ESSENTIAL

INTRAPARTUM CARE
From Evidence to Practice

MA. CYNTHIA F. TAN, M.D. FPOGS

Co-Convener
DOH/WHO EINC Scale-up Team
 Objectives
• Discuss the problem of maternal mortality rates
and its impact on the attainment of MDG 5
• Discuss evidence based interventions that are
recommended and are not recommended
during:
o Antepartum
o Labor
o Delivery
o Immediate post-partum
Too many mothers and newborns
are dying every year…
Most maternal deaths occur during labor, delivery and the immediate post-
partum period
Percent of maternal deaths in
developing countries

0-1 day 2-7 days 8-14 days 15-21 days 22-30 days 31-42 days

Day of maternal death after delivery

Source: X. F. Li et al., International Joumal
4
of
Gynecology & Obstetrics 54 (1996): 1-10
ANTEPARTUM CARE
 ANTENATAL CARE
• At least 4 antenatal visits with a skilled health
provider
• To detect diseases which may complicate
pregnancy

• To educate women on danger and emergency

signs & symptoms

• To prepare the woman and her family for

childbirth
 To detect diseases which may
complicate pregnancy
• Prevent
Screen – Ferrous and folic acid
• Anemia supplementation
• Pre-eclampsia – Tetanus toxoid
• Diabetes Mellitus immunization
• Syphilis – Corticosteroids for
• HIV preterm labor
 Antenatal Corticosteroids
• Administer ANTENATAL STEROIDS to all
patients who are at risk for preterm
delivery
– with preterm labor between 24-34 weeks AOG
– or with any of the following prior to term:
• Antepartal hemorrhage/bleeding
• Hypertension
• (preterm) Pre-labor rupture of membranes
 Antenatal Steroids
Betamethasone 12 mg IM q 24 hrs x 2 doses OR

DEXAMETHASONE 6 mg IM q 12 x 4 doses
• Overall reduction in neonatal death

• Reduction in RDS

• Reduction in cerebroventricular hemorrhage

• Reduction in sepsis in the first 48 hours of life

Roberts D, Dalziel SR. Cochrane Database of
Systematic Reviews 2006, Issue 3.
DEXAMETHASONE PHOSPHATE
2ml ampules: 4mg/ml
6 mg – 1.5 ml injected intramuscularly
Even a single dose of 6 mg IM before delivery
is beneficial

emergency drug
should be available
at the OPD and ER
GSCH Dexa Area & Tray in the ER, DR, Ward
 Educate women on
DANGER SIGNS and SYMPTOMS
• Headache
• Blurring of vision
• Dangerous fever (T°>38, weak)
• Severe difficulty breathing
• Abdominal Pain
• Burning on urination
• Vaginal bleeding
Prepare the woman and her family for
childbirth
• Counsel on
– Proper nutrition and self care during pregnancy
– Breastfeeding and family planning
• BIRTH PLAN
– Where she will deliver; transportation
– Who will assist her delivery
– What to expect during labor and delivery
– What to prepare, estimated cost of delivery
– Possible blood donors; where will she be referred
in case of emergency
 SAMPLE
BIRTH
AND
EMERGENCY
PLAN
Birth and Emergency
Planning in the OPD
INTRAPARTUM CARE
 Intrapartum Care
Clinical Practice Guidelines
• Updated, evidence based national guideline
on intrapartum and immediate postpartum
care
• To be used by health professionals
(OB SPECIALISTS, OB PRACTITIONERS,
NURSES and MIDWIVES) in all
GOVERNMENT AND PRIVATE
health facilities
 THE CPG DEVELOPMENT PROCESS
• Evidence based approach
– Based on the results of studies with acceptable
quality

• Formal consensus approach

– Discuss issues on generalizing the evidence to the
local scenario, taking into account
• Harms and benefits
• Costs RECOMMENDATIONS
• Preferences
• Best available evidence
RECOMMENDED PRACTICES
DURING LABOR
 Recommended Practices During Labor
• Active phase labor:
1. Admission to
labor room
– 2-3 contractions in 10
when the minutes
parturient is – Cervix is 4 cm dilated
already in the
active phase.
 Recommended Practices During Labor:
Admit when the parturient is already
in ACTIVE LABOR
• ↓need for Cesarean Section by 82%
• No difference in need for labor augmentation
• No difference in neonates with Apgar scores
<7 at 5 minutes

Rahnama, P., et.al., 2006: prospective cohort study on 810 low risk nulliparas
(474 in latent phase; 336 in active phase )
 Recommended Practices During Labor
1. Admission to labor when
the parturient is already in
the active phase.
2. Continuous
maternal support
 Continuous maternal support
• ↓Need for pain relief (RR 0.90, 95% CI 0.84-0.97)
• Duration of labor SHORTER (mean difference of
-0.58 hrs, 95% CI -0hrs to -0.30 hrs)

• Source of evidence: Cochrane review (21 trials, 15,061

women) comparing one-to-one intrapartum support given
by variety of providers (nurses, midwives, doulas, partner,
female relative, friend) versus usual care (Hodnett,
E.D., et.al., 2011)
 Continuous maternal support
• ↑SVD (RR 1.08, 95% CI 1.04-1.12)
• ↓ Instrumental vaginal delivery
(RR 0.90, 95% CI 0.84-0.96)
• ↓ CS (RR 0.79, 95% CI 0.84-0.96%)
• 5 minute Apgar < 7 ↓ by 30% (RR 0.70, 95% CI
0.92-1.01),

(Hodnett, E.D., et.al., 2011)

 Recommended Practices
During Labor
1. Admission to labor
when the parturient is
already in the active
phase.
2. Continuous maternal
support
3. Upright position
during first
stage of labor
Freedom of movement - distract
mothers from the discomfort of labor,
release muscle tension, and give a
mother the sense of control over her
labor (Storton, 2007).
 UPRIGHT POSITION DURING LABOR

• First stage of labor shorter by about 1 hour

• Need for epidural analgesia ↓ by 17%
• No difference in rates of SVD , CS, and
Apgar score < 7 at 5 minutes

Source of Evidence: Cochrane review (21 studies involving 3,706 women)

comparing upright versus recumbent position
(Lawrence, A., et.al., 2009)
 Restricting practices limit a mother’s
freedom to move and/or her position of choice.
1. IV lines*
2. fetal monitoring
3. labor stimulating medications that require
monitoring of uterine activity,
4. small labor rooms,
5. epidural placement
6. absence of support persons to “be with” the
intrapartum client
 Recommended Practices During Labor
1. Admission to labor
when the parturient is
already in the active
phase.
2. Continuous maternal
support
3. Upright position during
first stage of labor
4. Routine use of
WHO partograph to
monitor progress of
labor

For early identification of abnormal progress of labor

 Routine use of WHO Partograph
• No significant difference between use and
non-use of partograph in terms of
– CS rate (1590 patients, RR 0.64, 95% CI 0.24-1.70)
– Maternal Infection (1156 patients, RR 1.23, 95% CI .88-1.73)
– Instrumental vaginal delivery (1590 pts, RR 1.0,
95% CI 0.8-1.25)
Waiss-Rodrigues et al, 1987
Windrim et all, JOGC, 2006
• Guideline Panel: Use of partograph should be continued
because it encourages healthcare providers to diligently
monitor progress of labor
 Recommended Practices During Labor
1. Admission to labor
when the parturient is
• ↓ endometritis (OR 0.86, 95% CI
already in the active 0.72, 1.04)
phase.
2. Continuous maternal • ↓UTI by 34% (0.66, 95% CI 0.57,
support 0.76)
3. Upright position
during first stage of An observational study on 161,077 women (with
labor or w/o PPROM) who had < 5 exams (Ayzac, L.,
4. Routine use of WHO et.al., 2008)
partograph to monitor
progress of labor
• ↓ Chorioamnionitis by 72%
5. Limit total • ↓ Neonatal sepsis by 61%
number of IE to 1 RCT on 5,018 women with PROM with < 3 exams
(Seaward, P.G., et.al., 1998)
5 or less.
PRACTICES NOT
RECOMMENDED DURING LABOR
 Interventions that are NOT recommended
during labor

1. Routine • No difference in rates of

perineal maternal fever, perineal
shaving on wound infection, and
admission perineal wound
for labor and
delivery.
dehiscence
• No neonatal infection
was observed
Evidence: Cochrane review (3 trials) comparing it with
no shaving (Basevi, V. and Lavender, T., 2000 updated
2008)
 Interventions that are NOT
recommended during labor

1. Routine perineal • No difference in maternal

shaving on
admission for
puerperal infection, episiotomy
labor and dehiscence, neonatal infection,
delivery. and neonatal pneumonia
2. Routine • Comparable level of patient
enema satisfaction
during the • Fecal soiling during delivery
first stage reduced (RR-0.36; 95% CI 0.17-0.75)
of labor.
Source of Evidence: Cochrane review (4 trials)
comparing it with no enema (Reveiz, L., et.al.
2007 updated 2010)
 Practices that are NOT recommended
during labor
1. Routine perineal • No benefit for use of CTG
shaving on
admission for • ↑CS rate by 20% (RR .120, 95% CI
labor and delivery. 1.00-1.44)
2. Routine enema • No difference in instrumental
during the first
stage of labor. vaginal birth, perinatal
3. Admission mortality, Apgar score <7
CTG for low and NICU admission
risk term
Source of Evidence: Cochrane review - 4 RCTs
patients in comparing CTG on admission vs intermittent
labor auscultation of FHR for low risk term pregnant
patients in labor (Devane et al, 2012)
 Practices that are NOT recommended
during labor
1. Routine perineal • No difference in
shaving on
admission for chorioamnionitis,
labor and
delivery.
postpartum endometritis,
2. Routine enema perinatal mortality,
during the first
stage of labor.
neonatal sepsis
3. Admission CTG • No side effects reported
4. Routine Source of Evidence: Cochrane review
(3 trials that used different concentrations
vaginal and volumes of Chlorhexidine) comparing it
douching. with sterile saline (Lumbiganon, P., et.al.,
2004 updated 2009)
 Practices that are NOT recommended
during labor
1. Routine perineal
shaving on admission • ↓Risk of dysfunctional
for labor and delivery. labor (RR 0.75, 95% CI 0.64-0.88)
2. Routine enema
during the first stage • No difference in duration of
of labor.
3. Routine vaginal
labor, CS rate, cord
douching. prolapse, maternal infection
4. Routine & Apgar score < 7 at 5 mins
amniotomy to
shorten
spontaneous Source of Evidence: Cochrane review -14 trials
labor involving 4,893 women. (Smyth, R.M.D., et.al.,
2007 updated 2010)
 Routine IVF
Advantage Disadvantage
• to have ready • Interferes with the
access for natural birthing process
• restricts woman’s
emergency
freedom to move
medications • IVF not as effective as
• to maintain allowing food and fluids
maternal hydration in labor to treat/prevent
dehydration, ketosis or
electrolyte imbalance
POGS CPG on NORMAL LABOR AND DELIVERY, 2009
 Routine IVF
• No study found showing that having an IV in
place improves outcome
• Even the prophylactic insertion of
an IV line should be considered
unnecessary intervention.

Philippine Ob-Gyn Society CPG on Normal Labor and Delivery, 2009

 Routine NPO During Labor
• Possible risk of aspirating gastric contents with
the administration of anesthesia
• One study evaluated the probable risk of
maternal aspiration mortality, which is
approximately 7 in 10 million births.
• No evidence of improved outcomes for mother
or newborn.
• Use of epidural anesthesia for intrapartum
anesthesia in an otherwise normal labor should
not preclude oral intake.
leutel, M., and Golden, S., 1999
OGS CPG on Normal Labor and Delivery, 2009
 Routine NPO During Labor
• For the normal, low risk birth, there is no
need for restriction of food except where
intervention is anticipated.
• A diet of easy to digest foods and fluids
during labor is recommended.
• Isotonic calorific drinks consumed during
labor reduce the incidence of maternal
ketosis without increasing gastric volumes.
Singata M, Tranmer J, Gyte GML. Restricting oral fluid and food intake during labour.
Cochrane Database of Systematic Reviews 2010, Issue 1.
POGS CPG ON NORMAL LABOR AND DELIVERY, 2009
WHO Care in Normal Birth, 1996
 CARE DURING LABOR
RECOMMENDED NOT RECOMMENDED
 Admission to labor when Routine perineal shaving
in the active phase. on admission
 Companion of choice to Routine enema
provide continuous Routine NPO
maternal support Routine IVF
 Mobility and upright Routine vaginal douching.
position
Routine amniotomy
 Allow food and drink
Routine oxytocin
 Use of WHO partograph augmentation
to monitor progress of
labor
 Limit IE to 5 or less.
PRACTICES RECOMMENDED
DURING DELIVERY
Please wash
your hands!

46
 Traditional Non-Traditional

• Defined by a “fully • Redefined as “complete

dilated cervix” cervical dilatation” +
“spontaneous explusive
• Coached to push
efforts” (Simkin, 1991)
though out-of-phase
 Pelvic phase of
with her own
passive descent
sensation
 Perineal phase of
active pushing

Diagnosis of the 2nd Stage of Labor

• birth.avi
 Management of the 2nd Stage of Labor

Traditional Non-Traditional
DIRECTED PUSHING INVOLUNTARY BEARING DOWN
Valsalva pushing • Exhalation pushing
• Let air out
 Venous Return • Parturient-directed
 Perfusion to Uterus, • Physiologic: force of bearing
Placenta & Fetus down efforts increases as
fetal descent occurs
FHR Changes • Avoids hypoxia and acidosis

Fetal hypoxia & acidosis

Nikodem,VC. Beaaring down Methods during second stage labour
Roberts,1996; Simkin, 2000;Roberts,1987 as cited in Roberts, (Cochrane Review) In: The Cochrane Library, Issue 2, 2001 as cited
Joyce,Journal of Midwifery and Women’s Health.Vol. 47,No.1 by Roberts, 2002
Jan/Feb 2002
UPRIGHT POSITION DURING
DELIVERY
 UPRIGHT position during delivery
More efficient uterine contractions
Improved fetal alignment
Larger anterior-posterior and transverse
diameters of pelvic outlet  enhances fetal
movement through the maternal pelvis in
descent for birth
Faster delivery
Leads to less interventions : less episiotomies. 

Shilling, Romano, & DiFranco, 2007

 Interventions that are recommended
during delivery

1.Upright
position
during
delivery
2.Selective
(non-routine)
episiotomy
 Non-Routine Episiotomy
• ↑Anterior perineal trauma by 84%
n=4896, RR 1.84, 95% CI 1.61-2.1
• ↓ Posterior perineal trauma by 12%
n=2079, RR 0.88, 95% CI 0.84-0.92
• ↓ Need for suturing by 29%
n=4133, RR 0.71, 95% CI 0.61-0.81
• ↓ healing complications
n=119, RR 0.69, 95% CI 0.56-0.85
• No difference in severe vaginal and perineal
trauma, infection rate
Source of Evidence: Cochrane review - 8 trials including both primis and multis
with used median or mediolateral episiotomy (Carroli, G., and Mignini, L., 2009)
Perineal Support and Controlled Delivery
of the Head
During delivery of the head,
encourage woman to stop
pushing and breathe rapidly
with mouth open.

Keep one hand on the

head as it advances
during contractions while
the other hand supports
the perineum.
 Interventions that are recommended
during delivery
1. Upright position
during delivery
2. Selective episiotomy
3. Use of
prophylactic
oxytocin for
management of
third stage of
labor OXYTOCIN 10 U
intramuscular
Palpate abdomen to rule out
a second baby
 Prophylactic OXYTOCIN for the
3rd stage of labor
• Postpartum blood loss ≥ 500 ml reduced by 39%
• Need for additional uterotonic reduced by 47%
• No difference in need for maternal blood
transfusion, need for manual removal of
placenta, and duration of third stage

Source of Evidence: Cochrane review (4 trials on 2,213 women) using

varied doses, route, and timing of administration of oxytocin (Cotter,
A.M., et.al., 2002 updated 2004)
 Interventions that are recommended
during delivery
1. Upright position during Early clamping : <1 min after birth
delivery Delayed (properly timed) :1-3
2. Selective episiotomy minutes after birth or when
3. Use of prophylactic pulsations stop
oxytocin for mgt of 3rd
stage of labor

4.Delayed cord
clamping
 Interventions that
are recommended
during delivery
1. Upright position
during delivery
2. Selective episiotomy
3. Use of prophylactic
oxytocin for
management of third
stage of labor
4. Delayed cord
clamping
5. Controlled cord
traction with
countertraction to
deliver the
placenta
 Controlled Cord Traction
• ↓Postpartum blood loss >500ml by 7%
• ↓Postpartum blood loss >100ml by 24%
• No difference in rates of maternal mortality
or serious morbidity and need for
additional uterotonics.

Source of Evidence: Pooled analysis of 2 RCTs (23000 subjects) comparing it

with the “hands off” approach. (Althabe, F et al, 2009; Gulmezoglu AM et al,
2012)
 Interventions that are recommended
during delivery
1. Upright position
during delivery
•Lower mean blood loss
2. Selective episiotomy •Less need for uterotonics
3. Use of prophylactic
oxytocin Source of evidence: Cochrane review (1 trial on 200
4. Delayed cord women who delivered vaginally and AMTSL done vs
clamping massage. ) Hofmeyr, GJ et al 2008
5. Controlled cord
traction with
countertraction
6. Uterine massage
after placental
delivery
 Active Management of the Third
Stage (AMTSL)
1. Administration of uterotonic within one minute
of delivery of the baby.
2. Controlled cord traction with counter traction on
the uterus
3. Uterine massage
POPPHI. Prevention of Postpartum Hemorrhage: Implementing Active Management of the Third Stage
of Labor (AMTSL): A Reference Manual for Health Care Providers. Seattle: PATH; 2007.
 Approaches in the
Mgt of the 3rd Stage of Labor
Physiologic (Expectant) Active
(AMTSL)
Uterotonic NOT GIVEN before GIVEN within 1 min. of
placenta is delivered baby’s birth
Signs of placental WAIT DON’T WAIT
separation

Delivery of the By gravity with maternal CCT with counter

placenta effort traction on the uterus

Uterine massage After placenta is After placenta is

delivered delivered
PRACTICES NOT RECOMMENDED
DURING DELIVERY
 Interventions that are NOT
recommended during delivery
1. Perineal • Based on review, there is clear
massage benefit (↓3rd-4th degree teaars) and
in the 2nd no clear harm (no difference in 1st
stage of and 2nd degree tears, vaginal pain,
labor blood loss)
• Commonly noted complications in
practice (perineal edema, perineal
wound infection, and perineal
wound dehiscence) were not
evaluated
• Further studies are needed.
 Interventions that are NOT
recommended during delivery
1. Perineal massage
in the 2nd stage of
labor
2. Fundal
pressure
during the
second stage
of labor
 Fundal Pressure during 2nd stage
• 2nd stage longer by 29 minutes
• Increased 3rd and 4th degree perineal tears
• No difference in rates of postpartum
hemorrhage, instrumental vaginal delivery, Apgar
score < 7 at 5 minutes, and NICU admission
• Uterine rupture was not evaluated

Source of Evidence: Pooled analysis of Cochrane review (with 1 trial

only) (Verheijen, E.C., et.al., 2009) and 2 randomized trials
(Cosner, K., 1996; Matsuo, K., et.al., 2009) with overall total of
1,229 patients
 CARE DURING DELIVERY
RECOMMENDED NOT RECOMMENDED
 Upright position during Coaching the mother
delivery to push
 Selective episiotomy
Perineal massage in
 Use of prophylactic
the 2nd stage of labor
oxytocin for mgt of 3rd
stage of labor Fundal pressure
 Delayed cord clamping during the second
 Controlled cord traction stage of labor
with countertraction to
deliver the placenta
 Uterine massage
 POSTPARTUM CARE
RECOMMENDED NOT RECOMMENDED
 Routinely inspect the birth Manual exploration of
canal for lacerations
the uterus
 Inspect the placenta &
membranes for completeness Routine use of icepacks
 Early resumption of feeding over the hypogastrium.
(<6 hours after delivery) Routine oral
 Massage the uterus –ensure methylergometrine
uterus is well contracted
 Prophylactic antibiotics for
women with a 3rd or 4th
degree perineal tear
 Early postpartum discharge
May 20
Let us put it into practice!