child birth updates FOR NURSING STUDENTSMCON PRES.ppt

CHILDBIRTH UPDATES

1. Childbirth updates
Dr.C.Susila, principal, Billroth college
of nursing, Chennai,

2. Maternal mortality
•Every year, approximately 600 000
women die of pregnancy-related causes
(90% Asia and sub-Saharan Africa,
25% India)
•3 million suffer childbirth related injury,
•8 million infants die, 6 million in first
month of life.

3. Maternal Mortality
More than 80% of maternal deaths
worldwide are due to five direct causes:
•hemorrhage
•sepsis
•unsafe abortion
•obstructed labor
•hypertensive disease of pregnancy

4. What to do?
Health Policy Perspective
(WHO 2000, APHA 2001, SOGC 2008, Cochrane 2009)
•Evidence based care
–Improved maternal and
fetal outcomes
–appropriate use of
technology
–allocation of resources
–cost effectiveness

5. Outcomes
–Safety of birth
–Satisfaction of care provider (Hundley et al
1995) and client
–North American research has demonstrated
safety of home birth and the desire and
need for midwifery in rural environments
(Kornelsen et al. 2005a; 2005b, 2008)

6. Rates of Midwifery Care
•10-80% maternity care to all women in
developed nations (Malott, JOGC,2009)
•30% Gyn care provided by midwives
•30-40% primary care for women and
babies
•70% care to underserved internationally

7. Midwifery Model of Care
Holistic model
•Physical and psychosocial care
•Antepartum and intrapartum testing
•Time-prenatal, intrapartum, postpartum
•Focus on education, self-care, partnership,
individualized care
Preventive model
•Philosophy: normalcy and empowerment
•Family centered care
•Collaboration with health care team

8. RN
RM
RM
MD
RM
MDRN

9. Reality & modern hospital birth: pain management,
monitoring, interference with physiologic birth

10. The Nature and Management of
Labor Pain
Am J Ob Gyn, 186 (5) suppl, 2002
•Non-pharmacologic Relief

11. Pain Management in Active
Labor
•Walking/Movement
•Hydrotherapy
•Back Rubs
•Birth Ball, toilet
•Maternal Preference
•Analgesia/
Anesthesia
•Others?

12. hydrotherapy

13. One-on-One Labor Support:
the evidence

15. Continuous Labor Support
oNon-medical care by a trained person
oDifferent definitions/criteria depending on
studies:
o“minimum of 80%” presence
opresence “without interruption, except for
toileting”
oVarious terms: doula, labor assistant, birth
companion, monitrice
oMay refer to husband or untrained female
companion

20. 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.

21. Presence of Female Relative
During Labor: Conclusion
Support from female relative improves
labor outcomes
Madi et al 1999.

22. Epidurals: how do they contribute to
prolonged labor or dystocia, if at all?
•Length of labor
–First stage labor not impacted
•Studies do not uniformly look at or control for
confounding factors such as rate of dilation or rates of
spontaneous labor
–Length of second stage -longer
•General agreement
•Mal presentation helps in more
procedures

23. Monitoring for fetal well-being: the evidence

24. EFM

25. Monitoring FHR: the evidence
•Thacker et al (2005) reported in the Cochrane
Database-no differences found between intermittent
auscultation vs. continuous EFM (CEFM)
–Prevention of neonatal seizures
–No prevention of cerebral palsy
–Increase in cesarean section and instrumental
deliveries
–Limits movement of women during labor
–CEFM may also mean that “some resources tend to
be focused on the needs of the CTG rather than the
women in labour

26. EFM vs Intermittent Auscultation (IA)
•Research does not support one modality over the
other
•ACOG Practice Bulletin 70 (2005) states:
–“Those with high-risk conditions (eg, suspected fetal
growth restriction, preeclampsia, and type 1 diabetes
should be monitored continuously).”
•Current USPSTF Guideline (1996 to present):
–Routine intrapartum EFM not recommended
–Insufficient evidence regarding its routine use in
high risk pregnancies
http://www.ahrq.gov/clinic/uspstf/uspsiefm.htm Accessed 6/30/08

27. Oxytocin Augmentation

28. Clark SL, Simpson KR, Knox GE, Garite T.
Oxytocin: new perspectives on an old drug. Am J
Obstet Gynecol 2009;200:35.e1-35.e6.
•We know of no other area of medicine in which a
potentially dangerous drug is administered to
hasten the completion of a physiologic process
that would, if left to its own devices, usually
complete itself without incurring the risk of drug
administration. Yet the administration of oxytocin
is often undertaken under precisely these
circumstances when labor is electively induced or
Braxton-Hicks contractions are electively
augmented.”

29. 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.

30. Restricted Use of Episiotomy:
Results of Cochrane Review
Carroli and Belizan 2000.
Eason et al 2000; WHO 1999.
No increase in incidence of major
outcomes (e.g., severe vaginal or perineal
trauma nor in pain, dyspareunia or urinary
incontinence)
Incidence of 3
rd
degree tear reduced (1.2%
with episiotomy, 0.4% without)
No controlled delivery or guarding the
perineum to prevent trauma

31. Indicated Use of Episiotomy:
Reviewer’s Conclusions
•Implications for practice: Clear evidence to
restrict use of episiotomy in normal labor
•Implications for use of episiotomy at:
–Assisted delivery (forceps or vacuum)
–Preterm delivery
–Breech delivery
–Predicted macrosomia
–Presumed imminent tears (threatened 3
rd
degree
tear or history of 3
rd
degree tear with previous
delivery)
Carroli and Belizan 2000.
WHO 1999.

32. Clean Delivery
•Infection accounts for 14.9% of all
maternal deaths
•These deaths can be avoided with
infection prevention practices

33. 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 woman’s 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

34. 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

35. 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,
–Fewer assisted deliveries
–Fewer episiotomies
–Fewer reports of severe pain
–Less abnormal heart rate patterns for fetus
Gupta and Nikodem 2000.

36. 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
–22% of maternal deaths caused by retained
placenta
•Routine examination of vagina and perineum
for lacerations and injury
WHO 1999.

37. Best Practices: Labor and Childbirth
•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
Neilson 1998.

38. 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

39. 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.

40. 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

41. 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.

42. 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.

43. 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

44. 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

45. 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 woman’s choice for position during
labor and childbirth
•Provide continuous emotional and physical
support to woman throughout labor

46. Framework for Optimal Care
•Screening criteria
•Basic skills necessary as attendants
•Basic equipment
•Continuity of care
•Strong infrastructure support
•Access to medical consultation and referral

47. Barriers to Practice
•Lack of knowledge in hospital staff or
community providers re:
–home birth standards of care
–planned vs unplanned home birth
•Inability to secure hospital privileges
•Lack of neonatal trained transport
personnel
•Insurance

48. Settings
•Home
•Birthing Centers
•Hospitals-Labor, Delivery & Recovery
Rooms (LDR), LDRP (post-partum),
Single room maternity care, Birthing
rooms

50. Birthing Suite

51. C-Section Rooms

53. Latest Technologies
•Electronic Fetal Monitoring (EFM)
•Ultrasonography
•Infusion pumps
•Electronic monitoring devices:
1. Non-invasive
2. Invasive

54. Electronic Health Record
•Computers
•Paperless charts
•Integrates all aspects of assessment,
intervention and evaluation

57. Doppler

58. Ultrasonography
•Done at all stages of pregnancy
•Transvaginal or transabdominal
approach
•Done for maternal or fetal indications
•Done in office, clinic, mobile centers, ob
unit, L & D

60. Indications
•Maternal diseases
•Multiple gestations
•Fetal growth
•Establishment of fetal age
•Placental location and grading
•Assess fetal well-being (BPP)
•Pre-term labor-cervical lengths

61. It’s a Girl!!!

62. 3-D & 4-D Ultrasound

63. 3-D Early Gestation

65. S/D Ratios

66. Pulse Oximetry

67. V/S Monitors

68. Electronic B/P Monitor

71. Critically Ill OB
•Continuous cardiac monitoring
•Invasive hemodynamic monitoring
•CVP
•Arterial lines
•Pulmonary artery lines
•Ventilator

72. OB Critical Care Unit

73. Flight Nurses

74. Flight Nurse

75. Automated Medication Dispensing
Machines
•Cut down on errors
•Chart medications
•Control Labor & saving mothers

77. Fetal Surgeries

79. Twins 4/1000

80. West Triplets 1/7,000-10,000

81. Skopec Quads 1/600,000

82. Do provider attitudes affect
birth safety and access?

83. Provider Attitudes
•Providers’ attitudes influence women’s
choices
•Providers may present options that are
congruent with their own education,
experience, and scope of practice

84. External barriers that significantly
predicted less favorable attitudes
•Increased time commitment
•Problems with accessing MD consultation
•Perception that birth providers are looked down
upon by hospital providers
•Cost of practice
•Lack of confidence in skills

85. What is in your nursing
future for the 21
st
Century?

86. Meeting Health Human Resource
Challenges
•Rural maternity services
–Increase supply of providers
–Model and support inter-professional collaboration
–Prepare graduates for rural practice
•Support evidence based maternity care
–Maintain professional currency of providers
–Evaluate practice and practice models
–Document and evaluate methods to increase access

87. Women’s Health Care in the
New Millennium
•Evidence-based medicine
•Appropriate use of technology and resources
•More research needed on factors beyond
mortality and morbidity
– effects of birth environment on labor
– influences of maternal and provider anxiety
– effects of birth experience on long term physical
and psychological well-being

88. The challenge is, can you provide
vigilance without intervention….
Don’t just stand there.
Do nothing!”

89. Questions & Comments?

90. 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.
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): 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). 1999. Care in Normal Birth: A Practical Guide.
Report of a Technical Working Group. WHO: Geneva.