Normal Labor and Childbirth Objectives of Care During

Normal Labor and Childbirth

Objectives of Care During Labor and Childbirth l Protect the life of the mother and newborn l Support the normal labor and detect and treat complications in timely fashion l Support and respond to needs of the woman, her partner and family during labor and childbirth Normal Labor and Childbirth 2

Definition l Labor is the process by which contractions of the gravid uterus expel the fetus. l A term pregnancy delivers between 37 and 42 weeks from the last menstrual period (LMP). l Preterm labor is that occurring before 37 weeks of gestational age. l Postdate pregnancy occurs after 42 weeks gestation and requires careful monitoring. l Termination of pregnancy before 20 weeks of gestation is defined as either spontaneous or elective abortion.

Premonitory signs of labor l Cervical changes l softening and dilation with descent of the presenting part into the pelvic. This stage occurs one month to one hour before actual labor. l The cervix becomes shortened and thinned segment

Premonitory signs of labor l Lightening: occurs when the fetal presenting part begins l to descend into the maternal pelvic. The uterus lowers and l moves into a more anterior position. this change will cause: l l l Breathing becomes easier Increased pelvic pressure Cramping and low backache Lower extremities edema Increased vaginal secretion More frequent urination l In PG it occurs 2 weeks ore more before labor. l In MP it occurs during labor

Premonitory signs of labor l Increased energy level : many women will focus this energy in preparation by cleaning, cooking, preparing the nursery…it is usually occur 24 -48 hours before labor. l Bloody show: the mucus plug of the cervical canal during pregnancy is expelled as a result of cervical softening and increased pressure of the presenting part. The exposed cervical capillaries release a small amount of blood that mix with the mucus, resulting in bloody show.

Premonitory signs of labor l Braxton Hicks Contraction: these contractions aid in moving the cervix from the posterior position to the anterior position, they also help in ripining and softening of the cervix. l The contractions are irregular and diminished by walking, voiding, eating, increasing fluid intake, or changing position.

Premonitory signs of labor l Spontaneous rupture of membrane: one in four women experience SROM before onset of labor. This reduces the capacity of the uterus, thickens the uterine wall, and increases uterine irritability. Labor usually follows. At term, 90% will be in labor within 24 h after membrane rupture. If labor does not begin in 24 h, the case must be considered complicated by prolonged rupture of the membranes because of the increased risk of ascending infection.

True versus false labor: Differentiating True Labor and False Labor l Factors True labor False labor Contractions timing Regular intervals, becoming close together, usually 4 -6 minutes apart, lasting 30 -60 seconds. Irregular intervals, not occurring close together Contraction strength Becomes stronger with time, vaginal pressure is usually felt Frequently weak, not getting strong with time Contraction discomfort Start in the back and radiates around toward the front of the abdomen Usually felt in the front of the abdomen Position changes Contractions continue no matter what positional changes is made Contraction may stop or slow down with walking or changing position Effect of analgesia Not terminated by sedation Frequently abolished by sedation Cervical change Progressive effacement and dilation No change

Partograph and Criteria for Active Labor l Label with patient identifying information l Note fetal heart rate, color of amniotic fluid, presence of moulding, contraction pattern, medications given l Plot cervical dilation l Alert line starts at 4 cm-from here, expect to dilate at rate of 1 cm/hour l Action line: If patient does not progress as above, action is required Normal Labor and Childbirth 11

Support of Woman l Give woman as much information and explanation as she desires l Provide care in labor and childbirth at a level where woman feels safe and confident l Provide empathic support during labor and childbirth l Facilitate good communication between caregivers, the woman and her companions l Continuous empathetic and physical support is associated with shorter labor, less medication and epidural analgesia and fewer operative deliveries Normal Labor and Childbirth 12

Clean Delivery l Infection accounts for 14. 9% of all maternal deaths l These deaths can be avoided with infection prevention practices Normal Labor and Childbirth 13

Infection Prevention Practices l Use disposable materials once and decontaminate reusable materials throughout labor and childbirth l Wear gloves during vaginal examination, during birth of newborn and when handling placenta l Wear protective clothing (shoes, apron, glasses) l Wash hands l Wash woman’s perineum with soap and water and keep it clean l Ensure that surface on which newborn is delivered is kept clean l High-level disinfect instruments, gauze and ties for cutting cord Normal Labor and Childbirth 14

Best Practices: Labor and Childbirth l Use non-invasive, non-pharmacological methods of pain relief during labor (massage, relaxation techniques, etc. ): l l . 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 15

Position in Labor and Childbirth l Allow freedom in position and movement throughout labor and childbirth l Encourage any non-supine position: l Side lying l Squatting l Hands and knees l Semi-sitting l Sitting Normal Labor and Childbirth 16

Position in Labor and Childbirth (continued) Use of upright or lateral position compared with supine or lithotomy position is associated with: l Shorter second stage of labor (5. 4 minutes, 95% CI 3. 9– 6. 9) l Fewer assisted deliveries (OR 0. 82, CI 0. 69– 0. 98) l Fewer episiotomies (OR 0. 73, CI 0. 64– 0. 84) l Fewer reports of severe pain (OR 0. 59, CI 0. 41– 0. 83) l . Less abnormal heart rate patterns for fetus (OR 0. 31, CI 0. 11 – 0. 91) l More perineal tears (OR 1. 30, CI 1. 09– 1. 54) l Blood loss > 500 m. L (OR 1. 76, CI 1. 34– 3. 32) Normal Labor and Childbirth 17

Restricted Use of Episiotomy: Objectives and Design l Objective: To evaluate possible benefits, risks and costs of restricted use of episiotomy vs. routine episiotomy l Design: Meta analysis of six randomized control trials Normal Labor and Childbirth 18

Restricted Use of Episiotomy: Maternal Outcomes Assessed . l Severe vaginal/perineal trauma l Need for suturing l Posterior/anterior perineal trauma l Perineal pain l Dyspareunia l Urinary incontinence l Healing complications l Perineal infection Normal Labor and Childbirth 19

Indicated Use of Episiotomy: Reviewer’s Conclusions l Implications for practice: Clear evidence to restrict use of episiotomy in normal labor l Implications for research: Further trials needed to assess use of episiotomy at: l Assisted delivery (forceps or vacuum) l Preterm delivery l Breech delivery l Predicted macrosomia l . . Presumed imminent tears (threatened 3 rd degree tear or history of 3 rd degree tear with previous delivery) Normal Labor and Childbirth 20

Best Practices: Third Stage of Labor l Active management of third stage for ALL women: l Oxytocin administration l Controlled cord traction l l Routine examination of the placenta and membranes l l . Uterine massage after delivery of the placenta to keep the uterus contracted 22% of maternal deaths caused by retained placenta Routine examination of vagina and perineum for lacerations and injury Normal Labor and Childbirth 21

Best Practices: Postpartum l Close monitoring and surveillance during first 6 hours postpartum l Parameters: l – 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 22

Presence of Female Relative During Labor: Results Randomized 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 Normal Labor and Childbirth 23

Presence of Female Relative During Labor: Conclusion Support from female relative improves labor outcomes . Normal Labor and Childbirth 24

Harmful Routines l Use of enema: uncomfortable, may damage bowel, does not change duration of labor, incidence of neonatal infection or perinatal wound infection l Pubic shaving: discomfort with regrowth of hair, does not reduce infection, may increase transmission of HIV and hepatitis l Lavage of the uterus after delivery: can cause infection, mechanical trauma or shock l Manual exploration of the uterus after delivery Normal Labor and Childbirth 25

Harmful Practices l Examinations: l l l Rectal examination: Similar incidence of puerperal infection, uncomfortable for woman Routine use of x-ray pelvimetry: Increases incidence of childhood leukemia Position: l l Routine use of supine position during labor Routine use of lithotomy position with or without stirrups during labor Normal Labor and Childbirth 26

Harmful Interventions l Administration of oxytocin at any time before delivery in such a way that the effect cannot be controlled l Sustained, directed bearing down efforts during the second stage of labor l Massaging and stretching the perineum during the second stage of labor (no evidence) l Fundal pressure during labor Normal Labor and Childbirth 27

Inappropriate Practices . l Restriction of food and fluids during labor l Routine intravenous infusion in labor l Repeated or frequent vaginal examinations, especially by more than one caregiver l Routinely moving laboring woman to a different room at onset of second stage l Encouraging woman to push when full dilation or nearly full dilation of cervix has been diagnosed, before woman feels urge to bear down Normal Labor and Childbirth 28

Inappropriate Practices l 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 l Liberal or routine use of episiotomy l Liberal or routine use of amniotomy Normal Labor and Childbirth 29

Practices Used for Specific Clinical Indications l Bladder catheterization l Operative delivery l Oxytocin augmentation l Pain control with systemic agents l Pain control with epidural analgesia l Continuous electronic fetal monitoring Normal Labor and Childbirth 30

Normal Labor and Childbirth: Conclusion l Have a skilled attendant present l Use partograph l Use specific criteria to diagnose active labor l Restrict use of unnecessary interventions l Use active management of third stage of labor l Support woman’s choice for position during labor and childbirth l Provide continuous emotional and physical support to woman throughout labor Normal Labor and Childbirth 31