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%
Ronsmans LANCET 2010
3
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 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
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
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
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
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)
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.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 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
11
Intrapartum care to prevent asphyxia
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
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
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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
 Infected babies don’t breathe well
 Doing procedures right!
 Vacuum extraction and breech delivery
 Twin delivery – management of 2nd twin
 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
16
Thank you!
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