PRESENTATION –

5.1.

Basic Care During Labor and

Childbirth

Federal Democratic Republic of Ethiopia

Ministry of Health

BEmONC – LRP
ETHIOPIA Best Practices in Maternal and Newborn Care
 Session Objectives
 To discuss best practices for managing labor and
childbirth:
 Introduction
 Partograph
 Supportive care of a woman during labor & delivery
 Active management of the third stage of labor
 Restricted episiotomy
 Childbirth care in women with HIV/AIDS
 To identify harmful practices with the goal of
eliminating them from practice
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Best Practices in Maternal and Newborn
 Introduction
 Of the more than 130 million births occurring each
year, an estimated 303 000 result in the mother’s
death, 2.6 million in stillbirth and another 2.7 million
in a newborn death within the first 28 days of birth
[WHO 2015]
 The availability and quality of skilled care at birth
and immediately after birth is a major determinant of
the survival and health of both mothers and babies
BUT………………..

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Best Practices in Maternal and Newborn
 Introduction

 Only 42 percent of pregnant women in sub-Saharan

Africa give birth with a skilled attendant present.
 According to the most recent EDHS (2016), the
institutional birth rate in Ethiopia was very low
(26%.)

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Best Practices in Maternal and Newborn
 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

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Best Practices in Maternal and Newborn
 QUESTION ???

 At what time during pregnancy and childbirth

do most deaths occur?

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Best Practices in Maternal and Newborn
80% of deaths occur in the first 2 hrs after
delivery
Acting quickly is important because a
woman could die in a short period of
time:
• in antepartum hemorrhage she can
die in just 12 hours.
• in postpartum hemorrhage she can
die in just 2 hours.
• with complications of eclampsia in as
few as 12 hours and
• with sepsis in about 3 days!

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Best Practices in Maternal and Newborn
 Managing labour using the Partograph

 The partograph is the graphic recording of the

progress of labour and the salient condition of the
mother and the fetus.
 Use of partograph:
 Assessment of fetal well being
 Assessment of maternal well being
 Assessment of progress of labor

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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
Measuring Fetal Well Being During Labor

 Fetal heart rates and pattern

 Degree of molding, caput
 Color of amniotic fluid

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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 Measuring Maternal Well Being
During Labor

 Pulse, temperature, blood pressure,

respiration

 Urine output, ketones, protein

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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 Measuring Progress of Labor

 Cervical dilatation
 Descent of presenting part
 Contractions
 Duration
 Frequency
 Alert and action lines

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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 Using the Partograph

 Patient information: Name, gravida, para, hospital

number, date and time of admission, and time of
ruptured membranes
 Fetal heart rate: Record every half hour
 Amniotic fluid: Record the color at every vaginal
examination:
 I: membranes intact
 C: membranes ruptured, clear fluid
 M: meconium-stained fluid
 B: blood-stained fluid
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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 Using the Partograph (continued)

 Molding:
 1: sutures apposed
 2: sutures overlapped but reducible
 3: sutures overlapped and not reducible
 Cervical dilatation: Assess at every vaginal
examination, mark with cross (X)
 Alert line: Line starts at 4 cm of cervical dilatation to
the point of expected full dilatation at the rate of 1 cm
per hour
 Action line: Parallel and 4 hours to the right of the
alert line
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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 Using the Partograph (continued)

 Descent assessed by abdominal palpation: Part of

head (divided into 5 parts) palpable above the
symphysis pubis; recorded as a circle (O) at every
vaginal examination. At 0/5, the sinciput (S) is at the
level of the symphysis pubis

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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 Using the Partograph (continued)
 Hours: Time elapsed since onset of active phase of labor
(observed or extrapolated)
 Time: Record actual time
 Contractions: Chart every half hour; palpate the number of
contractions in 10 minutes and their duration in seconds
 Less than 20 seconds:
 Between 20 and 40 seconds:
 More than 40 seconds:
 Oxytocin: Record amount per volume IV fluids in
drops/min. every 30 min. when used
 Drugs given: Record any additional drugs given

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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 Using the Partograph (continued)

 Temperature: Record every 2 hours

 Pulse: Record every 30 minutes and mark with a dot
(•)
 Blood pressure: Record every 4 hours and mark with
arrows
 Protein, acetone and volume: Record every time urine
is passed

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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 Partograph

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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 Sample Partograph for
Normal Labor

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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 Individual Work

 Complete Partograph Exercise(s)

 Review with
reassembled group

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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 Supportive care of Woman in labor
 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.
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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 Presence of Female Relative
During Labor: Conclusion

Support from female relative improves labor

outcomes

Madi et al 1999. BEmONC – LRP: Ethiopia 21

Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 CARE DURING Labor and Childbirth
non pharmacologic pain relief
 Use non-invasive, non-pharmacological methods of
pain relief during labor (massage, relaxation
techniques, etc.):
 Less use of analgesia
 Fewer operative vaginal deliveries
 Less postpartum depression at 6 weeks
 Offer oral fluids throughout labor and childbirth

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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 Non pharmacologic pain relief….

 Stimulating certain points on the lower back to relieve pain.

BEmONC – LRP: Ethiopia Care During Labor and Childbirth

Best Practices in Maternal and Newborn
 Care labor delivery… pharmacologic pain
Releif
 Pethidine 50mg im stat in active 1st stage of labor
* repeat 50mg im stat after 4 hrs if no adequate pain
relief is gained
* avoid administering Pethidine late in labor as it may
cause neonatal depression.
 Other drugs that can be used (if available)
* morphine
* Epidural analgesia
* Pudendal block (esp in 2nd stage)
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Best Practices in Maternal and Newborn
 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

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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
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Best Practices in Maternal and Newborn
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Best Practices in Maternal and Newborn
 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
 Fewer assisted deliveries
 Fewer episiotomies
 Fewer reports of severe pain
 Less abnormal heart rate patterns for fetus
 More perineal tears
 Blood loss > 500 mL
Gupta and Nikodem 2000.

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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 ASSISTING BIRTH ….Clean Delivery

 Infection accounts for 11% of all maternal deaths

 Infection/pneumonia accounts for 26% of
newborn deaths
 Tetanus accounts for 7% of newborn deaths
 These deaths can be largely avoided with
infection prevention practices
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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 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

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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 Infection Prevention Practices

 clean perineum with saline

 Ensure that surface on which newborn is delivered is
kept clean
 Use High-level disinfect instruments or sterile
instruments, gauze and ties for cutting cord

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Best Practices in Maternal and Newborn
 Episiotomy: Up-to-date Conclusions on
restricted episiotomy
 Episiotomy is not recommended as a routine procedure.
*There is no evidence that routine episiotomy decreases
perineal damage, future vaginal prolapse, urinary
incontinence and dyspareunia. In fact,
*Routine episiotomy is associated with an increase of
third and fourth degree tears and subsequent anal
sphincter muscle dysfunction.
 Implications for practice: Clear evidence to restrict use
of episiotomy in normal labor

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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 CARE during the Third stage

 Time of greatest/most rapid physiologic change

& highest risk of hemorrhage
 Uterus as a muscle, must contract to stop
bleeding
 Placenta must separate from wall of uterus & be
delivered
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Care During Labor and Childbirth
Best Practices in Maternal and Newborn Continued
 Best Practices: Active Management of
Third Stage of Labor
 Offer active management of third stage for ALL women:
it includes
 Administration of Uterotonics (Oxytocin)

If not available, Misoprostol.

 Controlled cord traction and
 Check if the uterus is well contracted (do uterine massage
if is relaxed)
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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 Remember!

 The most important intervention to reduce postpartum

hemorrhage is the immediate postpartum administration
of a Uterotonic within one minute of birth.

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Best Practices in Maternal and Newborn
 QUESTION ?

How effective is active management of the third stage

of labor at preventing postpartum hemorrhage?

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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 QUESTION ???

 What measures can you take during labor and

delivery to reduce the risk of transmission of HIV?

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Best Practices in Maternal and Newborn
Intrapartum interventions to reduce MTCT

 Use of universal IP precautions

 Application of good infection prevention practices
during pelvic examinations and delivery
 Avoiding unnecessary artificial rupture of membranes
 Avoiding prolonged labour and prolonged rupture of
membranes

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Best Practices in Maternal and Newborn
 Intrapartum interventions to reduce MTCT
contd
 Avoid unnecessary trauma during delivery:
 Unnecessary episiotomy
 Fetal scalp electrode monitoring
 Forceps delivery
 Vacuum extraction

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Best Practices in Maternal and Newborn
 Vaginal versus Caesarean

Risk concern Vaginal Caesarean

Increased
Blood loss -
Increased in HIV+ women;
Infection - antibiotic prophylaxis
recommended
No evidence of increased Reduces risk of MTCT if
MTCT with ARV Rx and performed before labor onset
MTCT
adequate viral load

Increased
Mortality -
Requires greater resources
Resource issues - (supplies, equipment, staff)
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Best Practices in Maternal and Newborn
 HARRT regimen to HIV +pregnant
women

 Initiate HAART (option B+) to all HIV

women identified during pregnancy, labour
and postpartum period as follows
 TDF, 3TC, and EFV ( single tab combination one
tablet daily)

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Best Practices in Maternal and Newborn
 Normal Labor and Childbirth:
Summary
 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
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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 Harmful practices to avoid
 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

Nielson 1998; WHO 1999.

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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 Harmful Practices
 Manual exploration of the uterus after delivery
 Position:
 Routine use of supine position during labor
 Routine use of lithotomy position with or without
stirrups during labor

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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 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

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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 Inappropriate Practices
 Restriction of fluids during labor
 Routine intravenous infusion in labor
 Repeated or frequent vaginal examinations,
especially by more than one caregiver
 Encouraging woman to push when full dilation or
nearly full dilation of cervix has been diagnosed,
before woman feels urge to bear down
 Liberal or routine use of episiotomy
 Liberal or routine use of amniotomy
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Care During Labor and Childbirth
Best Practices in Maternal and Newborn
 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.
Kinzie and Gomez, Basic Maternal and Newborn Care. JHPIEGO.
Baltimore. 2003.
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
(WHO) 2017: management of complications during pregnancy & child
birth (2nd edition)
(WHO) 2016: integrated management of co
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Best Practices in Maternal and Newborn
 References (cont’d)

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). 2017. Managing complication s of
Pregnancy & Childbirth. WHO: Geneva.

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