Title: Normal Labor and Childbirth
1Normal Labor and Childbirth
- Advances in Maternal and Neonatal Health
2Session 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
3Objectives 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
4Skilled 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 caregivers
competence - Performs all basic midwifery interventions
WHO 1999.
5Birth 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
6Birth 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
7Complication 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
8Partograph 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
9WHO 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
WHO 1994.
10WHO Partograph Results of Study
WHO 1994.
11Cochrane 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 49 cm
- Rate of dilation ?1 cm/hour
- Fetal descent begins
Lauzon and Hodnett 2000.
12Criteria to Diagnose Active Labor Results with
Statistical Significance
Lauzon and Hodnett 2000.
13Criteria 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
Lauzon and Hodnett 2000.
14Restricted 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
Carroli and Belizan 2000.
15Restricted 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
Carroli and Belizan 2000.
16Restricted 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.
17Indicated Use of Episiotomy Reviewers
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.
18Clean Delivery
- Infection accounts for 14.9 of all maternal
deaths - These deaths can be avoided with infection
prevention practices
19Infection 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 womans 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
20Best 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
WHO 1999.
21Best 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 0.580.79)
- Fewer operative vaginal deliveries OR 0.73 (95
CI 0.620.88) - Less postpartum depression at 6 weeks OR 0.12 (CI
0.040.33) - Offer oral fluids throughout labor and childbirth
Neilson 1998.
22Best 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
23Position 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
24Position 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.
25Support 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
WHO 1999.
26Presence of Female Relative During Labor Results
- Randomized controlled trial in Botswana 53 women
with relative 56 without
Madi et al 1999.
27Presence of Female Relative During Labor
Conclusion
- Support from female relative improves labor
outcomes
Madi et al 1999.
28Harmful 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
Nielson 1998 WHO 1999.
29Harmful 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
30Harmful 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
Eason et al 2000.
31Inappropriate 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.
32Inappropriate 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
33Practices 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
34Normal 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 womans choice for position during labor
and childbirth - Provide continuous emotional and physical support
to woman throughout labor
35References
- 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 464471. - 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 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) 199207. - Madi BC et al. 1999. Effects of female relative
support in labor A randomized control trial.
Birth 26410. - Neilson JP. 1998. Evidence-based intrapartum
care evidence from the Cochrane Library. Int J
Gynecol Obstet 63 (Suppl 1) S97S102. - World Health Organization Safe Maternal Health
and Safe Motherhood Programme. 1994. World Health
Organization partograph in management of labour.
Lancet 343 (8910)13991404. - World Health Organization (WHO). 1999. Care in
Normal Birth A Practical Guide. Report of a
Technical Working Group. WHO Geneva.