Improved Labor Care to Reduce Neonatal Asphyxia

Jeffrey M. Smith Maternal Health Team Leader Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21-25 February, 2011

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 2

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% 3 Ronsmans LANCET 2010

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 4

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 5

Intrapartum Care to Prevent Asphyxia :

  Good maternal and newborn care:  Use partograph for vigilant labor monitoring   Allow companionship during labor and birth Ensure supportive 2 nd 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 6

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 7

Use of the Partograph

Intrapartum care to prevent asphyxia

      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 8

EMOTIONAL SUPPORT DURING LABOR 14 studies 5021 women 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

9

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) .1 .2

1 5 10

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 SO 4 Treat hypertension: anti-hypertensives   Ensure timely delivery Increase obstetrical monitoring –

and quiet at the end of the corridor

10

not darkness

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 11

Alternative positions

Intrapartum care to prevent asphyxia

   Supine/lithotomy: uterus compresses vessels  reduced uterine blood flow 1 st stage labor: left side, standing, walking 2 nd stage labor: squatting, sitting, hands & knees 12

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 13

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 14

Intrapartum care to prevent asphyxia

Other supportive practices

 Clean birthing practices/infection prevention  Infected babies don’t breathe well  Doing procedures right!   Vacuum extraction and breech delivery Twin delivery – management of 2 nd twin  Keep normal births normal! 15

Let Babies Breathe!

  Prevent asphyxia  Monitor with partograph  Companionship, hydration, position Prevent eclampsia No uncontrolled oxytocin  Supportive 2 nd stage based on fetal condition 16

Thank you!

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