Improved Labor Care to Reduce Neonatal Asphyxia

Jeffrey M. SmithMaternal Health Team Leader

Interventions for Impact in Essential Obstetric and Newborn CareAfrica Regional Meeting, 21-25 February, 2011

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Afghanistan2002

Maternal Mortality Survey showed an MMR of 1600 MD / 100 000 LB

77% of newborns died if they were born to mothers who died

Newborn mortality and health are directly linked to maternal mortality and health

Bartlett, et al. 2005

Parent Death & Child Survival in Bangladesh

Cumulative probability of survival of child to age 10 years

Father alive: 88.6%Father dead: 89.3%

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Mother alive: 88.9% Mother dead: 23.8%

Ronsmans LANCET 2010

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Improved maternal care will result in improved newborn outcomes

Use of evidence-based labor and delivery practices will achieve: Reduced maternal

and newborn morbidity and mortality

Improved quality of care

Respect for women and newborns

Obstetrics/Midwiferyis watchful waiting

Obstetrics – From the Latin obstare: to stand by To wait, to be vigilant, to be ready

Midwife With women

Watchful waiting • For mother, for newborn • For complications• Interventions when proven and necessary

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Intrapartum Care to Prevent Asphyxia:

Good maternal and newborn care: Use partograph for vigilant labor

monitoring Allow companionship during labor and birth Ensure supportive 2nd stage management

based on fetal and maternal condition Avoid incorrect practices Manage pre-eclampsia correctly

Ensure skilled attendance at birth to prevent and manage asphyxia

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Use of thePartograph

Partograph: Drugs provided

• Including oxytocin Amniotic fluid

condition Fetal heart rate

Use of Partograph combines all needed documentation

Ob and Peds leaders should ensure its use

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Use of the Partograph

How does the Partograph prevent asphyxia? Identify abnormal heart rate

patterns Prevent prolonged labor

• Prevents unnecessary augmentation using oxytocin

• Prevents infection Ensure timely Caesarean Prevent hyperstimulation Encourage greater vigilance

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Intrapartum care to prevent asphyxia

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Use of analgesia/anesthesia during laborElectronic fetal monitoring

Problems during laborProlonged labor

Operative vaginal birthEpisiotomy

Perineal traumaCesarean

Five-minute Apgar <7Newborn need for oxygen

Admission of Newborn to Newborn Care UnitProlonged hospital stay for newborn

Newborn sepsisSevere pain during labor

Labor worse than expectedStruggle in enduring birth

Feeling of tension and anxiety during laborPoor labor experience

Struggle with medical staffLack of exclusive breastfeeding at 6 weeksSevere postpartum depression at 6 weeks

14 studies 5021 women

Relative Risk (95%CI)

.1 .2 1 5 10

0.79 (0.75-0.84)0.78 (0.58-1.07)0.48 (0.36-0.63)0.05 (0.00-0.86)0.81 (0.72-0.92)0.66 (0.48-0.92)0.95 (0.88-1.03)0.80 (0.68-0.93)0.50 (0.29-0.89)0.94 (0.59-1.50)0.87 (0.68-1.11)0.61 (0.37-1.01)0.45 (0.21-0.96)1.01 (0.93-1.10)0.77 (0.62-0.97)0.74 (0.55-1.00)0.80 (0.63-1.03)0.72 (0.57-0.91)1.07 (0.51-2.26)0.82 (0.74-0.91)0.03 (0.00-0.52)

EMOTIONAL SUPPORTDURING LABOREMOTIONAL SUPPORTDURING LABOR

Pre-Eclampsia Management

Undiagnosed/inadequately managed severe pre-eclampsia results in Maternal seizure Severe hypertension Emergency Caesarean

Proper management of severe PE / Eclampsia Prevent seizures: Mg SO4

Treat hypertension: anti-hypertensives Ensure timely delivery Increase obstetrical monitoring – not darkness

and quiet at the end of the corridor

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Neonatal Asphyxia

Intrapartum care to prevent asphyxia

Second stage labor management

Continue monitoring of fetal heart Check every 5 minutes, record every 30 min. If fetal heart rate is normal, no need to rush

delivery Do NOT urge the woman to immediately and

continuously bear down Allow some descent – makes pushing easier Rest in between pushes allows oxygenated

blood to reach placenta/fetus Do NOT push on fundus

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Intrapartum care to prevent asphyxia

Alternative positions

Supine/lithotomy: uterus compresses vessels reduced uterine blood flow

1st stage labor: left side, standing, walking

2nd stage labor: squatting, sitting, hands & knees

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Intrapartum care to prevent asphyxia

Labor Management

Adequate hydration and nutrition during labor essential Dehydration compromises uterine blood

flow Allow women to drink freely and take

small amounts of food during labor

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Intrapartum care to prevent asphyxia

Labor augmentation

Medical decision based on medical reasons

Use Partograph to diagnose protracted active phase

Provide oxytocin using protocols in MCPC

Do NOT allow uncontrolled oxytocin for augmentation Causes tetanic uterine

contractions Complete restriction of blood

flow to fetus

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Intrapartum care to prevent asphyxia

Other supportive practices

Clean birthing practices/infection prevention Infected babies don’t breathe well

Doing procedures right! Vacuum extraction and breech delivery Twin delivery – management of 2nd twin

Keep normal births normal!

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Let Babies Breathe!

Prevent asphyxia Monitor with partographCompanionship, hydration, positionPrevent eclampsia No uncontrolled oxytocin Supportive 2nd stage based on fetal condition

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Thank you!

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