Essential Intrapartum Care 5/6/2013

Prepared by Team EINC for APDCN Faculty

May 6, 2013 1
ESSENTIAL
INTRAPARTUM CARE
From Evidence to Practice
Cynthia Tan, MD, FPOGS
Medical Specialist IV
Chief, Human Resource Development Services, Fabella Hospital
Co-convenor, Team EINC

5/6/2013 Prepared by Team EINC for APDCN Faculty
Objectives
Discuss the problem of maternal mortality
rates and its impact on the attainment of
MDG 5
Discuss interventions that are recommended
and are not recommended during:
o Antepartum
o Labor
o Delivery
o Immediate post-partum


5/6/2013 Prepared by Team EINC for APDCN Faculty
Too many mothers and newborns
are dying every year
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ANTEPARTUM CARE
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ANTENATAL CARE
At lease 4 antenatal visits with a skilled
health provider
To detect diseases which may complicate
pregnancy
To educate women on danger and emergency
signs & symptoms
To prepare the woman and her family for
childbirth

5/6/2013 Prepared by Team EINC for APDCN Faculty
Essential Intrapartum Care 5/6/2013
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To detect diseases which may
complicate pregnancy
Screen
Anemia
Pre-eclampsia
Diabetes Mellitus
Syphilis

Detect
PROM
Preterm labor
Prevent
Ferrous and folic acid
supplementation
Tetanus toxoid
immunization
Corticosteroids for
preterm labor
Treat
Ferrous sulfate for anemia
Antihypertensive meds and
Magnesium sulfate for
SEVERE pre-eclampsia
REFER





5/6/2013 Prepared by Team EINC for APDCN Faculty
Antenatal Corticosteroids
Administer ANTENATAL STEROIDS to all
patients who are at risk for preterm
delivery
with preterm labor between 24-34 weeks AOG
or with any of the following prior to term:
Antepartal hemorrhage/bleeding
Hypertension
(preterm) Pre-labor rupture of membranes



5/6/2013 Prepared by Team EINC for APDCN Faculty
Antenatal Steroids
Overall reduction in neonatal death

Reduction in RDS

Reduction in cerebroventricular hemorrhage


Reduction in sepsis in the first 48 hours of life

Roberts D, Dalziel SR. Cochrane Database of
Systematic Reviews 2006, Issue 3.


Betamethasone 12 mg IM q 24 hrs x 2 doses OR
DEXAMETHASONE 6 mg IM q 12 x 4 doses


5/6/2013 Prepared by Team EINC for APDCN Faculty
DEXAMETHASONE PHOSPHATE
2ml ampules: 4mg/ml
6 mg 1.5 ml injected intramuscularly
Even a single dose of 6 mg IM before
delivery is beneficial

emergency drug
should be available
at the OPD and ER
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GSCH Dexa Area & Tray in the ER, DR, Ward
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DANGER SIGNS and SYMPTOMS
Vaginal bleeding
Headache
Blurring of vision
Abdominal Pain
Severe difficulty breathing
Dangerous fever (T>38, weak)
Burning on urination



Educate women on
5/6/2013 Prepared by Team EINC for APDCN Faculty
Essential Intrapartum Care 5/6/2013
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May 6, 2013 3
Prepare the woman and her
family for childbirth
Counsel on
Proper nutrition and self care during pregnancy
Breastfeeding and family planning
BIRTH PLAN
Where she will deliver; transportation
Who will assist her delivery
What to expect during labor and delivery
What to prepare, estimated cost of delivery
Possible blood donors; where will she be referred
in case of emergency



5/6/2013 Prepared by Team EINC for APDCN Faculty
SAMPLE
BIRTH
AND
EMERGENCY
PLAN
5/6/2013 Prepared by Team EINC for APDCN Faculty
Birth and
Emergency
Planning in the
OPD 5/6/2013 Prepared by Team EINC for APDCN Faculty
INTRAPARTUM CARE
5/6/2013 Prepared by Team EINC for APDCN Faculty
Updated, evidence based national guideline
on intrapartum and immediate postpartum
care
To be used by health professionals
(OB SPECIALISTS, OB PRACTITIONERS,
NURSES and MIDWIVES) in all
GOVERNMENT AND PRIVATE
health facilities

Intrapartum Care
Clinical Practice Guidelines
5/6/2013 Prepared by Team EINC for APDCN Faculty
Evidence based approach
Based on the results of studies with acceptable
quality

Formal consensus approach
Discuss issues on generalizing the evidence to
the local scenario, taking into account
Harms and benefits
Costs
Preferences
Best available evidence

RECOMMENDATIONS
THE CPG DEVELOPMENT PROCESS

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Essential Intrapartum Care 5/6/2013
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RECOMMENDED PRACTICES
DURING LABOR
5/6/2013 Prepared by Team EINC for APDCN Faculty
Recommended Practices During Labor
Active phase labor:
2-3 contractions in 10
minutes
Cervix is 4 cm dilated
1. Admission to
labor when the
parturient is
already in the
active phase.


5/6/2013 Prepared by Team EINC for APDCN Faculty
Recommended Practices During Labor:
Admit when the parturient is already
in ACTIVE LABOR
No difference in Apgar score
need for Cesarean Section by 82%
No difference in need for labor
augmentation

Rahnama, P., et.al., 2006: prospective cohort study on 810 low risk
nulliparas (474 in latent phase; 336 in active phase )

5/6/2013 Prepared by Team EINC for APDCN Faculty
Recommended Practices During Labor
1. Admission to labor when
the parturient is already in
the active phase.
2. Continuous
maternal support


5/6/2013 Prepared by Team EINC for APDCN Faculty
Continuous maternal support
Need for pain relief by 10%
Duration of labor SHORTER by half an hour
spontaneous vaginal delivery by 8%
Instrumental vaginal delivery 10%
5 minute Apgar < 7 by 30%

Source of evidence: Cochrane review (21 trials, 15,061 women)
comparing one-to-one intrapartum support given by variety of
providers (nurses, midwives, doulas, partner, female relative,
friend) versus usual care (Hodnett, E.D., et.al., 2011)

5/6/2013 Prepared by Team EINC for APDCN Faculty
Having a LABOR COMPANION can
result in:
Less use of pain relief drugs Increased
alertness of baby
Baby less stressed , uses less energy
Reduced risk of infant hypothermia
Reduced risk of hypoglycemia
Early and frequent breastfeeding
Easier bonding with the baby
5/6/2013 Prepared by Team EINC for APDCN Faculty
Essential Intrapartum Care 5/6/2013
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May 6, 2013 5
1. Admission to labor
when the parturient is
already in the active
phase.
2. Continuous maternal
support
3. Upright position
during first stage
of labor
Recommended Practices
During Labor
5/6/2013 Prepared by Team EINC for APDCN Faculty
Freedom of movement - distract
mothers from the discomfort of labor,
release muscle tension, and give a
mother the sense of control over her
labor (Storton, 2007).

5/6/2013 Prepared by Team EINC for APDCN Faculty
UPRIGHT POSITION DURING
LABOR
First stage of labor shorter by about 1 hour
Need for epidural analgesia by 17%
No difference in rates of SVD , CS, and
Apgar score < 7 at 5 minutes



Source of Evidence: Cochrane review (21 studies involving 3,706 women)
comparing upright versus recumbent position
(Lawrence, A., et.al., 2009)

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Restricting practices limit a mothers
freedom to move and/or her position of choice.
1. IV lines*
2. fetal monitoring
3. labor stimulating medications that require
monitoring of uterine activity,
4. small labor rooms,
5. epidural placement
6. absence of support persons to be with the
intrapartum client
5/6/2013 Prepared by Team EINC for APDCN Faculty
Recommended Practices During Labor
1. Admission to labor
when the parturient is
already in the active
phase.
2. Continuous maternal
support
3. Upright position during
first stage of labor
4. Routine use of
WHO partograph to
monitor progress of
labor


For early identification of abnormal progress of labor
5/6/2013 Prepared by Team EINC for APDCN Faculty
Recommended Practices During Labor
No difference in
endometritis
UTI lower by 34%
An observational study on 161,077 women (with
or w/o PPROM) who had < 5 exams (Ayzac, L.,
et.al., 2008)

Chorioamnionitis by 72%
Neonatal sepsis by 61%
1 RCT on 5,018 women with PROM comparing < 3 exams
vs 3 exams (Seaward, P.G., et.al., 1998)



1. Admission to labor
when the parturient
is already in the
active phase.
2. Continuous maternal
support
3. Upright position
during first stage of
labor
4. Routine use of WHO
partograph to
monitor progress of
labor
5. Limit total
number of IE to
5 or less.


5/6/2013 Prepared by Team EINC for APDCN Faculty
Essential Intrapartum Care 5/6/2013
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May 6, 2013 6
PRACTICES NOT RECOMMENDED
DURING LABOR
5/6/2013 Prepared by Team EINC for APDCN Faculty
Interventions that are NOT recommended
during labor
No difference in rates of
maternal fever, perineal
wound infection, and
perineal wound
dehiscence
No neonatal infection
was observed

1. Routine
perineal
shaving on
admission
for labor and
delivery.

Evidence: Cochrane review (3 trials) comparing it with
no shaving (Basevi, V. and Lavender, T., 2000
updated 2008)


5/6/2013 Prepared by Team EINC for APDCN Faculty
Interventions that are NOT
recommended during labor
Fecal soiling during
delivery reduced by 64%
No difference in maternal
puerperal infection,
episiotomy dehiscence,
neonatal infection, and
neonatal pneumonia
1. Routine perineal
shaving on
admission for
labor and
delivery.
2. Routine
enema
during the
first stage
of labor.

Source of Evidence: Cochrane review (4 trials)
comparing it with no enema (Reveiz, L., et.al.
2007 updated 2010)

5/6/2013 Prepared by Team EINC for APDCN Faculty
Practices that are NOT recommended
during labor
No difference in
chorioamnionitis,
postpartum endometritis,
perinatal mortality,
neonatal sepsis
No side effects reported
1. Routine perineal
shaving on
admission for
labor and
delivery.
2. Routine enema
during the first
stage of labor.
3. Routine
vaginal
douching.

Source of Evidence: Cochrane review
(3 trials that used different concentrations
and volumes of Chlorhexidine) comparing it
with sterile saline (Lumbiganon, P., et.al.,
2004 updated 2009)

5/6/2013 Prepared by Team EINC for APDCN Faculty
Practices that are NOT recommended
during labor
Risk of dysfunctional
labor by 25%
No difference in duration of
labor, CS rate, cord
prolapse, maternal
infection and Apgar score
< 7 at 5 minutes
1. Routine perineal
shaving on
admission for labor
and delivery.
2. Routine enema
during the first
stage of labor.
3. Routine vaginal
douching.
4. Routine
amniotomy to
shorten
spontaneous
labor

Source of Evidence: Cochrane review -14 trials
involving 4,893 women. (Smyth, R.M.D., et.al.,
2007 updated 2010)

5/6/2013 Prepared by Team EINC for APDCN Faculty
Oxytocin Augmentation
Should only be used to augment labor in
facilities where there is immediate access
to caesarean section should the need
arise.

Use of any IM oxytocin before the birth of
the infant is generally regarded as
dangerous because the dosage cannot be
adapted to the level of uterine activity.
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Essential Intrapartum Care 5/6/2013
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Routine IVF
Advantage
to have ready
access for
emergency
medications
to maintain
maternal hydration

Disadvantage
Interferes with the
natural birthing process
restricts womans
freedom to move
IVF not as effective as
allowing food and fluids
in labor to treat/prevent
dehydration, ketosis or
electrolyte imbalance
POGS CPG on NORMAL LABOR AND DELIVERY, 2009
5/6/2013 Prepared by Team EINC for APDCN Faculty
Routine IVF
No study found showing that having an IV in
place improves outcome
Even the prophylactic insertion of
an IV line should be considered
unnecessary intervention.







Philippine Ob-Gyn Society CPG on Normal Labor and Delivery, 2009




5/6/2013 Prepared by Team EINC for APDCN Faculty
Routine NPO During Labor
Possible risk of aspirating gastric contents with
the administration of anesthesia
One study evaluated the probable risk of
maternal aspiration mortality, which is
approximately 7 in 10 million births.
No evidence of improved outcomes for mother
or newborn.
Use of epidural anesthesia for intrapartum
anesthesia in an otherwise normal labor should
not preclude oral intake.
Sleutel, M., and Golden, S., 1999
POGS CPG on Normal Labor and Delivery, 2009
5/6/2013 Prepared by Team EINC for APDCN Faculty
Routine NPO During Labor
For the normal, low risk birth, there is no
need for restriction of food except where
intervention is anticipated.
A diet of easy to digest foods and fluids
during labor is recommended.
Isotonic calorific drinks consumed during
labor reduce the incidence of maternal
ketosis without increasing gastric volumes.
Singata M, Tranmer J, Gyte GML. Restricting oral fluid and food intake during labour.
Cochrane Database of Systematic Reviews 2010, Issue 1.
POGS CPG ON NORMAL LABOR AND DELIVERY, 2009
WHO Care in Normal Birth, 1996
5/6/2013 Prepared by Team EINC for APDCN Faculty
CARE DURING LABOR
RECOMMENDED
Admission to labor when
in the active phase.
Companion of choice to
provide continuous
maternal support
Mobility and upright
position
Allow food and drink
Use of WHO partograph
to monitor progress of
labor
Limit IE to 5 or less.
NOT RECOMMENDED
Routine perineal shaving
on admission
Routine enema
Routine NPO
Routine IVF
Routine vaginal douching.
Routine amniotomy
Routine oxytocin
augmentation

5/6/2013 Prepared by Team EINC for APDCN Faculty
PRACTICES RECOMMENDED
DURING DELIVERY
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Essential Intrapartum Care 5/6/2013
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Please
wash your
hands!
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Traditional

Defined by a fully
dilated cervix
Coached to push
though out-of-phase
with her own
sensation

Redefined as complete
cervical dilatation +
spontaneous explusive
efforts (Simkin, 1991)
Pelvic phase of
passive descent
Perineal phase of
active pushing
Non-Traditional
Diagnosis of the 2
nd
Stage of Labor
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Management of the 2
nd
Stage of Labor
Traditional
DIRECTED PUSHING
Valsalva pushing

Venous Return

Perfusion to Uterus,
Placenta & Fetus

FHR Changes

Fetal hypoxia & acidosis


Roberts,1996; Simkin, 2000;Roberts,1987 as cited in Roberts,
Joyce,Journal of Midwifery and Womens Health.Vol. 47,No.1
Jan/Feb 2002
Non-Traditional
INVOLUNTARY BEARING DOWN
Exhalation pushing
Let air out
Parturient-directed
Physiologic: force of bearing
down efforts increases as
fetal descent occurs
Avoids hypoxia and acidosis



Nikodem,VC. Beaaring down Methods during second stage labour (Cochrane
Review) In: The Cochrane Library, Issue 2, 2001 as cited by Roberts,
2002
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UPRIGHT POSITION DURING
DELIVERY
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UPRIGHT position during delivery
More efficient uterine contractions
Improved fetal alignment
Larger anterior-posterior and transverse
diameters of pelvic outlet enhances fetal
movement through the maternal pelvis in
descent for birth
Faster delivery
Leads to less interventions : less episiotomies.

Shilling, Romano, & DiFranco, 2007

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Interventions that are recommended
during delivery
1.Upright
position
during
delivery
2.Selective
(non-routine)
episiotomy
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Perineal Support and Controlled Delivery of
the Head
Keep one hand on the
head as it advances
during contractions while
the other hand supports
the perineum.
During delivery of the head,
encourage woman to stop
pushing and breathe rapidly
with mouth open.
5/6/2013 Prepared by Team EINC for APDCN Faculty
Non-Routine Episiotomy
Anterior perineal trauma by 84%
Posterior perineal trauma by 12%
2
nd
-4
th
degree tears by 33%
Need for suturing by 29%
No difference in infection rate
Source of Evidence: Cochrane review (8 trials) that include both primis and multis
and used median or mediolateral episiotomy (Carroli, G., and Mignini, L., 2009)

5/6/2013 Prepared by Team EINC for APDCN Faculty
Interventions that are recommended
during delivery
1. Upright position
during delivery
2. Selective episiotomy
3. Use of
prophylactic
oxytocin for
management of
third stage of
labor OXYTOCIN 10 U
intramuscular
Palpate abdomen to rule out
a second baby
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Prophylactic OXYTOCIN for the
3
rd
stage of labor
Postpartum blood loss 500 ml reduced by 39%
Need for additional uterotonic reduced by 47%
No difference in need for maternal blood
transfusion, need for manual removal of
placenta, and duration of third stage


Source of Evidence: Cochrane review (4 trials on 2,213 women) using
varied doses, route, and timing of administration of oxytocin (Cotter,
A.M., et.al., 2002 updated 2004)

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Essential Intrapartum Care 5/6/2013
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Interventions that are recommended
during delivery
Early clamping : <1 min after birth
Delayed (properly timed) :1-3
minutes after birth or when
pulsations stop

1. Upright position during
delivery
2. Selective episiotomy
3. Use of prophylactic
oxytocin for mgt of 3rd
stage of labor
4. Delayed cord
clamping
5/6/2013 Prepared by Team EINC for APDCN Faculty
Lower infant hemoglobin at
birth and at 24 hrs after birth
prevented
Fewer infants requiring
phototherapy for jaundice
No difference in rates of
polycythemia, need for
neonatal resuscitation, and
NICU admission


PROPERLY TIMED CORD CLAMPING
Source of Evidence: Cochrane review (8
trials; 2,399 women) comparing early versus
delayed cord clamping (McDonald, S.J., and
Middleton, P., 2008)

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Interventions that
are recommended
during delivery
1. Upright position
during delivery
2. Selective episiotomy
3. Use of prophylactic
oxytocin for
management of third
stage of labor
4. Delayed cord
clamping
5. Controlled cord
traction with
countertraction to
deliver the
placenta
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Controlled Cord Traction
Postpartum blood loss >500ml by 7%
Postpartum blood loss >100ml by 24%
No difference in rates of maternal mortality
or serious morbidity and need for
additional uterotonics.

Source of Evidence: Pooled analysis of 2 RCTs (23000 subjects) comparing it
with the hands off approach. (Althabe, F et al, 2009; Gulmezoglu AM et al,
2012)
5/6/2013 Prepared by Team EINC for APDCN Faculty
Interventions that are recommended
during delivery
1. Upright position
during delivery
2. Selective episiotomy
3. Use of prophylactic
oxytocin
4. Delayed cord
clamping
5. Controlled cord
traction with
countertraction
6. Uterine massage
after placental
delivery
Lower mean blood loss
Less need for uterotonics

Source of evidence: Cochrane review (1 trial on 200
women who delivered vaginally and AMTSL done vs
massage. ) Hofmeyr, GJ et al 2008
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1. Administration of uterotonic within one minute
of delivery of the baby.
2. Controlled cord traction with counter traction on
the uterus
3. Uterine massage
POPPHI. Prevention of Postpartum Hemorrhage: Implementing Active Management of the Third Stage
of Labor (AMTSL): A Reference Manual for Health Care Providers. Seattle: PATH; 2007.
Active Management of the Third
Stage (AMTSL)
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Approaches in the
Mgt of the 3rd Stage of Labor
Physiologic (Expectant) Active
(AMTSL)
Uterotonic NOT GIVEN before
placenta is delivered
GIVEN within 1 min. of
babys birth
Signs of placental
separation
WAIT DONT WAIT
Delivery of the
placenta
By gravity with maternal
effort
CCT with counter
traction on the uterus
Uterine massage After placenta is
delivered
After placenta is
delivered
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PRACTICES NOT RECOMMENDED
DURING DELIVERY
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Interventions that are NOT
recommended during delivery
Based on review, there is clear
benefit (3
rd
-4
th
degree teaars)
and no clear harm (no difference
in 1sr and 2
nd
degree tears,
vaginal pain, blood loss)
Commonly noted complications in
practice (perineal edema, perineal
wound infection, and perineal
wound dehiscence) were not
evaluated
Further studies are needed.


1. Perineal
massage
in the 2
nd

stage of
labor


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Interventions that are NOT
recommended during delivery
1. Perineal massage
in the 2
nd
stage of
labor
2. Fundal
pressure
during the
second stage
of labor



5/6/2013 Prepared by Team EINC for APDCN Faculty
Fundal Pressure during 2nd stage
2nd stage longer by 29 minutes
Increased 3
rd
and 4
th
degree perineal tears
No difference in rates of postpartum
hemorrhage, instrumental vaginal delivery,
Apgar score < 7 at 5 minutes, and NICU
admission
Uterine rupture was not evaluated

Source of Evidence: Pooled analysis of Cochrane review (with 1 trial
only) (Verheijen, E.C., et.al., 2009) and 2 randomized trials (Cosner,
K., 1996; Matsuo, K., et.al., 2009) with overall total of 1,229 patients


5/6/2013 Prepared by Team EINC for APDCN Faculty
CARE DURING DELIVERY
RECOMMENDED
Upright position during
delivery
Selective episiotomy
Use of prophylactic
oxytocin for mgt of 3rd
stage of labor
Delayed cord clamping
Controlled cord traction
with countertraction to
deliver the placenta
Uterine massage
NOT RECOMMENDED
Coaching the mother
to push
Perineal massage in
the 2
nd
stage of labor
Fundal pressure
during the second
stage of labor

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POSTPARTUM CARE
RECOMMENDED
Routinely inspect the birth
canal for lacerations
Inspect the placenta &
membranes for
completeness
Early resumption of feeding
(<6 hours after delivery)
Massage the uterus ensure
uterus is well contracted
Prophylactic antibiotics for
women with a 3rd or 4th
degree perineal tear
Early postpartum discharge
NOT RECOMMENDED
Manual exploration of
the uterus
Routine use of icepacks
over the hypogastrium.
Routine oral
methylergometrine

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Summary- Key Points
Maternal and neonatal mortality in the
Philippines is still unacceptably high
Prevention of postpartum hemorrhage
through interventions like the use AMTSL
will address the #1 cause of maternal
mortality
The evidence-based practices in the EINC
Protocol are lifesaving for both mother and
baby
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Let us put it into practice!
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