Normal Labor and Childbirth

Advances in Maternal and Neonatal Health

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

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

Skilled Attendant

Is a professional caregiver

Has the knowledge and skills to:

WHO 1999.

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 caregivers competence

Performs all basic midwifery interventions

Normal Labor and Childbirth

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

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

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

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

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.

Normal Labor and Childbirth

WHO Partograph: Results of Study

All Women

Before
Implementation

After
Implementation

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

8428 (83.9%)

7869 (86.3%)

< 0.001

341 (3.4%)

227 (2.5%)

0.005

Normal Women
Mode of delivery
Spontaneous
cephalic
Forceps
WHO 1994.

Normal Labor and Childbirth

10

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 49 cm

Rate of dilation 1 cm/hour

Fetal descent begins

Lauzon and Hodnett 2000.

Normal Labor and Childbirth

11

Criteria to Diagnose Active Labor:

Results with Statistical Significance
Experimental
Group (105)

Control
Group (104)

Odds Ratio
(95% CI)

Cesarean section
for labor dystocia

0.28 (0.081.00)

Intrapartum
oxytocics

24

42

0.45 (0.250.80)

Any intrapartum
analgesia

84

96

0.36 (0.160.78)

Epidural analgesia

83

94

0.42 (0.200.89)

Lauzon and Hodnett 2000.

Normal Labor and Childbirth

12

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

Lauzon and Hodnett 2000.

Normal Labor and Childbirth

13

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.

Normal Labor and Childbirth

14

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

Carroli and Belizan 2000.

Normal Labor and Childbirth

15

Restricted Use of Episiotomy:

Results of Cochrane Review
Clinically Relevant Morbidities

Relative Risk

95% CI

Posterior perineal trauma

0.88

0.840.92

Need for suturing

0.74

0.710.77

Healing complications at 7 days

0.69

0.560.85

Anterior perineal trauma

1.79

1.552.07

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

Carroli and Belizan 2000.

Eason et al 2000; WHO 1999.

Normal Labor and Childbirth

16

Indicated Use of Episiotomy:

Reviewers 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

17

Clean Delivery

Infection accounts for 14.9% of all maternal deaths

These deaths can be avoided with infection prevention

practices

Normal Labor and Childbirth

18

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 womans 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

19

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

WHO 1999.

22% of maternal deaths caused by retained placenta

Routine examination of vagina and perineum for lacerations

and injury

Normal Labor and Childbirth

20

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 0.580.79)

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.

Normal Labor and Childbirth

21

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

22

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

23

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 3.96.9)

Fewer assisted deliveries (OR 0.82, CI 0.690.98)

Fewer episiotomies (OR 0.73, CI 0.640.84)

Fewer reports of severe pain (OR 0.59, CI 0.410.83)

Less abnormal heart rate patterns for fetus (OR 0.31, CI

0.110.91)

More perineal tears (OR 1.30, CI 1.091.54)

Blood loss > 500 mL (OR 1.76, CI 1.343.32)

Gupta and Nikodem 2000.

Normal Labor and Childbirth

24

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

WHO 1999.

Normal Labor and Childbirth

25

Presence of Female Relative

During Labor: Results
Randomized controlled trial in Botswana: 53 women with relative;
56 without
Labor Outcome

Experimental
Group (%)

Control
Group (%)

Spontaneous vaginal
delivery

91

71

0.03

Vacuum delivery

16

0.03

Cesarean section

13

0.03

Analgesia

53

73

0.03

Amniotomy

30

54

0.01

Oxytocin

13

30

0.03

Madi et al 1999.

Normal Labor and Childbirth

26

Presence of Female Relative

During Labor: Conclusion
Support from female relative improves labor outcomes

Madi et al 1999.

Normal Labor and Childbirth

27

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

Nielson 1998; WHO 1999.

Normal Labor and Childbirth

28

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

29

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

Eason et al 2000.

Normal Labor and Childbirth

30

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

31

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

32

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

33

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 womans choice for position during labor and

childbirth

Provide continuous emotional and physical support to woman

throughout labor

Normal Labor and Childbirth

34

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: 464471.
Gupta JK and VC Nikodem. 2000. Womans 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): 199207.
Madi BC et al. 1999. Effects of female relative support in labor: A randomized control
trial. Birth 26:410.
Neilson JP. 1998. Evidence-based intrapartum care: evidence from the Cochrane
Library. Int J Gynecol Obstet 63 (Suppl 1): S97S102.
World Health Organization Safe Maternal Health and Safe Motherhood Programme.
1994. World Health Organization partograph in management of labour. Lancet 343
(8910):13991404.
World Health Organization (WHO). 1999. Care in Normal Birth: A Practical Guide.
Report of a Technical Working Group. WHO: Geneva.
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