Norma Técnic 愀搀攀氀倀愀爀琀its.uvm.edu/Vertical Birth/Norma Técnica del Parto INGLES -...

��

��

1

��

��

��

��

��

��

��

2

Hecho el Depósito Legal en la Biblioteca Nacional del Perú Nº 2006-5060

Also Published in Spanish with the title:Norma técnica para la atención del parto vertical con adecuación interculturalISBN 9972-851-22-2Hecho el Depósito Legal Nº 2005-6714

© Copyright 20061000 Units

Ministry of Health, 2006Av. Salaverry N° 801 - Jesús María, Lima - PerúTelephono: (51-1)315-6600http://[email protected]

First Edition

Edition, translation proof reading:Raquel Hurtado La Rosa, MD, MPH - Technical AssistantNational Sanitation Strategy for Sexual and Reproductive Health (ESNSSR)

Translation proof reading:Paulina Giusti Hundskopf, MD - Advisor to the Vice Minister of Health

Translation:Alicia Mazurec de GaraycocheaFlavia López de Romaña Olivares

Printing:Editorial y Gráfica EBRA E.I.R.LTelefax: [email protected], 30 - Perú

Ministry of Health Library Cataloguing-in-Publication Data

Technical regulation for vertical delivery care with intercultural adaptation (N.T. Nº 033-MINSA/DGSP-V.O1) / Ministry of Health. General Directorate of People’s Health. NationalSanitation Strategy for Sexual and Reproductive Health — Lima: Ministry of Health, 2005

43 p. illus.

MATERNAL AND CHILD HEALTH, regulations / CULTURAL DIVERSITY / LEGISLATION,regulation / WOMAN’S HEALTH / LABOR, ethnol / PERU

��

��

3

PILAR MAZZETTI SOLERMINISTER OF HEALTH

JOSÉ DEL CARMEN SARAVICE MINISTER OF HEALTH

LUIS PODESTÁ GAVILANODIRECTOR OF THE GENERAL DIRECTORATE OF PEOPLE’S HEALTH

ISABEL CHAW ORTEGADIRECTOR – HEALTH QUALITY CARE

LUCY DEL CARPIO ANCAYANATIONAL COORDINATION OFFICER

NATIONAL SANITATION STRATEGY FOR SEXUAL AND REPRODUCTIVE HEALTH

��

��

4

��

��

5

This document was reviewed with the technical opinion of the following persons fromthe Ministry of Health, Regional Health Divisions and other Institutions:

Ministry of Health:Luis E. Podestá Gavilano, MD : Director of the General Directorate of People’s HealthIsabel Chaw Ortega, MD : Director– Health Quality CareWalter Ravelo, MD : Director – Health Care ServicesLucy del Carpio, MD : National Coordination Officer of the National Sanitation

Strategy for Sexual and Reproductive Health (ESNSSR)Raquel Hurtado, MD, MPH : ESNSSR Technical TeamMarysol Campos, BS : ESNSSR Technical TeamCarmen Julia Carpio, BS : ESNSSR Technical TeamCarmen Mayuri, BS : ESNSSR Technical TeamJaime Moya Granda, MD : Executive Officer – Health Care ServicesAna Borja Hernani, BS : Executive Officer – Comprehensive Health CareLuis Meza Santibáñez, MD : National Maternal and Perinatal Institute

Regional Health Division, Cajamarca:Enrique Marroquín Osorio, MD : Regional Health Director, CajamarcaJulio Ponce de León Gavilán, MD : Human Health DirectorRocío Portal Vásquez, BS : Coordination Officer – Adult Female StageRosa Becerra Palomino, BS : Coordination Officer – Child StageBertha Sagástegui Gil, BS : Health Promotion – Regional Health Division (DIRES)

CajamarcaMartín Albán, MD : Director of the Regional Hospital of CajamarcaCarmen Sagástegui, MD : Regional Hospital of Cajamarca, Head of the OB/GYN Dep.Margarita Isla Rojas, MD : Regional Hospital of CajamarcaJulia Arista Meléndez, BS : Regional Hospital of CajamarcaÁntero Zavaleta Calderón, MD : Responsible of the ODSISMariela Chávez Aldave, BS : Coordination Officer – Adult Female Stage, San Marcos 4th

NetworkRocío Tordota Victoria,BS : Coordination Officer – Adult Female Stage, San Marcos

Health Care FacilityMarleny Rojas Cáceres, BS : Chuco Health Care Station – San Marcos NetworkGlide Lozano Luna, BS : Huayobamba Health Care Station – San Marcos 4th

NetworkMiriam Rojas Zárate, BS : Shirac Health Care Station – San Marcos 4th NetworkAlicia Sigüenza, BS : Cachachi Health Care Station – Cajabamba 5th NetworkIrma Madueño Saldaña, BS : Red Hualgayoc – Bambamarca, Adult Female Coord.Gloria Leyva, BS : Red Hualgayoc – Bambamarca Health Care Facility

Morán LirioSantos Chávez Aguilar, BS : UNICEF Health ConsultantMaría Elena Valladares, BS : NGO Círculo Solidario

Regional Health Division, Cuzco:Danilo Villavicencio Muñoz, MD : General Director CuzcoJuan Spelucín Runciman, MD : Regional Hospital of CuzcoMauro Vargas León, MD : Executive Officer – Human HealthGraciela Zacarías Aguirre, MD : Pediatrician of the Lorena HospitalJavier Cuno, MD : Health Care Services DivisionHilda Robles Mena, BS : Director of Comprehensive Health Care Services

��

��

6

Isabel Fuentes Carayhua, BS : Director of Child StageMaritza Castro, BS : STI and HIV AIDS StrategyGina Humpire, BS : Urcos Health Care FacilityPatricia Velarde, BS : Canas Canchis NetworkKatia Catacora, MD : Antonio Lorena Hospital, CuzcoLuis Gonzáles de la Vega, MD : Regional Hospital – NeonatologyNeptalí Cueva Maza, MD : Manager of the Cuzco South NetworkElsa Díaz Rojas, BS : Paruro Micro Network (Cuzco South)Inés Pari Pandia, BS : Huancarani Micro Network (Cuzco South)Rosa Llacsa Valcárcel, BS : Paucartambo Micro Network (Cuzco South)Marina Ochoa Linares, MD : Manager of the Cuzco North NetworkWilliam Velasco, BS : Coord. Officer – Woman’s Health Area, Cuzco North NetworkElena Neyra Velarde, BS : Quispicanchi Acomayo Network Coord. Woman’s Health AreaSimón Cruz, BS : Ocongate Micro Network (Quispicanchi Acomayo Network).Marta Montalico, BS : Pucyura Micro Network (La Convención).Patricia Medina, BS : Quimbiri Micro Network (La Convención).Verónica Huallpa, BS : Santa Teresa Micro NetworkNélida Vilca, BS : Yauri Micro NetworkVíctor del Carpio, MD : Yaurisque Micro NetworkDeisy Moscoso, BS : UNICEFElizabeth Menéndez, BS : CADEP José María ArguedasLic.Patricia Velarde : Red Canas Canchis

Regional Health Division, Ayacucho:José Quispe Pérez, MD : Regional Health Director, AyacuchoJosé Anicama Barrios, MD : Human Health DirectorFlor de María Melgar, BS : Director of Comprehensive Health Care ServicesRosa Pomasonco, BS : Responsible for the Sexual and Reproductive Health Strategy

(SSR) of the Regional Health DivisionMiriam Arones Castro, BS : Center NetworkDiógenes Salvatierra, BS : Sucre Micro NetworkZulema Urbina, BS : San José de Secce Micro Network, HuantaGraciela Alca de la Cruz, BS : San Miguel NetworkRaquel Arones, BS : Sivia Micro NetworkRicardo Gutiérrez, BS : Vilcashuamán Micro Network

Regional Health Division, San Martín:Anderson Sánchez S., MD : General Health Director, San MartínFelipe Santiago Vela O., MD : Executive Officer – Human Health CareMilitza Huivín Grández, BS : Coord. Officer – Adult Stage – ESSSRMaría Linares Sandoval, BS : Coord. Officer Adult Female – Jepelacio Health Care Facility

SupervisorHilda Renee Miguel Honorio, BS : Head of the Jepelacio Health Care FacilityWilliam Bardales Vásquez, MD : Jepelacio Health Care FacilityGuillermo Arteaga Zaire, MD : Jepelacio Health Care FacilityDagni Rodríguez Pinedo, BS : Jepelacio Health Care FacilityNurse technician Edgardo Rojas S. : Jepelacio Health Care FacilityMaría Rosa Gárate, Anthropologist : Policy ProjectCidanelia Salas, BS : NGO Relachupan – PeruRosario Ruiz Santillán, MD : NGO CADESRosa Giove, MD : Foro Salud (Health Forum)

��

��

7

Regional Health Division, Apurímac II:

Angélica Peñaloza, BS : Regional Coord. Officer of the SSR Strategy

Other Institutions:Marco Martina Chávez, MD : Central Planning and Development Office – ESSaludMiguel Gutiérrez Ramos, MD : Peruvian Society of Obstetrics and GynecologyEduardo Maradiegue, MD : Peruvian Society of Obstetrics and GynecologyLuis Távara Orozco, MD : Peruvian Society of Obstetrics and GynecologyElena Lara Valderrama, BS : Dean of the Association of Obstetricians of PeruMario Tavera, MD : UNICEF

��

��

8

��

��

9

PRESENTATION

One of the cultural practices related to child delivery is the position that the womanadopts at the moment of labor. Most Andean and Amazon women prefer the verticalposition either by squatting, sitting or kneeling, among others (traditional child delivery).Health professionals have been trained to treat patients in labor in a horizontal position(lying down). These two different practices produce a cultural disagreement betweenthe health care professionals and the rural women, who often prefer to avoid going to thehealth institutions, risking their wellbeing and their life, as well as their unborn babies,if any difficulties may arise.

There is an important experience in vertical delivery in our country. The different culturalapproach has created an important increase in the percentage of deliveries handled bythe health care personnel in the last years. The last National Survey of Health andDemography, reports an increase of 24% (2000) to 44% (2004) in delivery assistance inthe health care services for rural population.

Within the framework of sexual and reproductive rights, where giving birth and be bornare decisive moments for our future life, the Health Ministry faces the challenge to findan equilibrium between the modern hospital care and the sensitivity and significancethat these events represent in the life of a large part of our population. Also, scientificevidence shows that vertical delivery is more physiological and helps the parturient inthe expulsion of the infant.

Consequently, the Health Ministry, through the National Sanitation Strategy for Sexualand Reproductive Health of the Human Health Division, has decided to support theinitiative of the departments of Cuzco, Cajamarca, San Martín, Huancavelica, Huánuco,Ayacucho, Puno, Apurímac and Amazonas in the preparation of the “Technical Standardfor Vertical Delivery with Intercultural Adaptation.”

The purpose of this regulation is to standardize the medical assistance on verticaldelivery according to international criteria and national experience, responding to theneed of adjusting the health care services offered to women in order to increaseinstitutional delivery and thus, reduce obstetric complications that cause maternaldeath.

Therefore, when this regulation becomes official, health care professionals will be ableto offer vertical delivery assistance in all health care facilities, guaranteeing qualityassistance in response to the needs of all Peruvian women.

Dra. Lucy del Carpio AncayaNational Coordinator

National Sanitation Strategy for Sexual and Reproductive Health

��

��

10

��

��

11

��

��

12

��

��

13

CONTENTS

I.- INTRODUCTION ............................................………………………………………………… 1 5

II.- PURPOSE ............................................…………………………………………………......... 15

III.- OBJETIVE ...........................................…………………………………………………......... 15

IV.- SCOPE OF APPLICATION ..............................…………………………………………......... 15

V.- LEGAL BASIS ............................................…………..………………………………......... 16

VI.- HISTORICAL AND EPIDEMIOLOGICAL ASPECTS …………………………...................... 16

VII.- PHYSICOLOGICAL ASPECTS ........................………………………………………….......... 17COMPARED PHYSIOLOGY ...........................……………………………………………......... 17Horizontal Delivery .................................…………………………………………………......... 17Vertical Delivery .......................................………………………………………………......... 17

VIII.- DEFINITIONS .......................................…………………………………………………......... 18Vertical delivery ............................................….………………………………………......... 18Interculturality ........................................…………………………………………………......... 18Delivery Plan ........................................…………………………………………………......... 18

IX.- VERTICAL DELIVERY ASSISTANCE ............................................……………….......... 19ORGANIZATION COMPONENT ............................................………………………......... 19Human Resources ....................................………………………………………………......... 19Infrastructure .........................................…………………………………………………......... 19Equipment, medication and materials ................................……………………………......... 19PROVISION COMPONENT .......................................…………………………………......... 20Indications ............................…………………………………................………………......... 21Counter-indications .........................................………………………………………….......... 21RECEPTION OF THE EXPECTANT PREGNANT WOMAN ..............…………………......... 21Supporting company ............................................…………………………………….......... 21Meals ............................................…………………………………………………............... 22ASSISTANCE IN THE DILATION PHASE ..............................…………………………......... 22Procedures ............................................………………………………………………........... 22Vaginal Examination .....................................…………………………………………............ 22Pain management ......................................………………………………………….............. 22Monitoring of labor progress .........................................………………………………......... 23Positions during the dilation phase ..................……………………………………………......... 23Relaxation and Massages ............................................……………………………........... 23ASSISTANCE IN THE EXPULSION PHASE .............................………………………......... 23Asepsia and hygiene ............................................……………………………………......... 24Positions in the Expelling Period ............................................………………………......... 24IMMEDIATE ASSISTANCE TO THE NEWBORN .............................…………………......... 26CHILDBIRTH PERIOD ASSISTANCE .......................................………………………......... 26Final Disposal of the Placenta ..........................................……………………………......... 26IMMEDIATE PUERPERIAL ATTENTION ...............................…………………………......... 26Diet and Hydration ..................................…………………………………………………......... 27

��

��

14

COMPLICATIONS DURING VERTICAL DELIVERY ................…………………………......... 27GUIDANCE/POST-DELIVERY ADVISORY ....................…………………………………......... 27CRITERIA FOR DISCHARGE ............................................…………………………………. 28REFERRAL AND COUNTER-REFERRAL ...................…………………………………......... 28CHILD DELIVERY SERVICES FLOWCHART ................…………………………………......... 29

X.- BIBLIOGRAPHY ....................…………………………………......................................... 30

XI.- ANNEXES ....................…………………………….........................................……......... 32Annexe 1A Delivery Plan Format ....................…………………………...........………......... 32Annexe 1B Waiting my Delivery ....................…………………………………..................... 33Annexe 2 List of herbs and other products used during Labor and after Delivery .............. 34Annexe 3 Waiting House or Maternity Home ....................………………………………....... 37

��

��

15

I. INTRODUCTION

Within the framework of the Guidelines on Health Policy and in fulfillment of its duty to conduct, regulateand promote quality assistance proceedings, aimed at satisfying the people’s health needs, the Ministryof Health provides technical regulating instruments for compliance by health institutes country-wide.

Thus, the Human Health Division has considered it necessary to develop a technical standard to facilitateadapting services in assisting vertical delivery, with an intercultural, gender, equity and respect-orientedapproach with respect to the High Andean and Amazon people’s rights, seeking to improve the quality,accessibility and satisfaction of users and health care providers.

The intention of addressing health assistance through these approaches is to empower people, from therural area, in particular, by recognizing their culture within a frame of equality and respect, generating,as a result, the lifting of their self-esteem and access to health care services.

The “Technical Standard for Vertical Delivery with Intercultural Adaptation” proposes the building ofmutual enrichment bridges between occidental and traditional models which, while different in theirconceptual frameworks, need not to oppose but complement one another. This implies rescuing theirtraditions and positioning the women’s right to actively participate in the way they wish to be assisted,strengthening the affective link between the mother, the baby and the family environment.

This regulation defines concepts and describes, in an organized way, the vertical delivery processesand the cultural adaptation of the health care facilities of different complexity level.

II. PURPOSE

To improve the access of High Andean and Amazon people to health care services for quality assistancein vertical delivery with intercultural adaptation.

III. OBJECTIVE

To establish the regulation framework for vertical delivery assistance with intercultural adaptation in thedifferent assistance levels of the health care service network.

IV. SCOPE OF APPLICATION

This technical standard shall be applied in Level I-4, Level II and Level III health care facilities, for verticaldelivery assistance with intercultural adaptation.

��

��

16

V. LEGAL BASIS

1. Law 26842, Health Law.2. Law 27657, Ministry of Heath Law.3. Supreme Decree 014-2002-SA, Ministry of Health Organization and Functions Regulations.4. Ministerial Order 768-2001-SA/DM Health Quality Management System.5. Ministerial Order 668-2004/MINSA, National Guidelines for Comprehensive Sexual and Reproductive

Health Assistance.6. Ministerial Order 195-2005/MINSA, 2004-2006 National Sanitation Strategy for Sexual and

Reproductive Health.

VI. HISTORICAL AND EPIDEMIOLOGICAL ASPECTS

Since the onset of humanity, delivery has been practiced in different vertical positions, as evidencedby engravings or sculptures of almost every culture. There are pictures illustrating chair designs usedfor childbirth in sitting position throughout Ancient Times, Middle Ages and the Renaissance.

It was in the 17th Century that the famous Obstetrician Mauriceau made women “lie down” for delivery,apparently, to be able to apply the forceps, the fashionable instrument at that time. With the use of EpiduralAnesthesia in the decade of the 70s, in an attempt to reduce delivery pain, the horizontal position waseven more favored, since what position other than horizontal could be asked from a woman underanesthetic effect.

The history of the delivery process dating back to the onset of humanity, illustrates its route with womenwho, for centuries, have chosen the sitting or squatting position to push; thus, refusing to recognize thisevidence does not form part of mature reflection and decision taking in this respect, that is, favoring thisphysiological position.

Biomedical approach to health care provision and the influence of urban culture consolidate women’sconviction in respect of the convenience of horizontal position at the time of delivery, recognizing it asa more advanced technology. However, the influence of occidental and urban culture science is alsounaware of the priorities and needs of women in general and rural women in particular, at delivery time,which they consider a natural event that does not require any intervention modifying the traditional wayof delivery assistance.

The vertical position traditionally used by different cultures and by a great number of ethnic groups, hasfinally started to spread in occidental countries: U.S.A. (Howard 1958); as well an in the Latin Americanregion: Uruguay (Caldeyro Barcia, 1974); Brasil (Paciornik, 1979) etc. and more recently, havingconsidered its advantages, by the World Health Organization (WHO, 1996).

In Peru, assistance in vertical delivery is being implemented by regional health care facilities servingrural people, as a strategy to simplify access to maternity assistance services.

The Regional Health Office (DIRESA) of Ayacucho reports that the 2,300 home deliveries that took placein 2004, which accounted for 28% of total deliveries in the Region of Ayacucho in that period, wereassisted in this upright position; there have been labor experiences in the Health Care Facilities ofVilcashuamán and San José de Secce. The records in DIRESA Cajamarca show that 9.3% of totaldeliveries assisted by the health care personnel at home and at the health care facilities in 2003, werevertical deliveries. In 2004 the rate increased to 14.8%.

��

��

17

(Footnotes)1 Giraldo, 19922 Arbues, 19823 Gallo, 19924 Garcia C. 19875 Sabatino,19926 Boreli, 1966

VII. PHYSICOLOGICAL ASPECTS

COMPARED PHYSIOLOGY

Horizontal Delivery

• The uterus of the pregnant woman might compress the large vessels, aorta and cava vein,originating decrease of the cardiac output, hypotension and bradycardia; it may also causealteration of the placenta irrigation, and thus, decrease of the oxygen amount the fetus receives(Aorta-Cava Compression). These translates in significant changes on the fetus beats, whichmay be verified by monitoring and which may lead to fetus stress if the expulsion period isextended1.

• The immobilized lower limbs act as “dead weight”, and do not allow the pushing effort or thepelvis movements to accommodate the fetus cephalic pole diameter with the mother’s pelvicdiameters, thus not favoring the final expulsion.

• The mother’s intrapelvic diameters reach their greatest values when the mother’s thighs areflexed upon her own abdomen (usual practice for Shoulders Dystocia), thus the conventionalhorizontal position might decrease the mother’s transverse and anteroposterior pelvis diameters.

• The uterine contractile activity tends to be weaker in horizontal position than it is in verticalposition. The need to push becomes more problematic due to the requirement of a greater effort,not being favored by gravity force.

• Nervous compression exercised by the pressure on the legs hanging on the stirrups, besidesuncomfortableness of the position, increases the adrenergic charge.

• Horizontal position does not allow fetal head exercise a sustained pressure on the perineum,making difficult an effective and slow distension.

• A lithotomy position with legs hanging, overstretches the perineum, making tearing possible.

Vertical Delivery

• In the vertical position, the pregnant woman’s uterus is not compressed, nor are the largevessels, the aorta or the cava vein and thus, there is no alteration in the mother’s circulation or inthe placenta irrigation; therefore the amount of oxygen received by the fetus is not affected.

• There is a better acid balance in the fetal basis during dilation2 period, as well as during theexpulsion period3,4, facilitating the fetus-neonatal transition5.

• As the lower limbs are leaning, they constitute a point of support and indirectly help with birth.• There is an increase in the delivery channel diameters: 2 cm in the anteroposterior way and 1 cm

in the transverse way6.• The vertical position determines that the dive angle be less acute (more open) favoring dive and

fetus progression.• The positive action of gravity forces also favors dive and descent of fetus. It is estimated that the

mother gains between 30-40 mm Hg in intrauterine pressure values when vertical position is

��

��

18

7 Mendez, B., 19768 Mendez B., 19759 Sabatino.199210 Paciornik, 199211 Dunn,197612 Sabatino. 199213 Araucaria Health Care Service – 9th Region. Ministry of Health of Chile. First National Meeting on Health and Indigenous People. PAHO-WHO. Saavedra Chile, 1996.

adopted7. Likewise, the contractile action of the abdominal press and the uterine contractionsfavored with this position helps fetus push out towards the vulva opening as unique exit.

• Increased efficiency of the uterine contractions during delivery labor and expulsion period whichsucceed one another with less frequency but more intensity, demanding less obstetric interventions,less oxytocin use and less alteration risk of the fetus cardiac beats8.

• As a result of the foregoing reasons, labor and delivery process is considerably shortened in thevertical position.9,10,11.

• Vertical delivery provides psycho-affective benefits such as less pain (or absence of same)feeling of freedom and greater satisfaction after delivery12.

• Women are allowed greater participation in their children’s birth, encouraging them to push in amore effective way, besides allowing a better control of the situation.

VIII. DEFINITIONS

VERTICAL DELIVERY

Vertical Delivery is that in which the pregnant woman places herself in a vertical position (standing onher feet, sitting position leaning one or both knees or squatting position) while the health personnelassisting her is in front or behind the pregnant woman, waiting to assist delivery. This position allows theproduct, which acts as final vector resulting from the expulsion forces, to orient itself towards thedelivery channel, favoring its birth, decreasing trauma effects of the newborn.

INTERCULTURALITY

The Pan-American Health Organization states: “…Interculturality is a relationship between severaldifferent cultures that takes place with respect and horizontality, where none of them, is above or belowthe other. The intercultural relationship aims at favoring mutual understanding between persons fromdifferent cultures, becoming aware of the way the others perceive the reality and the world of the other,thus enabling openness and mutual enrichment (…) Interculturality is based on dialogue, where bothparts listen to each other, where both parts talk to each other and where each part takes what may betaken from the other part, or simply respects the other’s particularities and individualities. It is not aquestion of imposition or subjugation but of concerting…13"

DELIVERY PLAN

The Delivery Plan is an effective tool that seeks to organize and mobilize family and communityresources for the timely assistance of the pregnant woman, the mother who has just given birth and thenewborn. The plan must set forth specific information to allow organizing the assistance process for thepregnant woman, indicating the aspects of delivery and referral if necessary. The plan provides thenecessary information so that the pregnant woman and her family know where to go upon evidence ofimminent delivery or alarm signals.

��

��

19

IX. VERTICAL DELIVERY ASSISTANCE

ORGANIZATION COMPONENT

The organization component for vertical delivery assistance with intercultural adaptation covers a set ofprocesses and actions that allow adapting the offer of maternity services to provide health care servicesto cover delivery assistance requirements of women of the Andean and Amazon populations.

Health care facilities must adapt and design organization proceedings that are essential to provide qualityassistance in vertical delivery.

Health care facilities shall consider the available resources within the area and, according to its complexitylevel, within the health care provider network they belong to.

Human Resources

The health personnel must be technically competent and have the skills required to allow them establish anempathic relationship with the parturient and their relatives since the beginning, providing a climate ofsafety and confidence.

Human resource availability will respond to complexity level of the health care facilities and existingresources. The health care service shall have the following staff:

• Gynecologist-Obstetrician Physician or a General Practitioner with Competence in Obstetrics forobstetric attention.

• Pediatrician or a General Practitioner with Competence in Newborn care.• Midwife.• Nurse with Competence in Newborn care.• Nurse technician with Competence to assist in Obstetrics and Newborn care.

Infrastructure

• Room conditioning with faint light and comfortable temperature (approximately 24 degrees centigrade)providing warmth with heaters or any other heating means.

• Protection of windows with color curtains made of adequate local material.• Painted walls in not too light colors.

Equipment, medication and materials

Health care facilities must have equipment, material and medication for vertical delivery assistance.The health care service shall be equipped with the following:

• Full equipment for delivery assistance.• · Tensiometer.• Stethoscope.• Newborn reanimation equipment.• A pediatric scale.• A flexible light shield.• A stretcher for vertical delivery.• A wooden circular stool 30 x 45 cm tall.• Two chairs.

��

��

20

• Glass cabinet to keep medication.• Heating source: heater or other heating means.• Two cushions 30 cm diameter each.• A small stool 50 cm tall.• Metal or wooden ring installed in the ceiling.• A thick, 5-meter rope.• A mat on the floor covered with linen, where the child will be born.• A bucket for blood reception.• Hot-water bottles.• A roll of cloth or wool ball, 10 x 5 wide.• · Cloth boots for the parturient to avoid contaminating the newborn child.• Sheets for child reception.• Wide robes to cover the parturient adequately.• Medication set for delivery.• Traditional medicines (thymolin, flower water, pink oil, Del Carmen water, orange, seven spirits water,

hot infusions such as muña, lemon verbena, rue, matico leaves, oregano, celery); all these elementsare considered necessary by the Andean and Amazon people to prevent complications.

The health care facility must organize the referral and counter-referral for continuity and timely assistancein case of complications during vertical delivery, pursuant to regulations in force and to provisions atlocal level for the service network.

The reason for referral responds to the resolving capacity of each health care facility.

PROVISION COMPONENT

The provision component covers the set of assistance and care services that the health team offers theparturient, together with the person, family and community.

For vertical delivery assistance, the pregnant woman must previously have prenatal care service,according to the national guidelines for comprehensive sexual and reproductive health assistance. Incase no prenatal attention has been received, the respective routine analysis shall be requested.

The health care facility providers must encourage Andean and Amazonian women to express their will withrespect to the position they wish to be assisted for delivery, through the design of a Delivery Plan (Annex 1A, 1B).

The delivery plan shall be designed with the participation of the pregnant woman so that she and herfamily will interest themselves in solving critical aspects that she may face during pregnancy anddelivery, counting with family and community resources available.

The delivery plan data sheet must include the following information:

• Personal details of the pregnant woman.• Probable delivery date.• Health care facility visited for prenatal care.• Analysis results.• Location where delivery will take place.• Preferred position to give birth.• Transportation means available in her community.• Persons who will help her in the transfer.• In case blood is required, who will be the donor?• If she will make use of the waiting house (Annex 3).

��

��

21

The health care professionals shall observe the clinical indications and counter-indications in order toproceed with vertical delivery assistance.

Indications:

• Pregnant woman without obstetric complication.• Cephalic presentation of fetus.• Fetus-pelvic compatibility.

Counter-indications:

Counter-indications for vertical delivery are all those complications that may have C-section as indication, themost frequent being:

• Previous C-section, one if it is of body type.• Iterative C-section.• Fetus-pelvic incompatibility.• Fetus stress.• Fetus in podalic position.• Twins pregnancy.• Presentation Dystocia.• Cord Dystocia.• Dystocia due to contraction.• Fetal macrosomy.• Prematurity.• Bleeding in the third quarter (previous placenta or premature detachment of placenta).• Premature rupture of membranes with head still high.• Post-term pregnancy.• Severe pre-edampsia, eclampsia.• Record of complicated delivery.

RECEPTION OF THE PREGNANT WOMAN

The health care personnel must offer the pregnant woman a warm welcome, explain her the proceduresin a simple way, respecting her beliefs and traditions and evaluating the possibility to consider them so as toimprove the health care professional relationship with the pregnant woman. Thereafter they will proceed to:

• Verify the information related to her pregnancy in the clinical record and Pre-natal care card(Pregnancy record).

• Identify alarm signals.• Control vital signs: blood pressure, pulse, temperature.• Practice obstetric assessment (Leopold’s maneuver, uterine height, fetus beats, uterine contractions)

and pelvic exam.• Determine delivery labor initiation.

Supporting company:

• The parturient must be allowed to bring with her a companion of her choice, who may be herspouse, mother, mother-in-law, midwife or any other relative. If she is not accompanied by arelative, members of the social network of support to pregnant woman may be involved, priorconsent of the parturient.

��

��

22

• The health care personnel shall inform the relative or companion about his/her role and responsibilitiesduring the parturient stay, in particular during delivery.

Meals:

• The staff shall allow for the parturient to take some light meals during labor and immediately afterdelivery. Meals shall be preferably warm and energetic: soups, infusions, jelly, etc. These willgive her a sensation of warmth that will favor labor progress. (Annex 2).

The following are recommended14:

− Tea or milk with cinnamon and cloves.− Hot chocolate.− Basil tea.− Three or four rue leaves per cup of water.− On teaspoon of melissa.

• The staff should be acquainted with the effect of some herbs and prevent the use of those thatstress uterine contractions.

ASSISTANCE IN THE DILATION PHASE

The health care personnel, according to their designated duties and competences will perform the following:

Procedures:

• Control vital functions on an hourly basis.• Evaluate cardiac fetal frequency every 30 to 45 minutes (at the beginning and immediately after

each contraction).• Keep a detailed record of the partogram, which will enable the health care personnel to carry out

the necessary actions if complications should arise (Take into consideration that the CLAP – WHOpartogram record allows monitoring child delivery in vertical position).

Vaginal Examination:

• Will only be carried out by qualified health care personnel, with clean hands, covered bysterile gloves. The number of vaginal examinations must be limited to the strictly necessaryduring the dilation phase. Once every four hours is enough except in the following cases:− When there is a decrease of the frequency and strength of the contractions.− When there are signs that the woman wants to push.

• Try, when possible, to practice the vaginal tact explaining why it is necessary, and, at the sametime, try to win the parturient and her family’s confidence. Be prudent and tolerant when practicingthis procedure.

Pain management:

• The health personnel must provide emotional support together with the companion that theparturient has chosen.

• Offer freedom of speech and action to the woman according to her habits.

14 There are diverse preparations and infusions that midwives recommend to pregnant women. As there is the possibility that wemay not be aware of their collateral effects, we prefer to provide only the most commonly used, known and innocuous.

��

��

23

• Evaluate relaxation techniques and massages.• Consumption of herb infusions according to local habits. (Annex 2).

Monitoring of labor progress:

• The evaluation of the progress of labor is performed by observing the pregnant woman: appearance,conduct, contractions and the descent of the fetal head.

• The most accurate measurement is the cervix dilation. A deviation of the normal dilation rate –1 cmper hour– should be a warning to review the plans for delivery and refer the parturient to a betterequipped hospital facility.

Positions during the dilation phase:

• The woman must choose the position she prefers. The supine position is not recommended duringthe dilation process because it presents a number of problems from the physiological point of view.

− The compression of the large dorsal blood vessels interferes with circulation and diminishesthe blood pressure causing a decrease of oxygen to the fetus.

− The contractile uterine activity becomes weaker, less frequent and the need to push becomesmore difficult because it demands more effort when the force of gravity is not present.

− The slow descent increases speed up techniques which accelerate the process and at thesame time, cause fetal stress.

− The coccyx is compressed against the bed and forced forward which narrows the pelvic exitmaking the delivery long and difficult.

• The woman in labor must be able to move and change positions whenever she considersnecessary. The vertical position is more physiological and shortens the time for the deliveryprocess in 25%. Walking or standing stimulates contractions, helps the descent of the fetus and thedilation of the cervix making contractions more efficient and less painful. This is why manywomen feel the need to walk helped by their companions.

• The only exception that supports the supine position during the dilation process is when themembranes have broken when the head is still high.

Relaxation and Massages:

• To give a massage, the personnel or the relatives, must have their hands warm. These will bedone slowly, with the palm of the hand and the fingertips. The use of oil or talcum powder will helpthe hands slide and press the lumbar zone softly and evenly. This will reduce the stress andanxiety levels, control the physical and emotional stress that labor causes, recover energy forthe next contractions, reduce muscular tension and thus, reduce fatigue.

ASSISTANCE IN THE EXPULSION PHASE

The staff, according to their functions and roles, will do the following:

• Verify the material and necessary medicine for assistance to the parturient and the newborn.• Equip or verify that the labor room has the following:

- Heat produced by heaters.- Stretcher or adequate chair for vertical delivery.- Rope hanging from a beam.

��

��

24

- A mat on the floor covered with linens where the baby will be placed.- An auxiliary small table will be provided to put all sterile equipment.

Asepsia and hygiene:

• Verify the hygiene and cleanliness of the environment.• Check if the set of instruments is decontaminated, washed and sterilized.• Wash the hands carefully with soap and water before wearing the sterile gloves.• Pay attention to the personal hygiene of the parturient.• Carry out perineal washing using warm water and additional herbs if customary, at the beginning

and repeat when necessary.• If necessary, cloth boots will be placed on the parturient in order to keep the zone clean.

Positions in the Expelling Period

In vertical position, the roles of health care personnel in the expelling period is limited to the reception ofthe baby, to the maneuvers required when the umbilical cord is trapped, to detect and help if anycomplications arise.

The woman must be allowed to move so that she may find the position where she can have more strengthto expel the fetus. The health care personnel assisting the delivery will have to adjust to the chosen position.

These are the positions that a parturient may adopt:

a. Squatting position: Front.b. Squatting position: Back.c . Kneeling down.d. Seated.e. Half-seated.f. Holding the rope.g. Hand and foot position (four support points).

Squatting Position: Front

Is one of the positions preferred by rural women because it eases the separation of the joints betweenthe pelvic bones increasing the pelvic diameters and thus helping the descent of the fetus through thedelivery channel.

• The health care personnel will perform the obstetric procedures of the expelling period in acomfortable position (kneeling down, squatting or sitting in a low stool) and will help the parturientin the guided delivery. The parturient must have her legs bent and separated to improve the widthof the transversal diameter of the pelvis.

• The midwife or relative acts as a support to the parturient, sitting on a low stool, placing the kneeon the lower part of the sacrum region, holding and embracing her by the hypochondrias andepigastric region. This procedure helps adapt the position of the fetus and guides it to the verticalaxe and favors the action of abdominal press.

Squatting Position: Back

• The health care personnel will perform the obstetric procedures of the expelling period in acomfortable position which will enable them to protect the perineum, placing their knee in theparturient’s inferior region of the sacrum and will later accommodate to help in the guided delivery.

��

��

25

• The companion must sit on a chair or on the edge of the bed and hold the parturient from below theunderarm region, placing his knee at the level of the diaphragm, acting as a support spot, lettingthe pregnant woman hold herself placing her arms around the neck of the companion.

Kneeling Down

• The health care personnel will practice the obstetric procedures of the expelling period, face toface with the parturient and will later accommodate to help in the guided delivery.

• The companion will sit on a chair or at the edge of the bed, with the legs open, separated and willembrace the parturient by the thorax letting the pregnant woman lean on her companion’s thighs.

• In this position, the parturient assumes a more rested and comfortable position while birth getscloser and helps with the obstetric procedures.

Seated and half-seated position

• Health care personnel will perform the obstetric procedures of the expulsion period and then willbe prepared to guide delivery.

• The companion must sit on a chair with legs opened or kneel on the bunk-bed, holding theparturient at chest level letting her lean on his thighs or hold the neck of her companion. While inthis position, the parturient must be sitting on a low chair (on a lower level than her companion)or on the edge of the bunk-bed, taking care that the mat is under her.

• In the half-seated position the parturient will lean on pillows or on her companion. She may sitstraight or bend herself to the front on the floor or on the edge of the bed. This position will relaxher and allows pelvis to open.

Holding-the-rope position

This position makes maneuvering difficult when there is a circular cord or to detect any suddencomplication.

• The health care personnel will perform the obstetric procedures of the expulsion period and thenwill be prepared to guide delivery.

• The parturient holds a rope that is suspended from a beam in the ceiling. The fetus is the favoredone, as helped by the force of gravity, slides down through the birth canal smoothly and calmly.

Feet and hands position

It is the preferred position for some women, particularly for the ones who experience pain in the lowerpart of their back.

• The health care personnel will perform the obstetric procedures of the expulsion period and thenwill be prepared to guide delivery.

• Some women prefer to kneel on a mat, leaning forward on their companion or on the bed.Probably when delivery is imminent the parturient must adopt a more reclined position to helpcontrol delivery.

• Reception of the baby shall be made from the back of the woman.

The health care personnel assisting a vertical delivery in any of the vertical positions shall instruct theparturient to practice shallow breathing (panting) to relax her body and breathe through the mouth; andto do it with the mouth closed when pushing, to increase her strength with the abdomen muscles.

��

��

26

IMMEDIATE ASSISTANCE TO THE NEWBORN

The health care personnel shall verify the material is prepared with anticipation, as well the place wherethe newborn will be assisted exclusively. The newborn care shall apply the techniques and proceduresestablished in the National Guidelines for Comprehensive Sexual and Reproductive Health Assistance.

CHILDBIRTH PERIOD ASSISTANCE

The health care personnel shall assist childbirth in the dorsal position (horizontal), due to the fact that thevertical position produces regular bleeding.

Personnel shall:

• Conduct guided delivery, seeking to shorten the third period of delivery and decreasing theamount of bleeding. Apply an ampoule of intramuscular oxytocin (10 UI) immediately afterchildbirth.

• Use techniques that are customary in the rural area to help expel the placenta:• Induce nausea stimulating the uvula in order to cause an effort.• Blow into a bottle.• Place a clip on the cord or tie it to the woman’s foot or leg to avoid it goes in again.• Assess the vaginal bleeding volume, the uterine contraction rate, the consciousness condition of

the mother and her vital signs (blood pressure, pulse).• Perform a thorough evaluation to verify placenta detachment, assist in its expulsion and examine

it very carefully, verifying that membranes are complete.• Examine for lacerations in the vulva, vagina and/or cervix.• · Assess bleeding volume after childbirth.• In case any complication arises during the childbirth period, parturient must be tubed using a

cannula No. 18 immediately to pass sodium chloride at 9/00 and she must be transferred to amore complex health care facility (Use some other solution only in case no sodium chloride isavailable).

Final Disposal of the Placenta:

• Health care personnel must allow the family to decide about the final disposal of the placentaaccording to their traditions, except if the health personnel should consider that the placenta maybe a contaminating factor. (VHS-AIDS and sexually transmitted infections).

• The personnel must understand that the burial of the placenta is an important tradition in the life ofthe family because they have the belief that their child did not come alone into this world, butaccompanied by the placenta which they consider an organ with a life of its own.

• In all cases, the placenta must be handed in a sealed bag following security procedures.

IMMEDIATE PUERPERIAL ATTENTION

The personnel must respect some harmless practices that the parturient and her family perform on herand on the newborn, taking into consideration the importance of the family ties that strengthen themembers of the family when they get accommodations together, the mother, new-born and their family.

The following procedure must be followed regardless of the place where the parturient is staying anddepending on infrastructure, equipment and the amount of patients in the health care facility:

��

��

27

• Vital functions control, tone of uterine contractions and vaginal bleeding every half hour for the firsttwo hours.

• Before the woman is allowed to rest, the personnel must check the following:- Tone of uterine contraction.- Control of vital functions, blood pressure, pulse.

These controls must be taken every half hour at least during the first four hours.• Massages to stimulate the release of lochia (clots) and the contraction of the uterus, which

provides a sense of wellbeing to the mother. Some mothers prefer to bandage their abdomenswith previously prepared bandages.

• Make the recent mother comfortable and place her in a warm room with low light.• You can provide the mother with a bed (bunk bed) of about 60 cm. high so that she can rest with

her spouse or relatives.• It is better to use sheets and blankets of bright or dark colors but not white because the rural

women feel embarrassed when the sheets get stained.• Allow the parturient to use the “chumpi” (sort of belt-bandage).

Diet and Hydration:

• Feeding will be allowed according to the needs, possibilities and traditions of the woman,encouraging them to eat healthy food using the resources in the area. The first food after deliveryis a bird broth.

• A hyper protein diet with few spices should be observed the first days after delivery. A largeamount of liquid is also recommended for breast-milk production.

• Take into consideration that some Andean and Amazon communities do not allow the consumptionof pork, avocado, or fish at this time.

• Do not allow the use of alcoholic beverages.

COMPLICATIONS DURING VERTICAL DELIVERY

The following complications may appear during vertical delivery:

• Increase of bleeding when oxytocin is not used during delivery.• Tearing in the perineal area.• Sudden expulsion of the fetus.• Umbilical cord prolapse.• Upper limbs protrusion.• Shoulders dystocia.

In the event any of the above complications should occur, adequate action shall be taken according tothe degree of complexity

GUIDANCE/POST-DELIVERY COUNSELING

Health personnel must provide information, guidance and counseling to the mother and to the family ontopics related to newborn care and sexual and reproductive health care.

• Exclusive breastfeeding, emphasizing benefits and teaching the technique.• Nutrition for the mother.• Reproductive health and family planning.

��

��

28

• Hygiene of mother and child.• Newborn vaccination.• Identifying alarm signs in the puerperial period.• Identifying alarm signs in the newborn.• Newborn care.

CRITERIA FOR DISCHARGE

The general, therapeutical measures, adverse collateral effects of treatment, alarm signs to be considered,as well as criteria for discharge and prognosis, are the same as those taken into account for assistancein a horizontal eutocic delivery.

REFERRAL AND COUNTER-REFERRAL

If the referral of the parturient or puerperal mother should be necessary due to any complication arisen,actions shall follow the procedures and protocols pursuant to the provisions under the Ministry of Health,according to the resolving capacity of the health care facility level.

Counter-referral must include the recommendations for the return of the mother to her home.

��

��

29

15 Adaptation Document PSNB 2000.

CHILD DELIVERY SERVICES FLOWCHART 158

Identification of pregnant wom an

Does she requ ire delivery proceed ing?

Transferred to Delivery Room

Exam ina tion by physician

Determine the rela tives that w ill accompany her du ring delivery

Transferred to Labor Waiting House

Info rm the pregnant w om an abou t the positions for child delivery so that she

m ay decide

C a n th e d e liv e ry b e a tten d e d to at th e H ea lth C a re F acility ?

Imm ediate Referral

Provide an environ with adequate tem perature, offer warm solutions, ind icate re lative what his/her ro le is.

M onitor delivery p rocess

Does De livery present any com plication?

Take action according to protocols and o rder Im m edia te Referral if necessary

Assist in Vertical

D e live ry

Does birth and expu lsion of placen ta present any com plication?

Take action according to protocols an d order Imm ed iate Referral if necessary

Assist in childbirth process and p rovide care to new born

Ask what will be done with the placenta, if the m other wishes, allow her to wear support gird le and/or scarf on her head.

A ss is t dur ing P uerperium

Inquire about sa tisfaction of User and her Re latives am iliares

Y E S

E u toc ic d e live ry

D ys toc ic de live ry

Y E S

Y E S

Y E S

N O

N O

N O

N O

��

��

30

BIBLIOGRAPHY

PERUVIAN

• Resolution 002-REG-CAJ/DRSC-DESP/AIS-MNA “Rules for Implementing the Cultural AdaptationProcess in the Health Care Facilities of the Cajamarca Health Division for Maternal Health CareServices”, dated December 19, 2003.

• Director’s Resolution issued by the Alto Mayo Moyobamba Health Sub-region 0100-2004/D-SRS-AM-M-SGMC-UGRDHH. Pilot Program – Cultural Adaptation of Maternal Health Care Services in theDistrict of Jepelacio, dated July 19, 2004.

• Martina Chávez, M. Parto en posición sentada (Sitting Position Child Delivery). Mad Medicina al día(Medicine updated) Vol.3 N° 3, May 1995.

• Ministry of Health. National Guidelines for Comprehensive Sexual and Reproductive Health Care -Lima – Peru, 2004.

• Kruger, H., Arias Stella, J. Offprint from the Gynecology and Obstetrics Journal Vol. XIII N° 3; Page 139.The Newborn and Placental Quotient in High Altitude, Dec. 1967.

• Vargas L., Nacarato P. De salvia y toronjil (About Sage and Melissa). CMP. Flora Tristán, 1995.

INTERNATIONAL

• Allister, H. Was Man more Aquatic in the Past? The New Scientist, page 642-645; March 1960.• Andrews CM. Changing Fetal Position through Maternal Posturing in Raff BS ed Perinatal Parental

Behavior: Nursing Research and Implications for Newborn Health. White Plains. NY: March ofDimes Foundations, 1981.

• Atwood, R. Parturition as Posture and related Birth Behavior Acta Obstet Gynecol Scand (supl 57):5; 1975.

• Barroso Nino, M.; Ruiz Clavijo, I. La posición adoptada para la primípara durante el trabajo de parto,sus efectos en la evolución del parto y condiciones del recién nacido (Position adopted by aPrimiparous Woman during Labor and Delivery, its Effects in the Delivery Evolution and Conditionsof the Newborn). Bogota, Colombia, National University, Nursing School, 144p; Jun. 1986.

• Borell, V. Fernstrom, L. The Mechanism of Labor, Radiol Clin north am; 5:73; 1966.• Bouchtara, K., Taleb et al. Position and Delivery. Rev.Fr-Gynecol-Obstet; 82 (3); p. 205-7; Mar. 1987.• Buchmann,E., Kritzinger,M; Tembe,R; Berry,D. Home Births in the Mosvold Health Ward of

Kwazulu.S.Afr-Med-J ;1.76(1) p 29-31; Jul. 1989.• Dunn PM. Obstetric Delivery Today. For Better or Worse 7. Lancet; 2: 790; 1976.• Caldeyro-Barcia, R. The Influence of Maternal Position on Time of Spontaneous Rupture of the

Membranes, Progress of Labor and Fetahead Compression Birth Fam J. , 6:7; 1979• Carlson, J., Diehl, J., Sachtelben-Murray, M., McRae, M., Fenwick, L., Friedman, E. Maternal

Positioning during Parturition in Normal Labor, Obstet, Gynecol; 68:443; 1986.• Chen, S.; Aisaka, K; Mori, H; Kigawa, T. Effects of Sitting Position on Uterine Activity during Labor.

Obstet-Gynecol; 69(1) p. 67-73; Jan. 1987.• Engelmann, G. Labor among Primitive Peoples. Reprint of 1882, edition New York: AMS Pres 1977.• Gardosi, J., Sylvester, S., Lycnch, C. Alternative Positions in the Second Stage of Labour:

A Randomized Controlled Trial. Br-J-Obstet-Gynecol; 96(11): 1290 – 6; nov. 1989.• Gardosi, J. Hutson, N.,Lynch, C. Randomised Controlled Trial of Squatting in the Second Stage of

Labour see comments. Lancet. 8. 2 (8654) p. 74-7; July1989.• Gold, E. Pelvic Drive in Obstetrics: An X-ray Study of 100 cases. Am J. Obstet Gynecol; 59:890; 1950.• Gowri, M. How to Prepare for a Safe and Easy Waterbirth; Video Napierala, S., Water Birth; 1994.

��

��

31

• International Medical New Service. Standing, Sitting, during Delivery not Dangerous. Report of aPresentation by H. Nagai at the 11th World Compress of Ginecology and Obstetrics in Berlin. Obstet.Gynecol New; 20:10; 1985.

• Johnson, J. and Odent, M. We are all Water Babies, 1995.• Kirchhoff, H. Women’s Positioning during Child Delivery “From Prehistory to Date”. Gottingen, Al.

occidental. Organorama; May 1976.• Koga, S. Effects of Delivery Positions on the Onset of first Cry and Umbilical Blood Gas Parameters.

Nippon-Sanka-Fujinka-Gakkaizasshi; 37 (1); 107-14; Jan 1985.• Lakshmi, B. y Odent, M. Choosing Waterbirth Global Maternal/Child Health Assoc. Inc, 2001. • Lupe, PJ. Gross, T.L. Maternal Upright Posture and Mobility in Labor a Review. Obstet. Gynecol

: 67:727; 1986.• Mehl, L. Home Delivery Researches Today a Review, Women Health. 1976.• Mitzuta, M. Studies on the influence of maternal delivery position on fetal status. Nippon-sanka-

Fujinka-Gakkai-Zasshi. 39 (6) p 965-71; Jun 1987.• Morgan, E. The Aquatic Ape Hypothesis; Souvenir Press, 1997. • Morgan, E. The Descent of the Child; Penguin Books, 1994. • Morgan, E. Scars of Evolution; Oxford University Press, 1990.• Morgan, E. The Aquatic Ape, 1982.• Morgan, E. The Descent of Woman; Souvenir Press, 1972.• Obsterical and Gynecological Survey. Vol 46, N° 9, Pulse Oximetry and Fetal Monitoring; 1991.• Olson,R; Olson,C; Cox,NS. Maternal Birthing Positions and Perineal Injury J-Fam – Pract; 30 (5):

553-7; May 1990.• Paciornik, M. et. al. Quality of Health Care Services in Pregnancy, Labor and Delivery within a

Framework of Rights. Montevideo, Uruguay; 2003.• Read, J.A, Miller, FC, Paul, R.H. Randomized trial of ambulation, versus oxytocin for labor

enhancement: a preliminary report. Am J. Obstet Gynecol; 139:669; 1981.• Sabatini, H. Parto fisiológico: la posición vertical es la fisiológica para el parto (Physiological

Delivery: Vertical Position is the Physiological Posture for Delivery). Campina University, SaoPablo Brasil; 1992.

• Araucaria Health Care Services, 9th Region. Ministry of Health of Chile. First National Meeting onHealth and Indigenous People. PAHO-WHO. Saavedra, Chile; 1996.

• Stewart, P. Spiby, H. Randomized Study of the Sitting Position for Delivery using a Newly DesignedObstetric Chair. Br-J-Obstet-Gynecol; 96(3): 327-33; Mar. 1989.

• Simkin P., Stress, Pain and Catecholamines in Labor: Part 1: a review. Birth; 13: 8; 1986.• Westenhofer, M. On the Preservation of Ancestor’s Characteristics in Human Beings, 1927.

��

��

32

ANNEXESANNEX 1A

��

��

33

ANNEX 1B

��

��

��

��

��

��

��

�

��

�

��

��

��

��

��

�

��

��

��

��

��

��

��

��

��

��

�

34

ANNEXES 2 LIST OF HERBS AND OTHER PRODUCTS USED DURING LABOR AND AFTER DELIVERY

BasilAbsinth wormwoodHorsetailCanchalagua (Cintaura)

Chancuas (Chauncas)

Black Maidenhair Fern

Mint Marigold/Black MarigoldGolden berry

Castor Bean (castor oil plant)Mint

Plantain (ixtle, cancer herb)

Piper (soldier’s tree)

Chamomile

Malva

OreganoParsley

Dog’s paw (Manuy tus)Mullaca (winter cherry, gooseberry,wild tomato)

Common Name Scientific NameOcimum basilicumArtemisia absinthiumEquisetum telmateia

Minthostachyssatureja

Adiantum capillus- veneris

Tageter minutaPrunus

Ricinus communisMentha

Taurnefortia polystachys

Matricaria chamomilla

Wild Malvas

Petrocilinum

PropertiesAccelerates labor processAccelerates labor processStrengthens the bonesIncreases the body temperatureand accelerates labor processIncreases body temperatureand accelerates labor processTo clean and purify bloodand helps to stop lochia(postpartum bleeding)Accelerates labor processAccelerates labor processStrengthens the bones

Good for deliveryHelps in delivery and «keepsthe belly warm»Used to clean the woman’sgenitalsAntiseptic, wound healing, useto clean the woman’s genitalsAntiseptic, wound healing, useto clean the woman’s genitalsAntiseptic, wound healing, useto clean the woman’s genitalsAccelerates labor processTo increase body temperature

Strengthens the bonesStrengthens the bones

Infusion - must be taken hotInfusión - must be taken hotInfusion – must be taken hotInfusion

Boil the herb’s twigs and fruitpeelings. Must be taken hot.

Hot infusion

To be taken cooked andsweetened with honeyTo be boiled and usedwhile warmTo be boiled and usedwhile warmTo be boiled and usedwhile warmTo be boiled and usedwhile warmHot infusionBoiled and combined withalgarrobina (algarobo syrup)Boil and drink as fresh waterBoil and drink as fresh water

Method of PreparationDilationDilationDilation and laborDilation

Dilation and labor

Dilation andpuerperium

DilationDilation, labor andpuerperium

Puerperium

Dilation andpuerperiumDilation andpuerperiumPuerperium

Puerperium

DilationDilation

PuerperiumPuerperium

When to Use

��

��

��

��

��

��

��

�

��

�

��

��

��

��

��

�

��

��

��

��

��

��

��

��

��

��

�

35

Common Name Scientific Name Properties Method of Preparation When to UseQuinoa (Field quinoa, wild quinoa)RueRosemary (Romeromacha,callaaquero)Staggerweed (Supiquehua farmbasil, quehaua, quhua, rosarioquehua deadman’s cordCactus fruit

Melissa

Trinidad (three-leaf, quiso,tritaria nichillo)

Valerian

COMBINATIONSGrated horn, Rosemary, Chancua,jorajora, peach flower, cactus flower,poroporo flower (Kangaroo apple)golden berry flower, parturient’s flower,ground olluco fruitMelissa and colcas

Lanche tree bark (Myrcianthes)rumilanche tree bark, canchaquerotree bark, bark from the Trinidad(three-leaf) guiso, wild quinoa bark,muñuño tree bark, taranco tree bark,huanga tree bark, Piper (matico) bark,canistel bark, guava tree bark, goldenberry bark, mullaca bark canchalagua,deer tongue, horse tail, dog’s paw

Ruta graveumensRosmarinus officinaris

Stachys arvensis

Melissa offcionalis

Valeriana officinales

Melissa offcionalis

Tritaria

Strengthens the bonesAccelerates labor processIncreases body temperature andaccelerates labor processAccelerates labor process

Increases body temperature andaccelerates labor processIncreases body temperature andaccelerates labor process(flexibilizes bones)Strengthens the bones

Accelerates labor process

Increases body temperature andaccelerates labor process

Increases body temperature andaccelerates labor process(flexibilizes bones)Strengthens the bones

Boil and drink as fresh water

Infusion

Boil one twig and take while stillvery hotBoil one twig and take while stillvery hot

Boil a small amount of each of theherbs mentioned and let cool,take as fresh waterHot infusion

Boil one twig of all the herbs andfruit grates. Take hot.

Prepare infusion with the melissatwig

Boil a small amount of each of theherbs mentioned and let cool,take as fresh water

PuerperiumDilationDilation

Dilation

Dilation and labor

Dilation and labor

Puerperium

Dilation

Dilation and labor

Dilation and labor

Puerperium

��

��

��

��

��

��

��

�

��

�

��

��

��

��

��

�

��

��

��

��

��

��

��

��

��

��

�

36 Common Name Scientific Name Properties Method of Preparation When to UseCanchalagua, snake herb, blackmaidenhair fern, coca and basilleavesCanchaquero, humburo, rumilanche,wild quinoa, huanga, three-leaf,three-rose, rosemary, dog’s paw,horse tailWalnut tree leaves, coca, whitesnakeroot / chilca (three shoots)Fox arracacha, basil, panisara,melissa, black mint

To clean and purify blood andhelps to stop lochia (postpartumbleeding)To clean genitals

To clean genitals

Helps in delivery and «keeps thebelly warm»

Boil all the products and sweetenwith honey. Drink during 8 days.

Boil all the products and usethem for warm vaginal cleaning

Boil all the products and usethem for warm vaginal cleaningTake cooked and sweetenedwith honey.

Puerperium

Puerperium

Puerperium

Puerperium

��

��

37

ANNEX 3

WAITING HOUSE OR MATERNITY HOME

During the past years, important strategies and initiatives have been developed in Peru, aimed atreducing the economic barriers (Mother-Infant Insurance and Comprehensive Health Insurance)geographical barriers (waiting house) and cultural barriers (cultural adaptation, vertical delivery withintercultural adaptation) in order to increase the incidence of institutional delivery and respond witheffective and timely assistance in obstetric complications. Furthermore, investments have been madein infrastructure, equipment and training of health care personnel from the Ministry of Health, to enhanceresolving capacity in the attention of obstetric complications.

The 2004 Demographic and Family Health Survey reveals a significant increase of institutional deliveryassistance in the rural areas, from 24% in 2000 to 42.9% in 2004. These figures show there may be animprovement in the accessibility to services (geographical and cultural) as well as greater resolvingcapacity in the response to obstetric emergencies presented by rural, indigenous and Amazonianwomen in poverty condition, who are the most vulnerable.

The waiting house or maternity home is a house that has been conditioned for the specific use, eitherbuilt, rented or donated through community efforts, jointly managed by local authorities, the communityand the health sector. Its main purpose is to shelter pregnant women and their families coming fromremote areas and keep them close to a health care facility with Basic or Essential Obstetric and NewbornCare facilities.

Identification of pregnant women qualifying as users shall be the responsibility of the primary health carelevel staff; local authorities; municipal agents; neighbor boards, relatives, friends and neighbors ofpregnant women.

The criteria for a pregnant women to qualify for access to the waiting house services are:

• To live in a rural area with difficult access.• To be exposed to child delivery without social or family support, being a widow, single or

abandoned mother, etc.• To be a victim of domestic violence because of spouse or any other family member.• To be exposed to being assisted by personnel not qualified for child delivery or new born care.• To be a pregnant woman with some kind of obstetric complication requiring treatment by specialized

personnel.

There are currently 337 waiting houses operating in the jurisdictions of the Health Divisions locatedmainly in rural areas:

��

��

38

WAITING HOUSES

��

��

39

WAITING HOUSE IN THE RURAL FOREST AREA

WAITING HOUSE IN THE RURAL ANDEAN AREA

��

��

40

HUACO CULTURA MOCHEPOSICIÓN PARA EL PARTO VERTICAL

VARIEDAD SENTADA

CERAMICA DE CHULUCANASPOSICIÓN PARA EL PARTO VERTICAL

��

��

41

RETABLO AYACUCHANO PARTO VERTICAL

��

��

42

KNEELING DOWN SQUATTING POSITION

VERTICAL DELIVERY HOLDING THE ROPE POSITION

��

��

43

VERTICAL DELIVERY KNEELING DOWN

FINAL DISPOSAL OF THE PLACENTA

Norma Técnic 愀搀攀氀倀愀爀琀its.uvm.edu/Vertical Birth/Norma Técnica del Parto INGLES -...

Documents

Transcript of Norma Técnic 愀搀攀氀倀愀爀琀its.uvm.edu/Vertical Birth/Norma Técnica del Parto INGLES -...

Norma Técnic 愀 搀攀氀 倀愀爀琀its.uvm.edu/Vertical Birth/Norma Técnica del Parto INGLES -...

Documents

Transcript of Norma Técnic 愀 搀攀氀 倀愀爀琀its.uvm.edu/Vertical Birth/Norma Técnica del Parto INGLES -...

Norma Técnic 愀搀攀氀倀愀爀琀its.uvm.edu/Vertical Birth/Norma Técnica del Parto INGLES -...

Transcript of Norma Técnic 愀搀攀氀倀愀爀琀its.uvm.edu/Vertical Birth/Norma Técnica del Parto INGLES -...