Essential Intrapartum Care 5/6/2013

Objectives
• Discuss the problem of maternal mortality
ESSENTIAL rates and its impact on the attainment of
MDG 5
INTRAPARTUM CARE • Discuss interventions that are recommended
From Evidence to Practice
and are not recommended during:
o Antepartum
Cynthia Tan, MD, FPOGS
o Labor
Medical Specialist IV
Chief, Human Resource Development Services, Fabella Hospital
o Delivery
Co-convenor, Team EINC o Immediate post-partum

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Too many mothers and newborns

are dying every year…

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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
ANTEPARTUM CARE
• To prepare the woman and her family for
childbirth

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To detect diseases which may

complicate pregnancy
Antenatal Corticosteroids
• Administer ANTENATAL STEROIDS to all
• Prevent
Screen patients who are at risk for preterm
– Ferrous and folic acid
• Anemia supplementation delivery
• Pre-eclampsia – Tetanus toxoid – with preterm labor between 24-34 weeks AOG
• Diabetes Mellitus immunization
• Syphilis – Corticosteroids for
– or with any of the following prior to term:
preterm labor • Antepartal hemorrhage/bleeding
• Treat • Hypertension
Detect
– Ferrous sulfate for anemia • (preterm) Pre-labor rupture of membranes
• PROM – Antihypertensive meds and
• Preterm labor Magnesium sulfate for
SEVERE pre-eclampsia
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Antenatal Steroids DEXAMETHASONE PHOSPHATE

Betamethasone 12 mg IM q 24 hrs x 2 doses OR 2ml ampules: 4mg/ml
6 mg – 1.5 ml injected intramuscularly
DEXAMETHASONE 6 mg IM q 12 x 4 doses
Even a single dose of 6 mg IM before
• Overall reduction in neonatal death delivery is beneficial
• Reduction in RDS
• Reduction in cerebroventricular hemorrhage emergency drug
should be available
• Reduction in sepsis in the first 48 hours of life at the OPD and ER

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Systematic Reviews 2006, Issue 3.

Educate women on
GSCH Dexa Area & Tray in the ER, DR, Ward
DANGER SIGNS and SYMPTOMS
• Vaginal bleeding
• Headache
• Blurring of vision
• Abdominal Pain
• Severe difficulty breathing
• Dangerous fever (T°>38, weak)
• Burning on urination

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Prepare the woman and her

family for childbirth
• Counsel on
– Proper nutrition and self care during pregnancy
– Breastfeeding and family planning SAMPLE
BIRTH
• BIRTH PLAN
AND
– Where she will deliver; transportation
EMERGENCY
– Who will assist her delivery
PLAN
– 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
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INTRAPARTUM CARE
Birth and
Emergency
Planning in the
OPD
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THE CPG DEVELOPMENT PROCESS

Intrapartum Care • Evidence based approach
Clinical Practice Guidelines – Based on the results of studies with acceptable
quality
• Updated, evidence based national guideline
on intrapartum and immediate postpartum • Formal consensus approach
care – Discuss issues on generalizing the evidence to
• To be used by health professionals the local scenario, taking into account
(OB SPECIALISTS, OB PRACTITIONERS, • Harms and benefits
• Costs RECOMMENDATIONS
NURSES and MIDWIVES) in all • Preferences
GOVERNMENT AND PRIVATE • Best available evidence
health facilities
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Recommended Practices During Labor

• Active phase labor:
1. Admission to
labor when the – 2-3 contractions in 10
parturient is minutes
already in the – Cervix is 4 cm dilated
active phase.

RECOMMENDED PRACTICES
DURING LABOR
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Recommended Practices During Labor: Recommended Practices During Labor

Admit when the parturient is already
1. Admission to labor when
in ACTIVE LABOR the parturient is already in
the active phase.
• No difference in Apgar score 2. Continuous
• ↓need for Cesarean Section by 82% maternal support

• 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 )

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Continuous maternal support Having a LABOR COMPANION can

result in:
• ↓Need for pain relief by 10% • Less use of pain relief drugs → Increased
• Duration of labor SHORTER by half an hour alertness of baby
• ↑spontaneous vaginal delivery by 8%
• Baby less stressed , uses less energy
• ↓ Instrumental vaginal delivery 10%
• 5 minute Apgar < 7 ↓ by 30%
– Reduced risk of infant hypothermia
– Reduced risk of hypoglycemia
• Source of evidence: Cochrane review (21 trials, 15,061 women)
comparing one-to-one intrapartum support given by variety of • Early and frequent breastfeeding
providers (nurses, midwives, doulas, partner, female relative,
friend) versus usual care (Hodnett, E.D., et.al., 2011) • Easier bonding with the baby
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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
Freedom of movement - distract
of labor mothers from the discomfort of labor,
release muscle tension, and give a
mother the sense of control over her
labor (Storton, 2007).

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UPRIGHT POSITION DURING

LABOR Restricting practices limit a mother’s
freedom to move and/or her position of choice.
• First stage of labor shorter by about 1 hour
• Need for epidural analgesia ↓ by 17% 1. IV lines*
• No difference in rates of SVD , CS, and 2. fetal monitoring
Apgar score < 7 at 5 minutes 3. labor stimulating medications that require
monitoring of uterine activity,
4. small labor rooms,
Source of Evidence: Cochrane review (21 studies involving 3,706 women) 5. epidural placement
comparing upright versus recumbent position
(Lawrence, A., et.al., 2009) 6. absence of support persons to “be with” the
intrapartum client
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Recommended Practices During Labor

Recommended Practices During Labor
1. Admission to labor
1. Admission to labor
when the parturient
• No difference in
when the parturient is
already in the active
is already in the
active phase. endometritis
phase. 2. Continuous maternal
support • UTI lower by 34%
2. Continuous maternal An observational study on 161,077 women (with
3. Upright position
support during first stage of or w/o PPROM) who had < 5 exams (Ayzac, L.,
3. Upright position during labor et.al., 2008)
first stage of labor 4. Routine use of WHO
partograph to
4. Routine use of monitor progress of • ↓ Chorioamnionitis by 72%
WHO partograph to labor
monitor progress of 5. Limit total • ↓ Neonatal sepsis by 61%
labor number of IE to 1 RCT on 5,018 women with PROM comparing < 3 exams
vs 3 exams (Seaward, P.G., et.al., 1998)
5 or less.
For early identification of abnormal progress of labor
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Essential Intrapartum Care 5/6/2013

Interventions that are NOT recommended

during labor

1. Routine • No difference in rates of

perineal maternal fever, perineal
shaving on wound infection, and
admission perineal wound
for labor and
dehiscence
delivery.
• No neonatal infection
PRACTICES NOT RECOMMENDED was observed
DURING LABOR Evidence: Cochrane review (3 trials) comparing it with
no shaving (Basevi, V. and Lavender, T., 2000
updated 2008)

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Interventions that are NOT

Practices that are NOT recommended
recommended during labor
during labor
1. Routine perineal • Fecal soiling during 1. Routine perineal • No difference in
shaving on shaving on
admission for delivery reduced by 64% admission for
chorioamnionitis,
labor and labor and postpartum endometritis,
delivery. • No difference in maternal delivery.
perinatal mortality,
2. Routine enema
2. Routine puerperal infection, during the first neonatal sepsis
enema episiotomy dehiscence, stage of labor.
• No side effects reported
during the neonatal infection, and 3. Routine
first stage neonatal pneumonia vaginal Source of Evidence: Cochrane review
(3 trials that used different concentrations
of labor. douching. and volumes of Chlorhexidine) comparing it
Source of Evidence: Cochrane review (4 trials) with sterile saline (Lumbiganon, P., et.al.,
comparing it with no enema (Reveiz, L., et.al. 2004 updated 2009)
2007 updated 2010)
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Practices that are NOT recommended

during labor
Oxytocin Augmentation
1. Routine perineal
shaving on • ↓Risk of dysfunctional • Should only be used to augment labor in
admission for labor labor by 25% facilities where there is immediate access
and delivery.
2. Routine enema • No difference in duration of to caesarean section should the need
during the first
labor, CS rate, cord arise.
stage of labor.
3. Routine vaginal prolapse, maternal
douching.
4. Routine
infection and Apgar score • Use of any IM oxytocin before the birth of
amniotomy to < 7 at 5 minutes the infant is generally regarded as
shorten Source of Evidence: Cochrane review -14 trials
spontaneous involving 4,893 women. (Smyth, R.M.D., et.al.,
dangerous because the dosage cannot be
labor 2007 updated 2010) adapted to the level of uterine activity.
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Routine IVF Routine IVF

Advantage Disadvantage
• No study found showing that having an IV in
• to have ready • Interferes with the
natural birthing process
place improves outcome
access for
emergency • restricts woman’s • Even the prophylactic insertion of
freedom to move an IV line should be considered
medications
• IVF not as effective as
• to maintain allowing food and fluids
unnecessary intervention.
maternal hydration in labor to treat/prevent
dehydration, ketosis or
electrolyte imbalance
Philippine Ob-Gyn Society CPG on Normal Labor and Delivery, 2009
POGS CPG on NORMAL LABOR AND DELIVERY, 2009

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Routine NPO During Labor Routine NPO During Labor

• Possible risk of aspirating gastric contents with • For the normal, low risk birth, there is no
the administration of anesthesia need for restriction of food except where
• One study evaluated the probable risk of intervention is anticipated.
maternal aspiration mortality, which is
approximately 7 in 10 million births.
• A diet of easy to digest foods and fluids
during labor is recommended.
• No evidence of improved outcomes for mother
or newborn. • Isotonic calorific drinks consumed during
• Use of epidural anesthesia for intrapartum labor reduce the incidence of maternal
anesthesia in an otherwise normal labor should ketosis without increasing gastric volumes.
not preclude oral intake.
Singata M, Tranmer J, Gyte GML. Restricting oral fluid and food intake during labour.
Cochrane Database of Systematic Reviews 2010, Issue 1.
Prepared
Sleutel, M., and Golden,byS.,Team
1999EINC for APDCN Faculty 5/6/2013 POGS CPG ONPrepared
NORMALbyLABOR
Team AND
EINC DELIVERY,
for APDCN2009
Faculty 5/6/2013
POGS CPG on Normal Labor and Delivery, 2009 WHO Care in Normal Birth, 1996

CARE DURING LABOR

RECOMMENDED NOT RECOMMENDED
 Admission to labor when Routine perineal shaving
in the active phase. on admission
 Companion of choice to Routine enema
provide continuous Routine NPO
maternal support Routine IVF
 Mobility and upright Routine vaginal douching.
position
 Allow food and drink
Routine amniotomy PRACTICES RECOMMENDED
Routine oxytocin
 Use of WHO partograph augmentation DURING DELIVERY
to monitor progress of
labor
 Limit IE to 5 or less.
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Traditional Non-Traditional

Please • Defined by a “fully • Redefined as “complete

dilated cervix” cervical dilatation” +
wash your • Coached to push
though out-of-phase
“spontaneous explusive
efforts” (Simkin, 1991)
 Pelvic phase of
hands! with her own
sensation
passive descent
 Perineal phase of
active pushing

Diagnosis of the 2nd Stage of Labor

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Management of the 2nd Stage of Labor

Traditional Non-Traditional
DIRECTED PUSHING INVOLUNTARY BEARING DOWN
Valsalva pushing • Exhalation pushing
• Let air out
 Venous Return
• Parturient-directed
 Perfusion to Uterus, • Physiologic: force of bearing
Placenta & Fetus down efforts increases as
fetal descent occurs
FHR Changes • Avoids hypoxia and acidosis
Fetal hypoxia & acidosis
Roberts,1996; Simkin, 2000;Roberts,1987 as cited in Roberts, Nikodem,VC. Beaaring down Methods during second stage labour (Cochrane
Joyce,Journal of Midwifery and Women’s Health.Vol. 47,No.1 Review) In: The Cochrane Library, Issue 2, 2001 as cited by Roberts,
Jan/Feb 2002 2002

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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.
UPRIGHT POSITION DURING
Shilling, Romano, & DiFranco, 2007
DELIVERY
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Interventions that are recommended

during delivery

1.Upright
position
during
delivery
2.Selective
(non-routine)
episiotomy

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

during delivery 3rd stage of labor
1. Upright position
during delivery • Postpartum blood loss ≥ 500 ml reduced by 39%
2. Selective episiotomy • Need for additional uterotonic reduced by 47%
3. Use of
prophylactic
• No difference in need for maternal blood
oxytocin for transfusion, need for manual removal of
management of placenta, and duration of third stage
third stage of
labor OXYTOCIN 10 U
intramuscular Source of Evidence: Cochrane review (4 trials on 2,213 women) using
varied doses, route, and timing of administration of oxytocin (Cotter,
Palpate abdomen to rule out A.M., et.al., 2002 updated 2004)

a second baby
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Interventions that are recommended

during delivery PROPERLY TIMED CORD CLAMPING

1. Upright position during Early clamping : <1 min after birth • Lower infant hemoglobin at
delivery Delayed (properly timed) :1-3 birth and at 24 hrs after birth
2. Selective episiotomy minutes after birth or when prevented
3. Use of prophylactic pulsations stop • Fewer infants requiring
oxytocin for mgt of 3rd phototherapy for jaundice
stage of labor
• No difference in rates of
4.Delayed cord polycythemia, need for
clamping neonatal resuscitation, and
NICU admission
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 Controlled Cord Traction
1. Upright position
during delivery • ↓Postpartum blood loss >500ml by 7%
2. Selective episiotomy
• ↓Postpartum blood loss >100ml by 24%
3. Use of prophylactic
oxytocin for • No difference in rates of maternal mortality
management of third
stage of labor or serious morbidity and need for
4. Delayed cord additional uterotonics.
clamping
5. Controlled cord
traction with 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,
countertraction to 2012)
deliver the
placenta
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Interventions that are recommended Active Management of the Third

during delivery
Stage (AMTSL)
1. Upright position
during delivery
•Lower mean blood loss 1. Administration of uterotonic within one minute
of delivery of the baby.
2. Selective episiotomy •Less need for uterotonics
3. Use of prophylactic 2. Controlled cord traction with counter traction on
oxytocin Source of evidence: Cochrane review (1 trial on 200
the uterus
4. Delayed cord women who delivered vaginally and AMTSL done vs 3. Uterine massage
clamping massage. ) Hofmeyr, GJ et al 2008 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.
5. Controlled cord
traction with
countertraction
6. Uterine massage
after placental
delivery

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Approaches in the
Mgt of the 3rd Stage of Labor
Physiologic (Expectant) Active
(AMTSL)
Uterotonic NOT GIVEN before GIVEN within 1 min. of
placenta is delivered baby’s birth
Signs of placental WAIT DON’T WAIT
separation

Delivery of the By gravity with maternal CCT with counter PRACTICES NOT RECOMMENDED
placenta effort traction on the uterus
DURING DELIVERY
Uterine massage After placenta is After placenta is
delivered delivered
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Interventions that are NOT Interventions that are NOT

recommended during delivery recommended during delivery
1. Perineal • Based on review, there is clear 1. Perineal massage
massage benefit (↓3rd-4th degree teaars) in the 2nd stage of
in the 2nd and no clear harm (no difference labor
stage of in 1sr and 2nd degree tears, 2. Fundal
labor vaginal pain, blood loss)
pressure
• Commonly noted complications in during the
practice (perineal edema, perineal
wound infection, and perineal second stage
wound dehiscence) were not of labor
evaluated
• Further studies are needed.
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Fundal Pressure during 2nd stage CARE DURING DELIVERY

• 2nd stage longer by 29 minutes
RECOMMENDED NOT RECOMMENDED
• Increased 3rd and 4th degree perineal tears  Upright position during Coaching the mother
• No difference in rates of postpartum delivery to push
hemorrhage, instrumental vaginal delivery,  Selective episiotomy
Apgar score < 7 at 5 minutes, and NICU Perineal massage in
 Use of prophylactic
admission the 2nd stage of labor
oxytocin for mgt of 3rd
• Uterine rupture was not evaluated stage of labor Fundal pressure
 Delayed cord clamping during the second
Source of Evidence: Pooled analysis of Cochrane review (with 1 trial  Controlled cord traction stage of labor
only) (Verheijen, E.C., et.al., 2009) and 2 randomized trials (Cosner, with countertraction to
K., 1996; Matsuo, K., et.al., 2009) with overall total of 1,229 patients deliver the placenta
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POSTPARTUM CARE Summary- Key Points

RECOMMENDED NOT RECOMMENDED • Maternal and neonatal mortality in the
 Routinely inspect the birth Manual exploration of
Philippines is still unacceptably high
canal for lacerations
 Inspect the placenta &
membranes for
the uterus • Prevention of postpartum hemorrhage
completeness Routine use of icepacks through interventions like the use AMTSL
 Early resumption of feeding over the hypogastrium.
(<6 hours after delivery) will address the #1 cause of maternal
Routine oral
 Massage the uterus –ensure
uterus is well contracted methylergometrine mortality
 Prophylactic antibiotics for
women with a 3rd or 4th • The evidence-based practices in the EINC
degree perineal tear Protocol are lifesaving for both mother and
 Early postpartum discharge
baby
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Let us put it into practice!

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