Normal Labor and Childbirth

1
Normal Labor and Childbirth

• Advances in Maternal and Neonatal Health

2
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

3
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

4
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
  competence
• Performs all basic midwifery interventions

WHO 1999.
5
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

6
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

7
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

8
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

9
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.
10
WHO Partograph Results of Study
WHO 1994.
11
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.
12
Criteria to Diagnose Active Labor Results with
Statistical Significance
Lauzon and Hodnett 2000.
13
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

Lauzon and Hodnett 2000.
14
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.
15
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.
16
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
1999.
17
Indicated Use of Episiotomy Reviewers
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.
18
Clean Delivery

• Infection accounts for 14.9 of all maternal
  deaths
• These deaths can be avoided with infection
  prevention practices

19
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 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

20
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.
21
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
  0.040.33)
• Offer oral fluids throughout labor and childbirth

Neilson 1998.
22
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

23
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

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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.
25
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.
26
Presence of Female Relative During Labor Results

• Randomized controlled trial in Botswana 53 women
  with relative 56 without

Madi et al 1999.
27
Presence of Female Relative During Labor
Conclusion

• Support from female relative improves labor
  outcomes

Madi et al 1999.
28
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.
29
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

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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.
31
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.
32
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

33
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

34
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

35
References

• 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.