Normal Childbirth

8/14/2019 Normal Childbirth

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Normal Labor and Childbirth

Advances in Maternal and Neonatal Health


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2Normal Labor and Childbirth

Session Objectives

To identify best practices for managing labor and childbirth:

Skilled attendant

Birth preparedness/complication readinessPartograph

Restricted episiotomy

To identify harmful practices with the goal of eliminating themfrom practice


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Objectives of Care During

Labor and ChildbirthProtect the life of the mother and newborn

Support the normal labor and detect and treat complications in

timely fashionSupport and respond to needs of the woman, her partner andfamily during labor and childbirth


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Skilled Attendant

Is a professional caregiver

Has the knowledge and skills to:

Manage labor, childbirth and postpartum periodRecognize complications

Diagnose, manage or refer woman or newborn to higher level of care if complications occur that requireinterventions beyond caregivers competence

Performs all basic midwifery interventions

WHO 1999.


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Birth Preparedness and Complication

Readiness for the Woman and FamilyRecognize 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


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Birth Preparedness and Complication

Readiness for the Provider Diagnose and manage problems and complicationsappropriately and in a timely manner

Arrange referral to higher level of care if neededProvide women-centered counseling about birth preparednessand complication readiness

Educate community about birth preparedness andcomplication readiness


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Complication Readiness

for the Provider Recognize and respond to danger signs

Establish plan and determine who is in authority to make

decisions in case of emergencyDevelop plan for immediate access to funds (savings or community loan)

Identify and plan for blood donors and donation


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Partograph and Criteria for Active Labor

Label with patientidentifying information

Note fetal heart rate, color of amniotic fluid, presenceof moulding, contraction

pattern, medications givenPlot cervical dilation

Alert line starts at 4 cm--from here, expect to dilateat rate of 1 cm/hour

Action line: If patient doesnot progress as above,action is required


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WHO Partograph Trial

Objectives:

To evaluate impact of WHO partograph on labor management and outcome

To devise and test protocol for labor management withpartograph

Design: Multicenter trial randomizing hospitals in Indonesia,Malaysia and Thailand

No intervention in latent phase until after 8 hoursAt active phase action line consider: Oxytocin augmentation,cesarean section, or observation AND supportive treatment

WHO 1994.


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WHO Partograph: Results of Study

All Women BeforeImplementation

After Implementation

p

Total deliveries 18254 17230

Labor > 18 hours 6.4% 3.4% 0.002

Labor augmented 20.7% 9.1% 0.023

Postpartum sepsis 0.70% 0.21% 0.028

Normal Women

Mode of deliverySpontaneous

cephalicForceps

8428 (83.9%)

341 (3.4%)

7869 (86.3%)

227 (2.5%)

< 0.001

0.005

WHO 1994.


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Cochrane Review of Specific Criteria to

Diagnose Active Labor: Objective and Design

Objective: Assess effectiveness of use by caregivers of specific criteria for diagnosis of active labor in term pregnancy

Design: Meta analysis of randomized control trials; only onestudy found

Criteria:

Cervix dilated 49 cm

Rate of dilation 1 cm/hour

Fetal descent begins

Lauzon and Hodnett 2000.


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Criteria to Diagnose Active Labor:

Results with Statistical SignificanceExperimentalGroup (105)

ControlGroup (104)

Odds Ratio(95% CI)

Cesarean sectionfor labor dystocia

2 8 0.28 (0.081.00)

Intrapartumoxytocics

24 42 0.45 (0.250.80)

Any intrapartumanalgesia

84 96 0.36 (0.160.78)

Epidural analgesia 83 94 0.42 (0.200.89)



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Criteria to Diagnose Active Labor:

DiscussionUse of strict criteria for diagnosis of active labor:

May prevent misdiagnosis of dystocia in latent phase labor

Prevent unnecessary (and potentially risky) interventionsincluding 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



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Restricted Use of Episiotomy:

Maternal Outcomes AssessedSevere vaginal/perineal trauma

Need for suturing

Posterior/anterior perineal traumaPerineal pain

Dyspareunia

Urinary incontinence

Healing complications

Perineal infection

Carroli and Belizan 2000.


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Restricted Use of Episiotomy:

Results of Cochrane ReviewClinically Relevant Morbidities Relative Risk 95% CI

Posterior perineal trauma 0.88 0.84 0.92

Need for suturing 0.74 0.71 0.77

Healing complications at 7 days 0.69 0.56 0.85

Anterior perineal trauma 1.79 1.55 2.07

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 perineumto prevent trauma

Carroli and Belizan 2000.Eason et al 2000; WHO 1999.


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Indicated Use of Episiotomy:

Reviewers ConclusionsImplications for practice: Clear evidence to restrict use of episiotomy in normal labor

Implications for research: Further trials needed to assess useof episiotomy at:

Assisted delivery (forceps or vacuum)

Preterm delivery

Breech delivery

Predicted macrosomiaPresumed imminent tears (threatened 3 rd degree tear or history of 3 rd degree tear with previous delivery)

Carroli and Belizan 2000.WHO 1999.


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Clean Delivery

Infection accounts for 14.9% of all maternal deaths

These deaths can be avoided with infection preventionpractices


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Infection Prevention Practices

Use disposable materials once and decontaminate reusablematerials throughout labor and childbirth

Wear gloves during vaginal examination, during birth of newbornand 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 cleanHigh-level disinfect instruments, gauze and ties for cutting cord


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Best Practices: Third Stage of Labor

Active management of third stage for ALL women:

Oxytocin administration

Controlled cord tractionUterine massage after delivery of the placenta to keep theuterus contracted

Routine examination of the placenta and membranes

22% of maternal deaths caused by retained placenta

Routine examination of vagina and perineum for lacerationsand injury

WHO 1999.


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Best Practices: Postpartum

Close monitoring and surveillance during first 6 hourspostpartum

Parameters: Blood pressure, pulse, vaginal bleeding, uterine

hardnessTiming:

Every 15 minutes for 2 hours Every 30 minutes for 1 hour Every hour for 3 hours


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Position in Labor and Childbirth

Allow freedom in position and movement throughout labor andchildbirth

Encourage any non-supine position:

Side lying

Squatting

Hands and knees

Semi-sitting

Sitting


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Position in Labor and Childbirth

(continued)Use of upright or lateral position compared with supine or lithotomy position is associated with:

Shorter second stage of labor (5.4 minutes, 95% CI 3.96.9)

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.


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Support of Woman

Give woman as much information and explanation as shedesires

Provide care in labor and childbirth at a level where womanfeels safe and confident

Provide empathic support during labor and childbirth

Facilitate good communication between caregivers, thewoman and her companions

Continuous empathetic and physical support is associatedwith shorter labor, less medication and epidural analgesia andfewer operative deliveries

WHO 1999.


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Presence of Female Relative

During Labor: ResultsRandomized controlled trial in Botswana: 53 women with relative;56 without

Labor Outcome Experimental

Group (%)

Control

Group (%)

p

Spontaneous vaginaldelivery

91 71 0.03

Vacuum delivery 4 16 0.03

Cesarean section 6 13 0.03

Analgesia 53 73 0.03

Amniotomy 30 54 0.01

Oxytocin 13 30 0.03

Madi et al 1999.


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Presence of Female Relative

During Labor: ConclusionSupport from female relative improves labor outcomes

Madi et al 1999.


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Harmful Routines

Use of enema: uncomfortable, may damage bowel, does notchange duration of labor, incidence of neonatal infection or perinatal wound infection

Pubic shaving: discomfort with regrowth of hair, does notreduce infection, may increase transmission of HIV andhepatitis

Lavage of the uterus after delivery: can cause infection,mechanical trauma or shock

Manual exploration of the uterus after delivery

Nielson 1998; WHO 1999.


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Harmful Practices

Examinations:

Rectal examination: Similar incidence of puerperalinfection, 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 stirrupsduring labor


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Harmful Interventions

Administration of oxytocin at any time before delivery in sucha way that the effect cannot be controlled

Sustained, directed bearing down efforts during the secondstage of labor

Massaging and stretching the perineum during the secondstage of labor (no evidence)

Fundal pressure during labor

Eason et al 2000.


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Inappropriate Practices

Rigid adherence to a stipulated duration of the second stage of labor (e.g., 1 hour) if maternal and fetal conditions are goodand there is progress of labor

Liberal or routine use of episiotomy

Liberal or routine use of amniotomy


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Practices Used for Specific

Clinical IndicationsBladder catheterization

Operative delivery

Oxytocin augmentationPain control with systemic agents

Pain control with epidural analgesia

Continuous electronic fetal monitoring


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Normal Labor and Childbirth:

ConclusionHave 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

childbirthProvide continuous emotional and physical support to womanthroughout labor


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ReferencesCarroli G and J Belizan. 2000. Episiotomy for vaginal birth (Cochrane Review), in TheCochrane Library. Issue 2. Update Software: Oxford.Eason E et al. 2000. Preventing perineal trauma during childbirth: A systematicreview. Obstet Gynecol 95: 464 4 71.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 activelabour in term pregnancy (Cochrane Review), in The Cochrane Library. UpdateSoftware: Oxford.Ludka LM and CC Roberts. 1993. Eating and drinking in labor: A literature review. J Nurse-Midwifery 38(4): 199 207.Madi BC et al. 1999. Effects of female relative support in labor: A randomized controltrial. Birth 26:4 10.Neilson JP. 1998. Evidence-based intrapartum care: evidence from the CochraneLibrary. Int J Gynecol Obstet 63 (Suppl 1): S97 S 102.World Health Organization Safe Maternal Health and Safe Motherhood Programme.1994. World Health Organization partograph in management of labour. Lancet 343(8910):1399 1404.World Health Organization (WHO). 1999. Care in Normal Birth: A Practical Guide.Report of a Technical Working Group . WHO: Geneva.

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