HO 4 Essential Intrapartum Care 6May2013

Essential Intrapartum Care 5/6/2013

Prepared by Team EINC for APDCN Faculty

May 6, 2013 1

ESSENTIAL

INTRAPARTUM CARE From Evidence to Practice

Cynthia Tan, MD, FPOGS Medical Specialist IV

Chief, Human Resource Development Services, Fabella Hospital Co-convenor, Team EINC

5/6/2013 Prepared by Team EINC for APDCN Faculty

Objectives Discuss the problem of maternal mortality

rates and its impact on the attainment of MDG 5

Discuss interventions that are recommended and are not recommended during: o Antepartum

o Labor

o Delivery

o Immediate post-partum


Too many mothers and newborns

are dying every year

5/6/2013 Prepared by Team EINC for APDCN Faculty 5/6/2013 Prepared by Team EINC for APDCN Faculty

ANTEPARTUM CARE


ANTENATAL CARE At lease 4 antenatal visits with a skilled

health provider

To detect diseases which may complicate

pregnancy

To educate women on danger and emergency

signs & symptoms

To prepare the woman and her family for

childbirth




May 6, 2013 2

To detect diseases which may

complicate pregnancy

Screen

Anemia

Pre-eclampsia

Diabetes Mellitus

Syphilis

Detect PROM

Preterm labor

Prevent

Ferrous and folic acid supplementation

Tetanus toxoid immunization

Corticosteroids for preterm labor

Treat Ferrous sulfate for anemia

Antihypertensive meds and Magnesium sulfate for SEVERE pre-eclampsia

REFER


Antenatal Corticosteroids Administer ANTENATAL STEROIDS to all

patients who are at risk for preterm

delivery

with preterm labor between 24-34 weeks AOG

or with any of the following prior to term:

Antepartal hemorrhage/bleeding

Hypertension

(preterm) Pre-labor rupture of membranes


Antenatal Steroids

Overall reduction in neonatal death

Reduction in RDS

Reduction in cerebroventricular hemorrhage

Reduction in sepsis in the first 48 hours of life

Roberts D, Dalziel SR. Cochrane Database of Systematic Reviews 2006, Issue 3.

Betamethasone 12 mg IM q 24 hrs x 2 doses OR

DEXAMETHASONE 6 mg IM q 12 x 4 doses


DEXAMETHASONE PHOSPHATE

2ml ampules: 4mg/ml

6 mg 1.5 ml injected intramuscularly

Even a single dose of 6 mg IM before delivery is beneficial

emergency drug

should be available

at the OPD and ER


GSCH Dexa Area & Tray in the ER, DR, Ward


DANGER SIGNS and SYMPTOMS

Vaginal bleeding

Headache

Blurring of vision

Abdominal Pain

Severe difficulty breathing

Dangerous fever (T>38, weak)

Burning on urination

Educate women on




May 6, 2013 3

Prepare the woman and her

family for childbirth Counsel on

Proper nutrition and self care during pregnancy

Breastfeeding and family planning

BIRTH PLAN Where she will deliver; transportation

Who will assist her delivery

What to expect during labor and delivery

What to prepare, estimated cost of delivery

Possible blood donors; where will she be referred in case of emergency


SAMPLE BIRTH AND

EMERGENCY PLAN


Birth and

Emergency

Planning in the

OPD 5/6/2013 Prepared by Team EINC for APDCN Faculty

INTRAPARTUM CARE


Updated, evidence based national guideline on intrapartum and immediate postpartum care To be used by health professionals (OB SPECIALISTS, OB PRACTITIONERS, NURSES and MIDWIVES) in all GOVERNMENT AND PRIVATE health facilities

Intrapartum Care

Clinical Practice Guidelines


Evidence based approach

Based on the results of studies with acceptable quality

Formal consensus approach

Discuss issues on generalizing the evidence to the local scenario, taking into account

Harms and benefits

Costs

Preferences

Best available evidence

RECOMMENDATIONS

THE CPG DEVELOPMENT PROCESS




May 6, 2013 4

RECOMMENDED PRACTICES

DURING LABOR


Recommended Practices During Labor

Active phase labor:

2-3 contractions in 10 minutes

Cervix is 4 cm dilated

1. Admission to

labor when the

parturient is

already in the

active phase.


Recommended Practices During Labor:

Admit when the parturient is already

in ACTIVE LABOR

No difference in Apgar score

need for Cesarean Section by 82%

No difference in need for labor augmentation

Rahnama, P., et.al., 2006: prospective cohort study on 810 low risk

nulliparas (474 in latent phase; 336 in active phase )



1. Admission to labor when

the parturient is already in

the active phase.

2.Continuous

maternal support


Continuous maternal support

Need for pain relief by 10%

Duration of labor SHORTER by half an hour

spontaneous vaginal delivery by 8%

Instrumental vaginal delivery 10%

5 minute Apgar < 7 by 30%

Source of evidence: Cochrane review (21 trials, 15,061 women) comparing one-to-one intrapartum support given by variety of

providers (nurses, midwives, doulas, partner, female relative,

friend) versus usual care (Hodnett, E.D., et.al., 2011)


Having a LABOR COMPANION can result in:

Less use of pain relief drugs Increased alertness of baby

Baby less stressed , uses less energy

Reduced risk of infant hypothermia Reduced risk of hypoglycemia

Early and frequent breastfeeding

Easier bonding with the baby




May 6, 2013 5

1. Admission to labor

when the parturient is

already in the active

phase.

2. Continuous maternal

support

3.Upright position

during first stage

of labor

Recommended Practices

During Labor


Freedom of movement - distract

mothers from the discomfort of labor,

release muscle tension, and give a

mother the sense of control over her

labor (Storton, 2007).


UPRIGHT POSITION DURING

LABOR First stage of labor shorter by about 1 hour

Need for epidural analgesia by 17%

No difference in rates of SVD , CS, and Apgar score < 7 at 5 minutes

Source of Evidence: Cochrane review (21 studies involving 3,706 women)

comparing upright versus recumbent position

(Lawrence, A., et.al., 2009)


Restricting practices limit a mothers freedom to move and/or her position of choice.

1. IV lines*

2. fetal monitoring

3. labor stimulating medications that require

monitoring of uterine activity,

4. small labor rooms,

5. epidural placement

6. absence of support persons to be with the intrapartum client



1. Admission to labor

when the parturient is

already in the active

phase.

2. Continuous maternal

support

3. Upright position during

first stage of labor

4. Routine use of

WHO partograph to

monitor progress of

labor

For early identification of abnormal progress of labor 5/6/2013 Prepared by Team EINC for APDCN Faculty


No difference in endometritis

UTI lower by 34% An observational study on 161,077 women (with

or w/o PPROM) who had < 5 exams (Ayzac, L.,

et.al., 2008)

Chorioamnionitis by 72%

Neonatal sepsis by 61% 1 RCT on 5,018 women with PROM comparing < 3 exams

vs 3 exams (Seaward, P.G., et.al., 1998)

1. Admission to labor when the parturient is already in the active phase.

2. Continuous maternal support

3. Upright position during first stage of labor

4. Routine use of WHO partograph to monitor progress of labor

5. Limit total number of IE to 5 or less.




May 6, 2013 6

PRACTICES NOT RECOMMENDED

DURING LABOR


Interventions that are NOT recommended

during labor

No difference in rates of maternal fever, perineal

wound infection, and

perineal wound

dehiscence

No neonatal infection was observed

1.Routine

perineal

shaving on

admission

for labor and

delivery.

Evidence: Cochrane review (3 trials) comparing it with

no shaving (Basevi, V. and Lavender, T., 2000

updated 2008)


Interventions that are NOT

recommended during labor

Fecal soiling during delivery reduced by 64%

No difference in maternal puerperal infection,

episiotomy dehiscence,

neonatal infection, and

neonatal pneumonia

1. Routine perineal

shaving on

admission for

labor and

delivery.

2.Routine

enema

during the

first stage

of labor. Source of Evidence: Cochrane review (4 trials)

comparing it with no enema (Reveiz, L., et.al.

2007 updated 2010)


Practices that are NOT recommended

during labor

No difference in chorioamnionitis, postpartum endometritis, perinatal mortality, neonatal sepsis

No side effects reported

1. Routine perineal

shaving on

admission for

labor and

delivery.

2. Routine enema

during the first

stage of labor.

3.Routine

vaginal

douching.

Source of Evidence: Cochrane review

(3 trials that used different concentrations

and volumes of Chlorhexidine) comparing it

with sterile saline (Lumbiganon, P., et.al.,

2004 updated 2009)


Practices that are NOT recommended

during labor

Risk of dysfunctional labor by 25%

No difference in duration of labor, CS rate, cord prolapse, maternal infection and Apgar score < 7 at 5 minutes

1. Routine perineal shaving on admission for labor and delivery.

2. Routine enema during the first stage of labor.

3. Routine vaginal douching.

4. Routine amniotomy to shorten spontaneous labor

Source of Evidence: Cochrane review -14 trials involving 4,893 women. (Smyth, R.M.D., et.al., 2007 updated 2010)


Oxytocin Augmentation Should only be used to augment labor in

facilities where there is immediate access

to caesarean section should the need

arise.

Use of any IM oxytocin before the birth of the infant is generally regarded as

dangerous because the dosage cannot be

adapted to the level of uterine activity.




May 6, 2013 7

Routine IVF Advantage

to have ready access for

emergency

medications

to maintain maternal hydration

Disadvantage

Interferes with the natural birthing process

restricts womans freedom to move

IVF not as effective as allowing food and fluids

in labor to treat/prevent

dehydration, ketosis or

electrolyte imbalance

POGS CPG on NORMAL LABOR AND DELIVERY, 2009


Routine IVF

No study found showing that having an IV in place improves outcome

Even the prophylactic insertion of an IV line should be considered

unnecessary intervention.

Philippine Ob-Gyn Society CPG on Normal Labor and Delivery, 2009


Routine NPO During Labor Possible risk of aspirating gastric contents with

the administration of anesthesia

One study evaluated the probable risk of maternal aspiration mortality, which is

approximately 7 in 10 million births.

No evidence of improved outcomes for mother or newborn.

Use of epidural anesthesia for intrapartum anesthesia in an otherwise normal labor should

not preclude oral intake.

Sleutel, M., and Golden, S., 1999 POGS CPG on Normal Labor and Delivery, 2009


Routine NPO During Labor For the normal, low risk birth, there is no

need for restriction of food except where

intervention is anticipated.

A diet of easy to digest foods and fluids during labor is recommended.

Isotonic calorific drinks consumed during labor reduce the incidence of maternal

ketosis without increasing gastric volumes.

Singata M, Tranmer J, Gyte GML. Restricting oral fluid and food intake during labour. Cochrane Database of Systematic Reviews 2010, Issue 1. POGS CPG ON NORMAL LABOR AND DELIVERY, 2009 WHO Care in Normal Birth, 1996


CARE DURING LABOR

RECOMMENDED

Admission to labor when in the active phase.

Companion of choice to provide continuous

maternal support

Mobility and upright position

Allow food and drink

Use of WHO partograph to monitor progress of

labor

Limit IE to 5 or less.

NOT RECOMMENDED

Routine perineal shaving

on admission

Routine enema

Routine NPO

Routine IVF

Routine vaginal douching.

Routine amniotomy

Routine oxytocin

augmentation


PRACTICES RECOMMENDED

DURING DELIVERY




May 6, 2013 8

Please

wash your

hands!


Traditional

Defined by a fully dilated cervix

Coached to push though out-of-phase

with her own

sensation

Redefined as complete cervical dilatation + spontaneous explusive efforts (Simkin, 1991)

Pelvic phase of passive descent

Perineal phase of active pushing

Non-Traditional

Diagnosis of the 2nd Stage of Labor 5/6/2013 Prepared by Team EINC for APDCN Faculty


Management of the 2nd Stage of Labor

Traditional DIRECTED PUSHING

Valsalva pushing

Venous Return

Perfusion to Uterus, Placenta & Fetus

FHR Changes

Fetal hypoxia & acidosis

Roberts,1996; Simkin, 2000;Roberts,1987 as cited in Roberts, Joyce,Journal of Midwifery and Womens Health.Vol. 47,No.1 Jan/Feb 2002

Non-Traditional INVOLUNTARY BEARING DOWN

Exhalation pushing

Let air out

Parturient-directed

Physiologic: force of bearing down efforts increases as

fetal descent occurs

Avoids hypoxia and acidosis

Nikodem,VC. Beaaring down Methods during second stage labour (Cochrane

Review) In: The Cochrane Library, Issue 2, 2001 as cited by Roberts,

2002


UPRIGHT POSITION DURING

DELIVERY 5/6/2013 Prepared by Team EINC for APDCN Faculty

UPRIGHT position during delivery More efficient uterine contractions

Improved fetal alignment

Larger anterior-posterior and transverse diameters of pelvic outlet enhances fetal movement through the maternal pelvis in descent for birth

Faster delivery

Leads to less interventions : less episiotomies. Shilling, Romano, & DiFranco, 2007




May 6, 2013 9


Interventions that are recommended

during delivery

1.Upright

position

during

delivery

2.Selective

(non-routine)

episiotomy


Perineal Support and Controlled Delivery of

the Head

Keep one hand on the head as it advances

during contractions while the other hand supports

the perineum.

During delivery of the head, encourage woman to stop

pushing and breathe rapidly with mouth open.


Non-Routine Episiotomy

Anterior perineal trauma by 84%

Posterior perineal trauma by 12%

2nd-4th degree tears by 33%

Need for suturing by 29%

No difference in infection rate Source of Evidence: Cochrane review (8 trials) that include both primis and multis

and used median or mediolateral episiotomy (Carroli, G., and Mignini, L., 2009)



during delivery 1. Upright position

during delivery

2. Selective episiotomy

3. Use of

prophylactic

oxytocin for

management of

third stage of

labor OXYTOCIN 10 U intramuscular

Palpate abdomen to rule out a second baby


Prophylactic OXYTOCIN for the

3rd stage of labor

Postpartum blood loss 500 ml reduced by 39%

Need for additional uterotonic reduced by 47%

No difference in need for maternal blood transfusion, need for manual removal of

placenta, and duration of third stage

Source of Evidence: Cochrane review (4 trials on 2,213 women) using

varied doses, route, and timing of administration of oxytocin (Cotter,

A.M., et.al., 2002 updated 2004)




May 6, 2013 10


during delivery

Early clamping : 500ml by 7%

Postpartum blood loss >100ml by 24%

No difference in rates of maternal mortality or serious morbidity and need for

additional uterotonics.

Source of Evidence: Pooled analysis of 2 RCTs (23000 subjects) comparing it

with the hands off approach. (Althabe, F et al, 2009; Gulmezoglu AM et al, 2012)



during delivery

1. Upright position

during delivery

2. Selective episiotomy

3. Use of prophylactic

oxytocin

4. Delayed cord

clamping

5. Controlled cord

traction with

countertraction

6. Uterine massage

after placental

delivery

Lower mean blood loss Less need for uterotonics Source of evidence: Cochrane review (1 trial on 200 women who delivered vaginally and AMTSL done vs massage. ) Hofmeyr, GJ et al 2008


1. Administration of uterotonic within one minute of delivery of the baby.

2. Controlled cord traction with counter traction on the uterus

3. Uterine massage POPPHI. Prevention of Postpartum Hemorrhage: Implementing Active Management of the Third Stage

of Labor (AMTSL): A Reference Manual for Health Care Providers. Seattle: PATH; 2007.

Active Management of the Third

Stage (AMTSL)




May 6, 2013 11

Approaches in the

Mgt of the 3rd Stage of Labor

Physiologic (Expectant) Active (AMTSL)

Uterotonic NOT GIVEN before placenta is delivered

GIVEN within 1 min. of babys birth

Signs of placental separation

WAIT DONT WAIT

Delivery of the placenta

By gravity with maternal effort

CCT with counter traction on the uterus

Uterine massage After placenta is delivered

After placenta is delivered


PRACTICES NOT RECOMMENDED

DURING DELIVERY



recommended during delivery

Based on review, there is clear benefit (3rd-4th degree teaars) and no clear harm (no difference in 1sr and 2nd degree tears, vaginal pain, blood loss)

Commonly noted complications in practice (perineal edema, perineal wound infection, and perineal wound dehiscence) were not evaluated

Further studies are needed.

1.Perineal

massage

in the 2nd

stage of

labor



recommended during delivery

1. Perineal massage

in the 2nd stage of

labor

2.Fundal

pressure

during the

second stage

of labor


Fundal Pressure during 2nd stage

2nd stage longer by 29 minutes

Increased 3rd and 4th degree perineal tears

No difference in rates of postpartum hemorrhage, instrumental vaginal delivery,

Apgar score < 7 at 5 minutes, and NICU

admission

Uterine rupture was not evaluated

Source of Evidence: Pooled analysis of Cochrane review (with 1 trial

only) (Verheijen, E.C., et.al., 2009) and 2 randomized trials (Cosner,

K., 1996; Matsuo, K., et.al., 2009) with overall total of 1,229 patients


CARE DURING DELIVERY

RECOMMENDED

Upright position during delivery

Selective episiotomy

Use of prophylactic oxytocin for mgt of 3rd

stage of labor

Delayed cord clamping

Controlled cord traction with countertraction to

deliver the placenta

Uterine massage

NOT RECOMMENDED

Coaching the mother

to push

Perineal massage in

the 2nd stage of labor

Fundal pressure

during the second

stage of labor




May 6, 2013 12

POSTPARTUM CARE

RECOMMENDED Routinely inspect the birth

canal for lacerations

Inspect the placenta & membranes for completeness

Early resumption of feeding (

HO 4 Essential Intrapartum Care 6May2013

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