SAFE MOTHERHOOD Physiologic labor Maryam Kashanian MD

1. SAFE MOTHERHOOD Physiologic labor MaryamKashanian MD Professor of Iran University of Medical Sciences, Akbarabadi Teaching Hospital.

2. SAFE MOTHERHOOD • No woman should die giving life.

4. Current obstetric practices: Are we on the right track?

6. 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

7. HOME BIRTH – NO SUPERVISION • HOSPITALIZED-MEDICALIZED • ROUTINE PROCEDURES • Shave-Enema-NPO-IV Line-Bed restriction-Oxytocin infusion- universal EFM- Lithotomy position - Episiotomy 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.

8. 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

9. SAFE MOTHERHOOD • 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

10. 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

14. 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, • Episiotomy Can be associated with complications without sufficient benefits and should probably be avoided

15. Delayed admission Admission to the labor and delivery suite only after certain criteria (regular painful contractions and cervical dilatation 3 cm.) Compared with Direct admission to hospital Is 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 )

16. Fetal admission tests • Fetal heart rate tracing for 20 minutes on admission • Compared • with Intermittent monitoring • Similar neonatal morbidity and mortality • with increased incidences of epidural anesthesia, continuous fetal monitoring, • and fetal blood sampling • (recommendation: C; quality: good)

17. Fetal admission tests • 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)

18. Enemas at admission for term laborCompared with women receiving no enemas • Similarlength of labor andmost 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)

19. 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)

20. Fluids and oral intake • 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

21. Ambulation (walking) during labor 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)

22. The Cochrane Collaboration (The Cochrane Library 2013, Issue 10) • 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.

28. Asupport 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)

30. INTRAPARTUM FHR MONITORINGcontinuous electronic FHR monitoring VS intermittent auscultation • Continuous cardio-tocographyduring 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-tocographywas associated with an increase in caesarean sections and instrumental vaginal births..

31. 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

32. Statements of some major organizations • 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

33. The upright position in the second stage • 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

34. 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

35. Effect of Birthing Position on Pelvic Bony Dimensions MR pelvimetry in vertical open configuration magnet system

41. Pushing • 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

42. 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.

43. 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 tears But the hand-on method is associated with higher incidence of third-degree tears and episiotomies (recommendation: D; quality: good)

44. Episiotomy • 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

45. 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

48. 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

49. Indications for episiotomy include : • nonreassuring fetal status, • shoulder dystocia, • “short” perineal body • and possibly operative vaginal delivery

50. RESPECTFUL MATERNITY CARE: • THE UNIVERSAL RIGHTS OF CHILDBEARING WOMEN: