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Normal Labor and Childbirth Advances in Maternal and Neonatal Health
Session Objectives • To identify best practices for managing labor and childbirth: • Skilled attendant • Birth preparedness/complication readiness • Partograph • Restricted episiotomy • To identify harmful practices with the goal of eliminating them from practice Normal Labor and Childbirth
Objectives of Care During Labor and Childbirth • Protect the life of the mother and newborn • Support the normal labor and detect and treat complications in timely fashion • Support and respond to needs of the woman, her partner and family during labor and childbirth Normal Labor and Childbirth
Skilled Attendant • Is a professional caregiver • Has the knowledge and skills to: • Manage labor, childbirth and postpartum period • Recognize complications • Diagnose, manage or refer woman or newborn to higher level of care if complications occur that require interventions beyond caregiver’s competence • Performs all basic midwifery interventions Normal Labor and Childbirth WHO 1999.
Birth Preparedness and Complication Readiness for the Woman and Family • Recognize 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 Normal Labor and Childbirth
Birth Preparedness and Complication Readiness for the Provider • Diagnose and manage problems and complications appropriately and in a timely manner • Arrange referral to higher level of care if needed • Provide women-centered counseling about birth preparedness and complication readiness • Educate community about birth preparedness and complication readiness Normal Labor and Childbirth
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 emergency • Develop plan for immediate access to funds (savings or community loan) • Identify and plan for blood donors and donation Normal Labor and Childbirth
Partograph and Criteria for Active Labor • Label with patient identifying information • Note fetal heart rate, color of amniotic fluid, presence of moulding, contraction pattern, medications given • Plot cervical dilation • Alert line starts at 4 cm--from here, expect to dilate at rate of 1 cm/hour • Action line: If patient does not progress as above, action is required Normal Labor and Childbirth
WHO Partograph Trial • Objectives: • To evaluate impact of WHO partograph on labor management and outcome • To devise and test protocol for labor management with partograph • Design: Multicenter trial randomizing hospitals in Indonesia, Malaysia and Thailand • No intervention in latent phase until after 8 hours • At active phase action line consider: Oxytocin augmentation, cesarean section, or observation AND supportive treatment Normal Labor and Childbirth WHO 1994.
WHO Partograph: Results of Study Normal Labor and Childbirth WHO 1994.
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 one study found • Criteria: • Cervix dilated 4–9 cm • Rate of dilation 1 cm/hour • Fetal descent begins Normal Labor and Childbirth Lauzon and Hodnett 2000.
Criteria to Diagnose Active Labor: Results with Statistical Significance Normal Labor and Childbirth Lauzon and Hodnett 2000.
Criteria to Diagnose Active Labor: Discussion • Use of strict criteria for diagnosis of active labor: • May prevent misdiagnosis of dystocia in latent phase labor • Prevent unnecessary (and potentially risky) interventions including 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 Normal Labor and Childbirth Lauzon and Hodnett 2000.
Restricted Use of Episiotomy: Objectives and Design • Objective: To evaluate possible benefits, risks and costs of restricted use of episiotomy vs. routine episiotomy • Design: Meta analysis of six randomized control trials Normal Labor and Childbirth Carroli and Belizan 2000.
Restricted Use of Episiotomy: Maternal Outcomes Assessed • Severe vaginal/perineal trauma • Need for suturing • Posterior/anterior perineal trauma • Perineal pain • Dyspareunia • Urinary incontinence • Healing complications • Perineal infection Normal Labor and Childbirth Carroli and Belizan 2000.
Restricted Use of Episiotomy: Results of Cochrane Review • 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 perineum to prevent trauma Carroli and Belizan 2000.Eason et al 2000; WHO 1999. Normal Labor and Childbirth
Indicated Use of Episiotomy: Reviewer’s Conclusions • Implications for practice: Clear evidence to restrict use of episiotomy in normal labor • Implications for research: Further trials needed to assess use of episiotomy at: • Assisted delivery (forceps or vacuum) • Preterm delivery • Breech delivery • Predicted macrosomia • Presumed imminent tears (threatened 3rd degree tear or history of 3rd degree tear with previous delivery) Carroli and Belizan 2000.WHO 1999. Normal Labor and Childbirth
Clean Delivery • Infection accounts for 14.9% of all maternal deaths • These deaths can be avoided with infection prevention practices Normal Labor and Childbirth
Infection Prevention Practices • Use disposable materials once and decontaminate reusable materials throughout labor and childbirth • Wear gloves during vaginal examination, during birth of newborn and when handling placenta • Wear protective clothing (shoes, apron, glasses) • Wash hands • Wash woman’s perineum with soap and water and keep it clean • Ensure that surface on which newborn is delivered is kept clean • High-level disinfect instruments, gauze and ties for cutting cord Normal Labor and Childbirth
Best Practices: Third Stage of Labor • Active management of third stage for ALL women: • Oxytocin administration • Controlled cord traction • Uterine massage after delivery of the placenta to keep the uterus contracted • Routine examination of the placenta and membranes • 22% of maternal deaths caused by retained placenta • Routine examination of vagina and perineum for lacerations and injury Normal Labor and Childbirth WHO 1999.
Best Practices: Labor and Childbirth • Use non-invasive, non-pharmacological methods of pain relief during labor (massage, relaxation techniques, etc.): • Less use of analgesia OR 0.68 (CI 0.58–0.79) • Fewer operative vaginal deliveries OR 0.73 (95% CI 0.62–0.88) • Less postpartum depression at 6 weeks OR 0.12 (CI 0.04–0.33) • Offer oral fluids throughout labor and childbirth Normal Labor and Childbirth Neilson 1998.
Best Practices: Postpartum • Close monitoring and surveillance during first 6 hours postpartum • Parameters: • Blood pressure, pulse, vaginal bleeding, uterine hardness • Timing: • Every 15 minutes for 2 hours • Every 30 minutes for 1 hour • Every hour for 3 hours Normal Labor and Childbirth
Position in Labor and Childbirth • Allow freedom in position and movement throughout labor and childbirth • Encourage any non-supine position: • Side lying • Squatting • Hands and knees • Semi-sitting • Sitting Normal Labor and Childbirth
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 3.9–6.9) • Fewer assisted deliveries (OR 0.82, CI 0.69–0.98) • Fewer episiotomies (OR 0.73, CI 0.64–0.84) • Fewer reports of severe pain (OR 0.59, CI 0.41–0.83) • Less abnormal heart rate patterns for fetus (OR 0.31, CI 0.11–0.91) • More perineal tears (OR 1.30, CI 1.09–1.54) • Blood loss > 500 mL (OR 1.76, CI 1.34–3.32) Normal Labor and Childbirth Gupta and Nikodem 2000.
Support of Woman • Give woman as much information and explanation as she desires • Provide care in labor and childbirth at a level where woman feels safe and confident • Provide empathic support during labor and childbirth • Facilitate good communication between caregivers, the woman and her companions • Continuous empathetic and physical support is associated with shorter labor, less medication and epidural analgesia and fewer operative deliveries Normal Labor and Childbirth WHO 1999.
Randomized controlled trial in Botswana: 53 women with relative; 56 without Presence of Female Relative During Labor: Results Normal Labor and Childbirth Madi et al 1999.
Presence of Female Relative During Labor: Conclusion Support from female relative improves labor outcomes Normal Labor and Childbirth Madi et al 1999.
Harmful Routines • Use of enema: uncomfortable, may damage bowel, does not change duration of labor, incidence of neonatal infection or perinatal wound infection • Pubic shaving: discomfort with regrowth of hair, does not reduce infection, may increase transmission of HIV and hepatitis • Lavage of the uterus after delivery: can cause infection, mechanical trauma or shock • Manual exploration of the uterus after delivery Normal Labor and Childbirth Nielson 1998; WHO 1999.
Harmful Practices • Examinations: • Rectal examination: Similar incidence of puerperal infection, 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 stirrups during labor Normal Labor and Childbirth
Harmful Interventions • Administration of oxytocin at any time before delivery in such a way that the effect cannot be controlled • Sustained, directed bearing down efforts during the second stage of labor • Massaging and stretching the perineum during the second stage of labor (no evidence) • Fundal pressure during labor Normal Labor and Childbirth Eason et al 2000.
Inappropriate Practices • Restriction of food and fluids during labor • Routine intravenous infusion in labor • Repeated or frequent vaginal examinations, especially by more than one caregiver • Routinely moving laboring woman to a different room at onset of second stage • Encouraging woman to push when full dilation or nearly full dilation of cervix has been diagnosed, before woman feels urge to bear down Nielson 1998; Ludka and Roberts 1993. Normal Labor and Childbirth
Inappropriate Practices • Rigid adherence to a stipulated duration of the second stage of labor (e.g., 1 hour) if maternal and fetal conditions are good and there is progress of labor • Liberal or routine use of episiotomy • Liberal or routine use of amniotomy Normal Labor and Childbirth
Practices Used for Specific Clinical Indications • Bladder catheterization • Operative delivery • Oxytocin augmentation • Pain control with systemic agents • Pain control with epidural analgesia • Continuous electronic fetal monitoring Normal Labor and Childbirth
Normal Labor and Childbirth: Conclusion • Have 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 woman’s choice for position during labor and childbirth • Provide continuous emotional and physical support to woman throughout labor Normal Labor and Childbirth
References Carroli G and J Belizan. 2000. Episiotomy for vaginal birth (Cochrane Review), in The Cochrane Library. Issue 2. Update Software: Oxford. Eason E et al. 2000. Preventing perineal trauma during childbirth: A systematic review. Obstet Gynecol 95: 464–471. Gupta JK and VC Nikodem. 2000. Woman’s 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 active labour in term pregnancy (Cochrane Review), in The Cochrane Library. Update Software: 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 control trial. Birth 26:4–10. Neilson JP. 1998. Evidence-based intrapartum care: evidence from the Cochrane Library. Int J Gynecol Obstet 63 (Suppl 1): S97–S102. 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. Normal Labor and Childbirth