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 Normal Labor and Childbirth

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 Normal 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 caregiver’s competence • Performs all basic midwifery interventions Normal Labor and Childbirth 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 Normal Labor and Childbirth

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 Normal Labor and Childbirth

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 Normal Labor and Childbirth

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 Normal Labor and Childbirth

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 Normal Labor and Childbirth WHO 1994.

10. WHO Partograph: Results of Study Normal Labor and Childbirth 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 4–9 cm • Rate of dilation 1 cm/hour • Fetal descent begins Normal Labor and Childbirth Lauzon and Hodnett 2000.

12. Criteria to Diagnose Active Labor: Results with Statistical Significance Normal Labor and Childbirth 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 Normal Labor and Childbirth 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 Normal Labor and Childbirth 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 Normal Labor and Childbirth 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. Normal Labor and Childbirth

17. 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. Normal Labor and Childbirth

18. Clean Delivery • Infection accounts for 14.9% of all maternal deaths • These deaths can be avoided with infection prevention practices Normal Labor and Childbirth

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 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 Normal Labor and Childbirth

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 Normal Labor and Childbirth 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 0.58–0.79) • 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 Normal 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 Normal Labor and Childbirth

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 Normal Labor and Childbirth

24. 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) Normal Labor and Childbirth 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 Normal Labor and Childbirth WHO 1999.

26. Randomized controlled trial in Botswana: 53 women with relative; 56 without Presence of Female Relative During Labor: Results Normal Labor and Childbirth Madi et al 1999.

27. Presence of Female Relative During Labor: Conclusion Support from female relative improves labor outcomes Normal Labor and Childbirth 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 Normal Labor and Childbirth 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 Normal Labor and Childbirth

30. 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 Normal Labor and Childbirth 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. Normal Labor and Childbirth

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 Normal Labor and Childbirth

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 Normal Labor and Childbirth

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 woman’s choice for position during labor and childbirth • Provide continuous emotional and physical support to woman throughout labor Normal Labor and Childbirth

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: 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