SAFE MOTHERHOOD Physiologic labor Maryam Kashanian MD

SAFE MOTHERHOODPhysiologic labor

Maryam Kashanian MDProfessor of Iran University of Medical Sciences, Akbarabadi Teaching Hospital.

No woman should die giving life.

SAFE MOTHERHOOD

Current obstetric practices: Are we on

the right track?

The word obstetrics is derived from

the Latin “ob” and “stare” Which mean “to stand by”

Standing by, or in front of, the laboring woman :

is intended to be the assistance to the pregnant

woman during labor and delivery

HOSPITALIZED-MEDICALIZED

ROUTINE PROCEDURES Shave-Enema-NPO-IV

Line-Bed restriction-Oxytocin infusion- universal EFM- Lithotomy position - Episiotomy

HOME BIRTH – NO

SUPERVISION

HUMANIZE (NO GOOD –NO HARM)60-70% LOW RISK PREGNANCY a birth environment that is empowering, non stressful, affords privacy, communicates respect, and is not characterized by routine interventions that add risk without clear benefit.

Low risk A pregnant woman is considered low risk when

no risk factors have been identified during the antenatal or intra partum period

Normal labor WHO defines normal birth as: spontaneous

in onset, low-risk at the start of labor and remaining so throughout labor and delivery. The infant is born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy. After birth mother and infant are in good condition

Physiologic labor, Natural Birth (HUMANIZE :–NO HARM)

a birth environment that is empowering, non stressful,

affords privacy, communicates, respect, and is not characterized by routine interventions that add risk without clear benefit.

RESPECTFUL MATERNITY CARE

Assessment tool for the quality of hospital care

SAFE MOTHERHOOD

Labor and delivery interventions for the healthy women carrying a vertex singleton , term gestation that are routinely performed, should be supported by good quality data (Evidence-based guidance)

MEDLINE, PubMed, and COCHRANE … databases

Evidence-based good quality data FAVOR Hospital births, Delayed admission Support by doula, training birth assistants in

developing countries, Upright position in the second stage. BUT Home-births Enema, Shaving Early amniotomy “Hands-on” method, Fundal pressure, EpisiotomyCan be associated with complications without

sufficient benefits and should probably be avoided

Admission to the labor and delivery suite only after certain criteria (regular painful contractions and cervical dilatation 3 cm.)

Compared withDirect admission to hospitalIs Associated With: Less time in the labor ward, Less intra-partum oxytocics, Less analgesia Higher levels of control during labor 30-40%decrease in CD

Pregnant women should be informed of these data during prenatal care (recommendation: B; quality: fair )

Delayed admission

Fetal admission tests

Fetal heart rate tracing for 20 minutes on admissionCompared with Intermittent monitoring

Similar neonatal morbidity and mortalitywith increased incidences of epidural anesthesia, continuous fetal monitoring, and fetal blood sampling (recommendation: C; quality: good)

Assessment of amniotic fluid volume Compared with no such assessment

Increased risk of CD and similar neonatal outcomes

Neither a 2 X 1-cm pocket(abnormal in 8%) nor an (AFI) 5 cm (abnormal in 25%)

Identifies a pregnancy at risk for adverse outcome

such as: non-reassuring fetal heart rate (NRFHR) or CD for NRFHR

(recommendation: D; quality: good)

Fetal admission tests

Similar length of labor and most maternal and neonatal outcomes

There is a trend for lower infection rates These benefits are very modest, as the

incidence of each of these complications in the no enema groups is 3%

This intervention (enema) generates discomfort in women and increases the costs of delivery, so that the small benefits do not supplant these limitations (recommendation: D; quality: fair)

Enemas at admission for term laborCompared with women receiving no enemas

Perineal shaving on admission for labor compared with just selective clipping of hair

Similar maternal febrile morbidity, wound infection, and neonatal infection The potential for complications (redness, multiple superficial scratches, burning and itching of the vulva, embarrassment, and discomfort afterwards when the hair grows back) suggests that shaving should not be part of routine clinical practice

(recommendation: D; quality: fair)

 There is no consensus on acceptable maternal oral intake or need for intravenous fluids during an uncomplicated labor.

The only randomized trial on eating and drinking in early labor reported no adverse maternal or neonatal outcomes in women with unrestricted oral intake, but the trial was too small to detect clinically important differences

heparin lock at the time admission laboratory tests are drawn

Fluids and oral intake

  Walking during the first stage of labor is

often recommended and may reduce patients' discomfort,

It does not alter the duration of labor, the need for labor augmentation with oxytocin, the use of analgesia, or the rate of assisted vaginal delivery and cesarean delivery

On the basis of this evidence, women should

be allowed to choose freely regarding walking during labor

(recommendation: C; quality: good)

Ambulation (walking) during labor

There is clear and important evidence that walking and upright positions in the first stage of labor reduces:

the duration of labor, the risk of caesarean birth, the need for epidural, and does not seem to be associated

with increased intervention or negative effects on

Mothers’ and babies’ well being.

The Cochrane Collaboration (The Cochrane Library 2013, Issue 10)

A support person (Doula) during labor is associated with: Decreased use of analgesia, Decreased incidence of operative birth, Increased incidence of spontaneous

vaginal delivery, Increased maternal satisfaction The most effective form of support starts

early in labor, and is continuous (recommendation: A; quality: good)

Continuous cardio-tocography during labor

is associated with a reduction in neonatal seizures,

But no significant differences in cerebral palsy, infant mortality or other standard measures of neonatal well-being

However, continuous cardio-tocography was associated with an increase in caesarean sections and instrumental vaginal births..

INTRAPARTUM FHR MONITORING continuous electronic FHR monitoring VS intermittent auscultation

The intra-partum fetal death rate is approximately 0.5 per 1000 births with either approach

APGAR scores and neonatal intensive care unit admission rates are similar for both modalities

Neither approach reduces the risk of long-term neurologic impairment or cerebral palsy

continuous electronic FHR monitoring VS intermittent auscultation

  The United States Preventive Services Task Force and The Canadian Task Force on Preventive Health Care : Routine electronic FHR monitoring for low-risk women

in labor is not recommended There is insufficient evidence to recommend for or against

intra-partum electronic FHR monitoring for high-risk pregnant women

The American College of Obstetricians and Gynecologists :

Either intermittent auscultation or electronic FHR monitoring is appropriate for uncomplicated pregnancies

High risk pregnancies should be monitored continuously during labor

Statements of some major organizations

4-minutes shorter interval to delivery, Less pain, Lower incidences of NRFHR monitoring

and of operative vaginal delivery, as well as higher rates blood loss of 500

mL compared with other positions

The upright positions studied include : sitting(obstetric chair/stool);

semirecumbent (trunk tilted backwards 30° to the vertical);kneeling; squatting (unaided or using squatting bars); and squatting

The upright position in the second stage

The benefits of the upright position may be related to:

Gravity, Less aorto-vagal compression, Improved fetal alignment, and Larger

anterior-posterior and transverse pelvic outlets

The higher blood loss may be secondary to easier collection of blood in the upright position

The upright position in the second stage

Effect of Birthing Position on Pelvic Bony Dimensions

MR pelvimetry in vertical open configuration magnet system

 Randomized prospective studies have questioned this practice and suggested delaying pushing until the presenting fetal part descends.

delayed pushing was an effective means of reducing difficult deliveries in nulliparous women

Delayed pushing predictably increased the duration of the second stage (by 54 minutes),

resulted in lower umbilical cord blood pH, But no difference was detected in overall

neonatal morbidity

Pushing 

The decision to delay pushing should reflect the balance between the need to expedite delivery versus the desire to minimize the need for operative vaginal delivery

If the FHR tracing is reassuring and the head is high, delay pushing until the woman feels an urge to push.

Pushing 

The “hands-on” method described by Ritgen in 1855 (pressure on the infant’s head on crowning, and support with the other hand of the perineum, with the aim of protecting for lacerations) The “hands poised” method(the fetal head and perineum are not touched or supported by the delivering personnel)These 2 methods are associated with similar incidences of perineal and vaginal tearsBut the hand-on method is associated with higher incidence of third-degree tears and episiotomies

(recommendation: D; quality: good)

In 1742, Sir Fielding Ould, a male-midwife, was the first to describe the procedure

In 1799, Michaelis was the first physician to report utilizing a midline episiotomy

In 1820 , Ritgen proposed numerous superficial incisions In 1847 , Dubois, a French physician, suggested the

medio-lateral method In 1920 , DeLee, an influential obstetrician in Chicago,

recommended universal elective medio-lateral episiotomy

In 1970, the standard of care in the United States shifted to the midline episiotomy

By 1980s, both parturient and physicians began questioning

whether or not the purported "benefits" of episiotomy were true

Episiotomy

Maternal benefits were thought to include a reduced risk of:

Perineal trauma, Subsequent pelvic floor dysfunction and

prolapse, Urinary incontinence, Fecal incontinence, and Sexual dysfunction

Fetal benefits were thought to include a shortened second stage of labor resulting from more rapid spontaneous delivery or from instrumented vaginal delivery

Despite limited data, this procedure became virtually routine

resulting in an underestimation of the potential adverse consequences of episiotomy, including extension to a third- or fourth-degree tear, anal sphincter dysfunction, and dyspareunia

MEDIAN EPISIOTOMIES

Higher risk of extension into the

rectum

Compromise of the external anal

sphincter muscle

MEDIOLATERAL EPISIOTOMIES

More postpartum pain

More blood loss

More dyspareunia

Greater difficulty in repair

Benefits of Restrictive episiotomy policies compared to

Routine episiotomy policies:Less posterior perineal trauma,Less suturing and fewer complications, No difference for most pain measures

and severe vaginal or perineal trauma

But there was an increased risk of anterior perineal trauma with restrictive episiotomy

Indications for episiotomy include :

nonreassuring fetal status,

shoulder dystocia, “short” perineal body and possibly operative vaginal delivery

THE UNIVERSAL RIGHTS OF CHILDBEARING WOMEN:

RESPECTFUL MATERNITY CARE:

Seven categories of common disrespect and abuse in facility-based childbirth, include:

Physical abuse Non-dignified care Non-consented care Non-confidential care Discrimination Abandonment of care Detention in facilities

Respectful Care During Childbirth

Tackling Disrespect and Abuse: Seven Rights of childbearing Women

Categories of Disrespect and Abuse

• Physical Abuse• Non-Dignified Care• Non-Consented

Care• Non-Confidential

Care• Discrimination• Abandonment or

Withholding of Care

• Detention in Facilities

-Bower and Hill (2010)

Source: USAID TrAction Project

category of Disrespect and Abuse i

Corresponding Right

1.Physical abuse Freedom from harm and ill

treatment

2. Non-consented care Right to information, informed consent and refusal, and respect for choices and preferences, including companionship during maternity care

3. Non-confidential care Confidentiality, privacy

4. Non-dignified care (including verbal abuse)

Dignity, respect

5. Discrimination based on specific attributes

Equality, freedom from discrimination, equitable care

6. Abandonment or denial of care

Right to timely healthcare and to the highest attainable level of health

7. Detention in facilities Liberty, autonomy, self-determination, and freedom from coercion

Help ensure that Every woman’s right to respectful maternity care is upheld.

MAKING PREGNANCY SAFER

Assessment tool for the quality of hospital care

for mothers and newborn babies

FIND OUT! SPEAK OUT!THANK YOU!!