Improved Labor Care to Reduce Intrapartum-Related Newborn Deaths

Jeffrey M. Smith Maternal Health Team Leader Global Newborn Health Conference Johannesburg, 16 April 2013

Afghanistan 2002
Maternal Mortality Survey showed an MMR of 1600 MD / 100 000 LB 77% of newborns died if they were born to mothers who died Newborn mortality and health are directly linked to maternal mortality and health
Bartlett, et al. 2005
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Parent Death & Child Survival in Bangladesh

Cumulative probability of survival of child to age 10 years
Mother alive: 88.9% Mother dead: 23.8% Father alive: 88.6% Father dead: 89.3%

Ronsmans LANCET 2010

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Improved maternal care will result in improved newborn outcomes

Use of evidence-based labor and delivery practices will achieve:

Reduced maternal and

newborn morbidity and mortality Improved quality of care Respect for women and newborns
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Obstetrics/Midwifery is watchful waiting

Obstetrics
From the Latin obstare: to stand by To wait, to be vigilant, to be ready

Midwife
With women

Watchful waiting
For mother, for newborn For complications Interventions when proven and necessary
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Intrapartum Care to Prevent Asphyxia

Good maternal and newborn care:
Use partograph for vigilant labor monitoring Allow companionship during labor and birth

Ensure supportive 2nd stage management

based on fetal and maternal condition Avoid incorrect practices Manage pre-eclampsia correctly

Ensure skilled attendance at birth to prevent and manage asphyxia

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Use of the Partograph

Partograph:
Drugs provided Including oxytocin

Amniotic fluid condition

Fetal heart rate

Use of Partograph combines all needed documentation Ob and Peds leaders should ensure its use
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Intrapartum care to prevent asphyxia

Use of the Partograph

How does the Partograph prevent asphyxia?
Identify abnormal heart rate

patterns Prevent prolonged labor

Prevents unnecessary augmentation using oxytocin Prevents infection

Ensure timely Caesarean Prevent hyperstimulation Encourage greater vigilance

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EMOTIONAL SUPPORT DURING LABOR

14 studies 5021 women

Relative Risk (95%CI)
0.79 (0.75-0.84) 0.78 (0.58-1.07) 0.48 (0.36-0.63) 0.05 (0.00-0.86) 0.81 (0.72-0.92) 0.66 (0.48-0.92) 0.95 (0.88-1.03) 0.80 (0.68-0.93) 0.50 (0.29-0.89) 0.94 (0.59-1.50) 0.87 (0.68-1.11) 0.61 (0.37-1.01) 0.45 (0.21-0.96) 1.01 (0.93-1.10) 0.77 (0.62-0.97) 0.74 (0.55-1.00) 0.80 (0.63-1.03) 0.72 (0.57-0.91) 1.07 (0.51-2.26) 0.82 (0.74-0.91) 0.03 (0.00-0.52)

Use of analgesia/anesthesia during labor Electronic fetal monitoring Problems during labor Prolonged labor Operative vaginal birth Episiotomy Perineal trauma Cesarean Five-minute Apgar <7 Newborn need for oxygen Admission of Newborn to Newborn Care Unit Prolonged hospital stay for newborn Newborn sepsis Severe pain during labor Labor worse than expected Struggle in enduring birth Feeling of tension and anxiety during labor Poor labor experience Struggle with medical staff Lack of exclusive breastfeeding at 6 weeks Severe postpartum depression at 6 weeks
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Intrapartum care to prevent asphyxia

Pre-Eclampsia Management
Undiagnosed/inadequately managed severe pre-eclampsia results in
Maternal seizure Severe hypertension Emergency Caesarean

Neonatal Asphyxia

Proper management of severe PE / Eclampsia

Prevent seizures: Mg SO4 Treat hypertension: anti-hypertensives Ensure timely delivery Increase obstetrical monitoring not darkness
and quiet at the end of the corridor
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Intrapartum care to prevent asphyxia

Second stage labor management

Continue monitoring of fetal heart
Check every 5 minutes, record every 30 min. If fetal heart rate is normal, no need to rush

delivery

Do NOT urge the woman to immediately and continuously bear down

Allow some descent makes pushing easier Rest in between pushes allows oxygenated

blood to reach placenta/fetus

Do NOT push on fundus

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Alternative positions
Supine/lithotomy: uterus compresses vessels reduced uterine blood flow
1st stage labor: left side, standing, walking 2nd stage labor: squatting, sitting, hands & knees

Intrapartum care to prevent asphyxia

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Intrapartum care to prevent asphyxia

Labor Management
Adequate hydration and nutrition during labor essential
Dehydration compromises uterine blood flow

Allow women to drink freely and take small amounts of food during labor

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Intrapartum care to prevent asphyxia

Labor augmentation
Medical decision based on medical reasons Use Partograph to diagnose protracted active phase Provide oxytocin using protocols in MCPC Do NOT allow uncontrolled oxytocin for augmentation
Causes tetanic uterine

contractions Complete restriction of blood flow to fetus

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Other supportive practices

Clean birthing practices/infection prevention and prevention of prolonged labor
Infected babies dont breathe well

Doing procedures right!

Vacuum extraction and breech delivery Twin delivery management of 2nd twin

Episiotomy for prevention of neonatal asphyxia only for reduced fetal heart rate Keep normal births normal!
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Let Babies Breathe!

Prevent asphyxia Monitor with partograph Companionship, hydration, position Prevent eclampsia No uncontrolled oxytocin Supportive 2nd stage based on fetal condition
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