Jeffrey M. Smith Maternal Health Team Leader

1. Improved Labor Care to Reduce Neonatal Asphyxia Jeffrey M. Smith Maternal Health Team Leader Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February, 2011

2. Afghanistan 2002 • Maternal Mortality Survey showed an MMR of 1600 MD / 100 000 LB • 77% of newborns died if they were born to mothers who died • Newborn mortality and health are directly linked to maternal mortality and health Bartlett, et al. 2005

3. Parent Death & Child Survival in Bangladesh Cumulative probability of survival of child to age 10 years Father alive: 88.6% Father dead:89.3% Mother alive:88.9% Mother dead: 23.8% Ronsmans LANCET 2010

4. Improved maternal care will result in improved newborn outcomes • Use of evidence-based labor and delivery practices will achieve: • Reduced maternal and newborn morbidity and mortality • Improved quality of care • Respect for women and newborns

5. Obstetrics/Midwiferyis watchful waiting • Obstetrics – • From the Latin obstare: to stand by • To wait, to be vigilant, to be ready • Midwife • With women • Watchful waiting • For mother, for newborn • For complications • Interventions when proven and necessary

6. Intrapartum Care to Prevent Asphyxia: • Good maternal and newborn care: • Use partograph for vigilant labor monitoring • Allow companionship during labor and birth • Ensure supportive 2nd stage management based on fetal and maternal condition • Avoid incorrect practices • Manage pre-eclampsia correctly • Ensure skilled attendance at birth to prevent and manage asphyxia

7. Use of thePartograph • Partograph: • Drugs provided • Including oxytocin • Amniotic fluid condition • Fetal heart rate • Use of Partograph combines all needed documentation • Ob and Peds leaders should ensure its use

8. Intrapartum care to prevent asphyxia Use of the Partograph • How does the Partograph prevent asphyxia? • Identify abnormal heart rate patterns • Prevent prolonged labor • Prevents unnecessary augmentation using oxytocin • Prevents infection • Ensure timely Caesarean • Prevent hyperstimulation • Encourage greater vigilance

9. EMOTIONAL SUPPORT DURING LABOR

10. Intrapartum care to prevent asphyxia Pre-Eclampsia Management • Undiagnosed/inadequately managed severe pre-eclampsia results in • Maternal seizure • Severe hypertension • Emergency Caesarean • Proper management of severe PE / Eclampsia • Prevent seizures: Mg SO4 • Treat hypertension: anti-hypertensives • Ensure timely delivery • Increase obstetrical monitoring – not darkness and quiet at the end of the corridor Neonatal Asphyxia

11. Intrapartum care to prevent asphyxia Second stage labor management • Continue monitoring of fetal heart • Check every 5 minutes, record every 30 min. • If fetal heart rate is normal, no need to rush delivery • Do NOT urge the woman to immediately and continuously bear down • Allow some descent – makes pushing easier • Rest in between pushes allows oxygenated blood to reach placenta/fetus • Do NOT push on fundus

12. Intrapartum care to prevent asphyxia Alternative positions • Supine/lithotomy: uterus compresses vessels  reduced uterine blood flow • 1st stage labor: left side, standing, walking • 2nd stage labor: squatting, sitting, hands & knees

13. Intrapartum care to prevent asphyxia Labor Management • Adequate hydration and nutrition during labor essential • Dehydration compromises uterine blood flow • Allow women to drink freely and take small amounts of food during labor

14. Intrapartum care to prevent asphyxia Labor augmentation • Medical decision based on medical reasons • Use Partograph to diagnose protracted active phase • Provide oxytocin using protocols in MCPC • Do NOT allow uncontrolled oxytocin for augmentation • Causes tetanic uterine contractions • Complete restriction of blood flow to fetus

15. Other supportive practices • Clean birthing practices/infection prevention • Infected babies don’t breathe well • Doing procedures right! • Vacuum extraction and breech delivery • Twin delivery – management of 2nd twin • Keep normal births normal!

16. Let Babies Breathe! Prevent asphyxia • Monitor with partograph • Companionship, hydration, position • Prevent eclampsia • No uncontrolled oxytocin • Supportive 2nd stage based on fetal condition

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