normal labor and childbirth advances in maternal and neonatal health

Normal Labor and Childbirth

Advances in Maternal and Neonatal Health

2 Normal Labor and Childbirth

Session Objectives

To identify best practices for managing labor and childbirth:

Skilled attendant Birth preparedness/complication readiness Partograph Restricted episiotomy

To identify harmful practices with the goal of eliminating them from practice


Objectives of Care During Labor and Childbirth

Protect the life of the mother and newborn

Support the normal labor and detect and treat complications in timely fashion

Support and respond to needs of the woman, her partner and family during labor and childbirth


Skilled Attendant

Is a professional caregiver

Has the knowledge and skills to:

Manage labor, childbirth and postpartum period Recognize complications Diagnose, manage or refer woman or newborn to higher

level of care if complications occur that require interventions beyond caregiver’s competence

Performs all basic midwifery interventions

WHO 1999.


Birth Preparedness and Complication Readiness for the Woman and Family

Recognize danger signs

Plan for managing complications

Save money or access funds

Arrange transportation

Plan route

Plan place for delivery

Choose provider

Follow instructions for self-care


Birth Preparedness and Complication Readiness for the Provider

Diagnose and manage problems and complications appropriately and in a timely manner

Arrange referral to higher level of care if needed

Provide women-centered counseling about birth preparedness and complication readiness

Educate community about birth preparedness and complication readiness


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 emergency

Develop plan for immediate access to funds (savings or community loan)

Identify and plan for blood donors and donation


Partograph and Criteria for Active Labor

Label with patient identifying information

Note fetal heart rate, color of amniotic fluid, presence of moulding, contraction pattern, medications given

Plot cervical dilation

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

Action line: If patient does not progress as above, action is required


WHO Partograph Trial

Objectives:

To evaluate impact of WHO partograph on labor management and outcome

To devise and test protocol for labor management with partograph

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

No intervention in latent phase until after 8 hours

At active phase action line consider: Oxytocin augmentation, cesarean section, or observation AND supportive treatment

WHO 1994.


WHO Partograph: Results of Study

All Women Before Implementation

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

cephalic

Forceps

8428 (83.9%)

341 (3.4%)

7869 (86.3%)

227 (2.5%)

< 0.001

0.005

WHO 1994.


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 one study found

Criteria:

Cervix dilated 4–9 cm Rate of dilation 1 cm/hour Fetal descent begins

Lauzon and Hodnett 2000.


Criteria to Diagnose Active Labor: Results with Statistical Significance

Experimental Group (105)

Control Group (104)

Odds Ratio (95% CI)

Cesarean section for labor dystocia

2 8 0.28 (0.08–1.00)

Intrapartum oxytocics

24 42 0.45 (0.25–0.80)

Any intrapartum analgesia

84 96 0.36 (0.16–0.78)

Epidural analgesia 83 94 0.42 (0.20–0.89)



Criteria to Diagnose Active Labor: Discussion

Use of strict criteria for diagnosis of active labor:

May prevent misdiagnosis of dystocia in latent phase labor Prevent unnecessary (and potentially risky) interventions

including cesarean section Insufficient power to test effects of intervention on rates of

cesarean section, unplanned out-of-hospital birth or other important maternal and newborn outcomes



Restricted Use of Episiotomy: Objectives and Design

Objective: To evaluate possible benefits, risks and costs of restricted use of episiotomy vs. routine episiotomy

Design: Meta analysis of six randomized control trials

Carroli and Belizan 2000.


Restricted Use of Episiotomy: Maternal Outcomes Assessed

Severe vaginal/perineal trauma

Need for suturing

Posterior/anterior perineal trauma

Perineal pain

Dyspareunia

Urinary incontinence

Healing complications

Perineal infection

Carroli and Belizan 2000.


Restricted Use of Episiotomy: Results of Cochrane Review

Clinically 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 perineum to prevent trauma

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


Indicated Use of Episiotomy: Reviewer’s Conclusions

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

Implications for research: Further trials needed to assess use of episiotomy at:

Assisted delivery (forceps or vacuum) Preterm delivery Breech delivery Predicted macrosomia Presumed imminent tears (threatened 3rd degree tear or

history of 3rd degree tear with previous delivery)

Carroli and Belizan 2000.WHO 1999.


Clean Delivery

Infection accounts for 14.9% of all maternal deaths

These deaths can be avoided with infection prevention practices


Infection Prevention Practices

Use disposable materials once and decontaminate reusable materials throughout labor and childbirth

Wear gloves during vaginal examination, during birth of newborn and when handling placenta

Wear protective clothing (shoes, apron, glasses)

Wash hands

Wash woman’s perineum with soap and water and keep it clean

Ensure that surface on which newborn is delivered is kept clean

High-level disinfect instruments, gauze and ties for cutting cord


Best Practices: Third Stage of Labor

Active management of third stage for ALL women:

Oxytocin administration Controlled cord traction Uterine massage after delivery of the placenta to keep the

uterus contracted Routine examination of the placenta and membranes

22% of maternal deaths caused by retained placenta Routine examination of vagina and perineum for lacerations

and injury

WHO 1999.


Best Practices: Labor and Childbirth

Use non-invasive, non-pharmacological methods of pain relief during labor (massage, relaxation techniques, etc.):

Less use of analgesia OR 0.68 (CI 0.58–0.79) Fewer operative vaginal deliveries OR 0.73 (95% CI 0.62–

0.88) Less postpartum depression at 6 weeks OR 0.12 (CI 0.04–

0.33) Offer oral fluids throughout labor and childbirth

Neilson 1998.


Best Practices: Postpartum

Close monitoring and surveillance during first 6 hours postpartum

Parameters:

– Blood pressure, pulse, vaginal bleeding, uterine hardness

Timing:

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


Position in Labor and Childbirth

Allow freedom in position and movement throughout labor and childbirth

Encourage any non-supine position:

Side lying Squatting Hands and knees Semi-sitting Sitting


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 3.9–6.9) Fewer assisted deliveries (OR 0.82, CI 0.69–0.98) Fewer episiotomies (OR 0.73, CI 0.64–0.84) Fewer reports of severe pain (OR 0.59, CI 0.41–0.83) Less abnormal heart rate patterns for fetus (OR 0.31, CI

0.11–0.91) More perineal tears (OR 1.30, CI 1.09–1.54) Blood loss > 500 mL (OR 1.76, CI 1.34–3.32)

Gupta and Nikodem 2000.


Support of Woman

Give woman as much information and explanation as she desires

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

Provide empathic support during labor and childbirth

Facilitate good communication between caregivers, the woman and her companions

Continuous empathetic and physical support is associated with shorter labor, less medication and epidural analgesia and fewer operative deliveries

WHO 1999.


Presence of Female Relative During Labor: Results

Randomized controlled trial in Botswana: 53 women with relative; 56 without

Labor Outcome Experimental Group (%)

Control Group (%)

p

Spontaneous vaginal delivery

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.


Presence of Female Relative During Labor: Conclusion

Support from female relative improves labor outcomes

Madi et al 1999.


Harmful Routines

Use of enema: uncomfortable, may damage bowel, does not change duration of labor, incidence of neonatal infection or perinatal wound infection

Pubic shaving: discomfort with regrowth of hair, does not reduce infection, may increase transmission of HIV and hepatitis

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

Manual exploration of the uterus after delivery

Nielson 1998; WHO 1999.


Harmful Practices

Examinations:

Rectal examination: Similar incidence of puerperal infection, uncomfortable for woman

Routine use of x-ray pelvimetry: Increases incidence of childhood leukemia

Position:

Routine use of supine position during labor Routine use of lithotomy position with or without stirrups

during labor


Harmful Interventions

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

Sustained, directed bearing down efforts during the second stage of labor

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

Fundal pressure during labor

Eason et al 2000.


Inappropriate Practices

Restriction of food and fluids during labor

Routine intravenous infusion in labor

Repeated or frequent vaginal examinations, especially by more than one caregiver

Routinely moving laboring woman to a different room at onset of second stage

Encouraging woman to push when full dilation or nearly full dilation of cervix has been diagnosed, before woman feels urge to bear down

Nielson 1998; Ludka and Roberts 1993.


Inappropriate Practices

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

Liberal or routine use of episiotomy

Liberal or routine use of amniotomy


Practices Used for Specific Clinical Indications

Bladder catheterization

Operative delivery

Oxytocin augmentation

Pain control with systemic agents

Pain control with epidural analgesia

Continuous electronic fetal monitoring


Normal Labor and Childbirth: Conclusion

Have a skilled attendant present

Use partograph

Use specific criteria to diagnose active labor

Restrict use of unnecessary interventions

Use active management of third stage of labor

Support woman’s choice for position during labor and childbirth

Provide continuous emotional and physical support to woman throughout labor


ReferencesCarroli G and J Belizan. 2000. Episiotomy for vaginal birth (Cochrane Review), in The Cochrane Library. Issue 2. Update Software: Oxford.Eason E et al. 2000. Preventing perineal trauma during childbirth: A systematic review. Obstet Gynecol 95: 464–471.Gupta JK and VC Nikodem. 2000. Woman’s position during second stage of labour (Cochrane Review), in The Cochrane Library. Issue 4. Update Software: Oxford.Lauzon L and E Hodnett. 2000. Caregivers' use of strict criteria for diagnosing active labour in term pregnancy (Cochrane Review), in The Cochrane Library. Update Software: Oxford.Ludka LM and CC Roberts. 1993. Eating and drinking in labor: A literature review. J Nurse-Midwifery 38(4): 199–207.Madi BC et al. 1999. Effects of female relative support in labor: A randomized control trial. Birth 26:4–10.Neilson JP. 1998. Evidence-based intrapartum care: evidence from the Cochrane Library. Int J Gynecol Obstet 63 (Suppl 1): S97–S102.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.

normal labor and childbirth advances in maternal and neonatal health

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