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Normal Labor and Childbirth


Protect the life of the mother and newborn ... Rectal examination: Similar incidence of puerperal infection, uncomfortable for woman ... – PowerPoint PPT presentation

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Title: Normal Labor and Childbirth

Normal Labor and Childbirth
  • Advances in Maternal and Neonatal Health

Session Objectives
  • To identify best practices for managing labor and
  • 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 caregivers
  • 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
  • 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
  • At active phase action line consider Oxytocin
    augmentation, cesarean section, or observation
    AND supportive treatment

WHO 1994.
WHO Partograph Results of Study
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 49 cm
  • Rate of dilation ?1 cm/hour
  • Fetal descent begins

Lauzon and Hodnett 2000.
Criteria to Diagnose Active Labor Results with
Statistical Significance
Lauzon and Hodnett 2000.
Criteria to Diagnose Active Labor Discussion
  • Use of strict criteria for diagnosis of active
  • May prevent misdiagnosis of dystocia in latent
    phase labor
  • Prevent unnecessary (and potentially risky)
    interventions including cesarean section
  • Insufficient power to test effects of
    intervention on rates of cesarean section,
    unplanned out-of-hospital birth or other
    important maternal and newborn outcomes

Lauzon and Hodnett 2000.
Restricted Use of Episiotomy Objectives and
  • Objective To evaluate possible benefits, risks
    and costs of restricted use of episiotomy vs.
    routine episiotomy
  • Design Meta analysis of six randomized control

Carroli and Belizan 2000.
Restricted Use of Episiotomy Maternal Outcomes
  • 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
  • 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
Indicated Use of Episiotomy Reviewers
  • 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

Carroli and Belizan 2000.WHO 1999.
Clean Delivery
  • Infection accounts for 14.9 of all maternal
  • These deaths can be avoided with infection
    prevention practices

Infection Prevention Practices
  • Use disposable materials once and decontaminate
    reusable materials throughout labor and
  • Wear gloves during vaginal examination, during
    birth of newborn and when handling placenta
  • Wear protective clothing (shoes, apron, glasses)
  • Wash hands
  • Wash womans perineum with soap and water and
    keep it clean
  • Ensure that surface on which newborn is delivered
    is kept clean
  • High-level disinfect instruments, gauze and ties
    for cutting cord

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
  • 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 0.580.79)
  • Fewer operative vaginal deliveries OR 0.73 (95
    CI 0.620.88)
  • Less postpartum depression at 6 weeks OR 0.12 (CI
  • 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
  • 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 3.96.9)
  • 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
  • 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 gt 500 mL (OR 1.76, CI 1.343.32)

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
  • 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

WHO 1999.
Presence of Female Relative During Labor Results
  • Randomized controlled trial in Botswana 53 women
    with relative 56 without

Madi et al 1999.
Presence of Female Relative During Labor
  • Support from female relative improves labor

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
  • 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 womans choice for position during labor
    and childbirth
  • Provide continuous emotional and physical support
    to woman throughout labor

  • Carroli G and J Belizan. 2000. Episiotomy for
    vaginal birth (Cochrane Review), in The Cochrane
    Library. Issue 2. Update Software Oxford.
  • Eason E et al. 2000. Preventing perineal trauma
    during childbirth A systematic review. Obstet
    Gynecol 95 464471.
  • Gupta JK and VC Nikodem. 2000. Womans position
    during second stage of labour (Cochrane Review),
    in The Cochrane Library. Issue 4. Update
    Software Oxford.
  • Lauzon L and E Hodnett. 2000. Caregivers' use of
    strict criteria for diagnosing active labour in
    term pregnancy (Cochrane Review), in The Cochrane
    Library. Update Software Oxford.
  • Ludka LM and CC Roberts. 1993. Eating and
    drinking in labor A literature review. J
    Nurse-Midwifery 38(4) 199207.
  • Madi BC et al. 1999. Effects of female relative
    support in labor A randomized control trial.
    Birth 26410.
  • Neilson JP. 1998. Evidence-based intrapartum
    care evidence from the Cochrane Library. Int J
    Gynecol Obstet 63 (Suppl 1) S97S102.
  • World Health Organization Safe Maternal Health
    and Safe Motherhood Programme. 1994. World Health
    Organization partograph in management of labour.
    Lancet 343 (8910)13991404.
  • World Health Organization (WHO). 1999. Care in
    Normal Birth A Practical Guide. Report of a
    Technical Working Group. WHO Geneva.