Normal Labor andd Childbirth

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Normal Labor and Childbirth

Advances in Maternal and Neonatal Health



2Normal 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 patientidentifying 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 delivery

Spontaneous

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) 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





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.





Maternal Outcomes Assessed

Severe vaginal/perineal trauma

Need for suturing

Posterior/anterior perineal trauma

Perineal pain

Dyspareunia

Urinary incontinence

Healing complications

Perineal infection






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 perineum

to prevent trauma


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)


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 lacerationsand 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






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 associatedwith shorter labor, less medication and epidural analgesia and

fewer operative deliveries

WHO 1999.




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 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 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 stirrupsduring labor






Inappropriate Practices

Restriction of food and fluids during labor

Routine intravenous infusion in labor

Repeated or frequent vaginal examinations, especially by morethan 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 feelsurge to bear down

Nielson 1998;

Ludka and Roberts 1993.






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

Cochr ane Library. Issue 2. Update Software: Oxford.

Eason E et al. 2000. Preventing perineal trauma during childbirth: A systematicreview. 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 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. JNurse-Midwifery 38(4): 199 –207.

Madi BC et al. 1999. Effects of female relative support in labor: A randomized controltrial. Bir th 26:4 –10.

Neilson JP. 1998. Evidence-based intrapartum care: evidence from the CochraneLibrary. In t 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 Technica l Work ing Grou p . WHO: Geneva.

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