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Normal Labor and Childbirth
Advances in Maternal and Neonatal Health
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Session Objectives
To identify best practices for managing labor and childbirth:
Skilled attendant
Birth preparedness/complication readinessPartograph
Restricted episiotomy
To identify harmful practices with the goal of eliminating themfrom practice
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Objectives of Care During
Labor and ChildbirthProtect the life of the mother and newborn
Support the normal labor and detect and treat complications in
timely fashionSupport and respond to needs of the woman, her partner andfamily during labor and childbirth
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Skilled Attendant
Is a professional caregiver
Has the knowledge and skills to:
Manage labor, childbirth and postpartum periodRecognize complications
Diagnose, manage or refer woman or newborn to higher level of care if complications occur that requireinterventions beyond caregivers competence
Performs all basic midwifery interventions
WHO 1999.
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Birth Preparedness and Complication
Readiness for the Woman and FamilyRecognize danger signs
Plan for managing complications
Save money or access funds
Arrange transportation
Plan route
Plan place for delivery
Choose provider
Follow instructions for self-care
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Birth Preparedness and Complication
Readiness for the Provider Diagnose and manage problems and complicationsappropriately and in a timely manner
Arrange referral to higher level of care if neededProvide women-centered counseling about birth preparednessand complication readiness
Educate community about birth preparedness andcomplication readiness
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Complication Readiness
for the Provider Recognize and respond to danger signs
Establish plan and determine who is in authority to make
decisions in case of emergencyDevelop plan for immediate access to funds (savings or community loan)
Identify and plan for blood donors and donation
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Partograph and Criteria for Active Labor
Label with patientidentifying information
Note fetal heart rate, color of amniotic fluid, presenceof moulding, contraction
pattern, medications givenPlot cervical dilation
Alert line starts at 4 cm--from here, expect to dilateat rate of 1 cm/hour
Action line: If patient doesnot progress as above,action is required
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WHO Partograph Trial
Objectives:
To evaluate impact of WHO partograph on labor management and outcome
To devise and test protocol for labor management withpartograph
Design: Multicenter trial randomizing hospitals in Indonesia,Malaysia and Thailand
No intervention in latent phase until after 8 hoursAt active phase action line consider: Oxytocin augmentation,cesarean section, or observation AND supportive treatment
WHO 1994.
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WHO Partograph: Results of Study
All Women BeforeImplementation
After Implementation
p
Total deliveries 18254 17230
Labor > 18 hours 6.4% 3.4% 0.002
Labor augmented 20.7% 9.1% 0.023
Postpartum sepsis 0.70% 0.21% 0.028
Normal Women
Mode of deliverySpontaneous
cephalicForceps
8428 (83.9%)
341 (3.4%)
7869 (86.3%)
227 (2.5%)
< 0.001
0.005
WHO 1994.
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Cochrane Review of Specific Criteria to
Diagnose Active Labor: Objective and Design
Objective: Assess effectiveness of use by caregivers of specific criteria for diagnosis of active labor in term pregnancy
Design: Meta analysis of randomized control trials; only onestudy found
Criteria:
Cervix dilated 49 cm
Rate of dilation 1 cm/hour
Fetal descent begins
Lauzon and Hodnett 2000.
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Criteria to Diagnose Active Labor:
Results with Statistical SignificanceExperimentalGroup (105)
ControlGroup (104)
Odds Ratio(95% CI)
Cesarean sectionfor labor dystocia
2 8 0.28 (0.081.00)
Intrapartumoxytocics
24 42 0.45 (0.250.80)
Any intrapartumanalgesia
84 96 0.36 (0.160.78)
Epidural analgesia 83 94 0.42 (0.200.89)
Lauzon and Hodnett 2000.
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Criteria to Diagnose Active Labor:
DiscussionUse of strict criteria for diagnosis of active labor:
May prevent misdiagnosis of dystocia in latent phase labor
Prevent unnecessary (and potentially risky) interventionsincluding cesarean section
Insufficient power to test effects of intervention on rates of cesarean section, unplanned out-of-hospital birth or other important maternal and newborn outcomes
Lauzon and Hodnett 2000.
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Restricted Use of Episiotomy:
Maternal Outcomes AssessedSevere vaginal/perineal trauma
Need for suturing
Posterior/anterior perineal traumaPerineal pain
Dyspareunia
Urinary incontinence
Healing complications
Perineal infection
Carroli and Belizan 2000.
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Restricted Use of Episiotomy:
Results of Cochrane ReviewClinically Relevant Morbidities Relative Risk 95% CI
Posterior perineal trauma 0.88 0.84 0.92
Need for suturing 0.74 0.71 0.77
Healing complications at 7 days 0.69 0.56 0.85
Anterior perineal trauma 1.79 1.55 2.07
No increase in incidence of major outcomes (e.g., severe vaginal or perineal trauma nor in pain, dyspareunia or urinary incontinence)
Incidence of 3rd
degree tear reduced (1.2% with episiotomy, 0.4%without)No controlled trials on controlled delivery or guarding the perineumto prevent trauma
Carroli and Belizan 2000.Eason et al 2000; WHO 1999.
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Indicated Use of Episiotomy:
Reviewers ConclusionsImplications for practice: Clear evidence to restrict use of episiotomy in normal labor
Implications for research: Further trials needed to assess useof episiotomy at:
Assisted delivery (forceps or vacuum)
Preterm delivery
Breech delivery
Predicted macrosomiaPresumed imminent tears (threatened 3 rd degree tear or history of 3 rd degree tear with previous delivery)
Carroli and Belizan 2000.WHO 1999.
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Clean Delivery
Infection accounts for 14.9% of all maternal deaths
These deaths can be avoided with infection preventionpractices
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Infection Prevention Practices
Use disposable materials once and decontaminate reusablematerials throughout labor and childbirth
Wear gloves during vaginal examination, during birth of newbornand when handling placenta
Wear protective clothing (shoes, apron, glasses)
Wash hands
Wash womans perineum with soap and water and keep it clean
Ensure that surface on which newborn is delivered is kept cleanHigh-level disinfect instruments, gauze and ties for cutting cord
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Best Practices: Third Stage of Labor
Active management of third stage for ALL women:
Oxytocin administration
Controlled cord tractionUterine massage after delivery of the placenta to keep theuterus contracted
Routine examination of the placenta and membranes
22% of maternal deaths caused by retained placenta
Routine examination of vagina and perineum for lacerationsand injury
WHO 1999.
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Best Practices: Postpartum
Close monitoring and surveillance during first 6 hourspostpartum
Parameters: Blood pressure, pulse, vaginal bleeding, uterine
hardnessTiming:
Every 15 minutes for 2 hours Every 30 minutes for 1 hour Every hour for 3 hours
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Position in Labor and Childbirth
Allow freedom in position and movement throughout labor andchildbirth
Encourage any non-supine position:
Side lying
Squatting
Hands and knees
Semi-sitting
Sitting
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Position in Labor and Childbirth
(continued)Use of upright or lateral position compared with supine or lithotomy position is associated with:
Shorter second stage of labor (5.4 minutes, 95% CI 3.96.9)
Fewer assisted deliveries (OR 0.82, CI 0.690.98)
Fewer episiotomies (OR 0.73, CI 0.640.84)
Fewer reports of severe pain (OR 0.59, CI 0.410.83)
Less abnormal heart rate patterns for fetus (OR 0.31, CI
0.110.91)More perineal tears (OR 1.30, CI 1.091.54)
Blood loss > 500 mL (OR 1.76, CI 1.343.32)
Gupta and Nikodem 2000.
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Support of Woman
Give woman as much information and explanation as shedesires
Provide care in labor and childbirth at a level where womanfeels safe and confident
Provide empathic support during labor and childbirth
Facilitate good communication between caregivers, thewoman and her companions
Continuous empathetic and physical support is associatedwith shorter labor, less medication and epidural analgesia andfewer operative deliveries
WHO 1999.
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Presence of Female Relative
During Labor: ResultsRandomized controlled trial in Botswana: 53 women with relative;56 without
Labor Outcome Experimental
Group (%)
Control
Group (%)
p
Spontaneous vaginaldelivery
91 71 0.03
Vacuum delivery 4 16 0.03
Cesarean section 6 13 0.03
Analgesia 53 73 0.03
Amniotomy 30 54 0.01
Oxytocin 13 30 0.03
Madi et al 1999.
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Presence of Female Relative
During Labor: ConclusionSupport from female relative improves labor outcomes
Madi et al 1999.
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Harmful Routines
Use of enema: uncomfortable, may damage bowel, does notchange duration of labor, incidence of neonatal infection or perinatal wound infection
Pubic shaving: discomfort with regrowth of hair, does notreduce infection, may increase transmission of HIV andhepatitis
Lavage of the uterus after delivery: can cause infection,mechanical trauma or shock
Manual exploration of the uterus after delivery
Nielson 1998; WHO 1999.
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Harmful Practices
Examinations:
Rectal examination: Similar incidence of puerperalinfection, uncomfortable for woman
Routine use of x-ray pelvimetry: Increases incidence of childhood leukemia
Position:
Routine use of supine position during labor
Routine use of lithotomy position with or without stirrupsduring labor
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Harmful Interventions
Administration of oxytocin at any time before delivery in sucha way that the effect cannot be controlled
Sustained, directed bearing down efforts during the secondstage of labor
Massaging and stretching the perineum during the secondstage of labor (no evidence)
Fundal pressure during labor
Eason et al 2000.
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Inappropriate Practices
Rigid adherence to a stipulated duration of the second stage of labor (e.g., 1 hour) if maternal and fetal conditions are goodand there is progress of labor
Liberal or routine use of episiotomy
Liberal or routine use of amniotomy
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Practices Used for Specific
Clinical IndicationsBladder catheterization
Operative delivery
Oxytocin augmentationPain control with systemic agents
Pain control with epidural analgesia
Continuous electronic fetal monitoring
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Normal Labor and Childbirth:
ConclusionHave a skilled attendant present
Use partograph
Use specific criteria to diagnose active labor Restrict use of unnecessary interventions
Use active management of third stage of labor
Support womans choice for position during labor and
childbirthProvide continuous emotional and physical support to womanthroughout labor
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ReferencesCarroli G and J Belizan. 2000. Episiotomy for vaginal birth (Cochrane Review), in TheCochrane Library. Issue 2. Update Software: Oxford.Eason E et al. 2000. Preventing perineal trauma during childbirth: A systematicreview. Obstet Gynecol 95: 464 4 71.Gupta JK and VC Nikodem. 2000. Womans position during second stage of labour (Cochrane Review), in The Cochrane Library . Issue 4. Update Software: Oxford.Lauzon L and E Hodnett. 2000. Caregivers' use of strict criteria for diagnosing activelabour in term pregnancy (Cochrane Review), in The Cochrane Library. UpdateSoftware: Oxford.Ludka LM and CC Roberts. 1993. Eating and drinking in labor: A literature review. J Nurse-Midwifery 38(4): 199 207.Madi BC et al. 1999. Effects of female relative support in labor: A randomized controltrial. Birth 26:4 10.Neilson JP. 1998. Evidence-based intrapartum care: evidence from the CochraneLibrary. Int J Gynecol Obstet 63 (Suppl 1): S97 S 102.World Health Organization Safe Maternal Health and Safe Motherhood Programme.1994. World Health Organization partograph in management of labour. Lancet 343(8910):1399 1404.World Health Organization (WHO). 1999. Care in Normal Birth: A Practical Guide.Report of a Technical Working Group . WHO: Geneva.