initially suck for brief periods, but with repeated attempts will feed longer

until normal breastfeeding begins.

How do I know whether my baby is breastfeeding sufficiently?

Babies receiving sufficient breast milk are calm and are not distressed. Steady growth is the best

sign that the baby is getting adequate breast milk. It is normal for preterm babies to lose 10% of

their body weight in the first 7–10 days of life, even if they are receiving adequate breast milk. By

7–10 days after birth, they should have gone back to their birthweight. After 10 days, a weight gain

of at least 10 g/kg per day is expected if babies are receiving an adequate amount of breast milk.

Babies born by caesarean section may lose a higher percentage of their birthweight because they

do not pass through the birth canal and therefore have more retained fluid at birth.

When can my baby go home?

Your baby can go home when she or he is feeding well, gaining weight, has a stable temperature,

and when the mother and family have the confidence to practise KMC at home.

My baby does not gain weight, should I feed her or him some formula?

Formula should not be given. Poor weight gain can usually be solved by positioning better on

the breast, making sure the baby is attaching and feeding properly, expressing more breast milk

(by expressing day and night) and feeding with a cup or spoon, ensuring that feeds are given

often enough. If weight still doesn’t improve, the baby can be fed more nutrient-dense hindmilk.

Also, KMC should be practised as much as possible which helps keep baby warm and promotes

growth. Babies who suddenly stop gaining weight need to be assessed for a medical problem.

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What signs I should watch for at home?

Signs that the baby may be sick and needs to be seen by a health professional include:

• rapid breathing (> 60 breaths/minute),• chest being sucked in under the ribs (indrawing), irregular or loud breathing (gasping or grunting),• stopping breathing for 20 seconds or more (apnoea),• pale colour or blue on the lips and around the mouth,• baby feels cold or hot,• difficultly feeding or persistent vomiting, diarrhoea or a distended abdomen,• convulsions, or• yellow colour of skin (jaundice).

When should my baby have immunizations?

Immunizations should be given to your baby before discharge. They will be given according to

the current national vaccination schedule for babies. Vaccinations given will be entered into your

baby’s health card.

How can I prevent regurgitation, vomiting, aspiration and choking at home?

After feeding your baby, ensure that enough time is allowed to bring up air that she or he has

swallowed during the feed. Keep them calm and in the KMC position. After a feed keep your

baby in an upright position for at least 10–15 minutes to give time for the feed to be at least

partially absorbed.

What should I do if my baby develops a rash at the STS contact site?

Stop using any soaps, creams or perfumes on you or your baby’s skin. Keep your own skin as dry

as possible by periodically wiping it with a clean cloth. It is important to continue KMC.

My baby sometimes seems distressed. What should I do?

Your baby may feel distressed because of hunger, being cold, reflux after a feed or a medical

problem. Have the baby examined by a health worker to rule out medical problems. Often the

cause of distress is not clear, but many babies respond well to continued KMC, holding and mas-

sage that comforts babies and reinforces the bond between mother and baby. Mothers often

learn to understand the body language of their baby and how to comfort them when necessary.

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KMC fact sheet: DOs and DON’Ts of supporting families to practise KMC

Who can help the mother give KMC?

DO ALLOW DON’T ALLOW

Healthy fathers and grandparents of the baby Children

Anyone with a cough, cold or fever

Anyone with skin infections over their chest area (e.g. furuncles, abscesses, boils)

Anyone who is mentally impaired (e.g. mental illness, intoxication with alcohol or illicit or prescription drugs)

Anyone with a systemic infectious illness that can be transmitted by direct contact – for example hepatitis A and E

How can we make sure the baby does not pick up an infection at the hospital?


Teach all family members to practise good handwashing

Handling of the baby by anyone who has not washed his or her hands thoroughly immediately before handling the babyNotify staff if sinks do not have soap, towels and

adequate water; or if supplies of alcohol and hand gel need to be replaced

Notify staff if you see others not practising adequate hand hygiene

Handling of the baby by anyone with any of the conditions mentioned in the previous box

Keep the baby in continuous KMC

How can we support families to practise KMC properly?


Experienced families coaching new families on KMC through demonstrations with their own baby

Experienced families to demonstrate KMC using another family’s baby

Families doing KMC to discuss their successes, challenges and how they overcame the challenges with families beginning KMC

Lecturing or discouraging families from communicating

Health staff giving mothers and families positive reinforcement when they practise KMC well

Ignoring mothers’ and families’ need for encouragement

2.

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Key practices (1)

Place the baby between the mother’s breasts directly on the skin in an upright position. Turn the head to the side, in a slightly ex-tended position. Put the baby’s legs and arms in a flexed position.

Secure the baby in a kangaroo binder while holding the baby securely.

Pull the top of the binder to the baby’s ears. Put the baby’s legs into frog position and pull the binder down to cover both legs.

KMC counselling guide:Pictorial summary of key practices

3.

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Key practices (2)

Ensure that the baby is supported by the binder. Make sure the baby can breathe easily. Do not put too much pressure on the baby’s abdomen.

Cover with a shirt. Ensure that the mother can walk around comfortably

Conduct breastfeeding in the KMC position. Express breast milk while the baby is in the KMC position.

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Key practices (3)

Feed the baby the mother’s breast milk through a stomach tube until spoon-or cup-feeding becomes possible.

Feed the baby the mother’s breast milk with a spoon – or cup-feeding until the baby can breastfeed on its own.

Engage grandmothers and other grand-parents to provide KMC to assist the mother.

Engage fathers to provide KMC to assist the mother.

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Key practices (4)

Engage fathers to provide KMC to assist the mother.

Keep the baby in the KMC position during examinations by medical staff. Encourage caregivers to have eye contact with, talk to, touch, stroke or sing to the preterm infant to encourage brain growth and development.

Practise KMC for twins. Give KMC with CPAP and monitoring.

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Steps for expressing breast milk – Breast massage

Use fingers to stroke from the edge of the breast to the nipple.

Use fists to stroke from the edge of the breast to the nipple.

Use thumbs in a circular motion to massage from the edge of the breast to the nipple.

Use the thumb to spin around the areola.

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Express breast milk

Use the thumb and the index finger to roll the nipple.

Form the hand into a “C” on the area be-hind the areola, about 2–4 cm from the centre of the nipple.

Press back towards the chest wall and compress the breast rhythmically between the thumb and fingers until milk expresses. When the flow slows, move the fingers and thumb to a new position gradually moving around the areola. Repeat on the second side until the milk flow stops.