1. 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

2. 2 Afghanistan2002  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

3. Parent Death & Child Survival in Bangladesh Cumulative probability of survival of child to age 10 years Father alive: 88.6% Father dead: 89.3% 3 Mother alive: 88.9% Mother dead: 23.8% Ronsmans LANCET 2010

4. 4 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

5. 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

6. 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

7. 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

8. 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 Intrapartum care to prevent asphyxia

9. 9 EMOTIONAL SUPPORT DURING LABOR EMOTIONAL SUPPORT DURING LABOR

10. Pre-Eclampsia Management  Undiagnosed/inadequately managed severe pre-eclampsia results in  Maternal seizure  Severe hypertension  Emergency Caesarean  Proper management of severe PE / Eclampsia  Prevent seizures: Mg SO 4  Treat hypertension: anti-hypertensives  Ensure timely delivery  Increase obstetrical monitoring – not darkness and quiet at the end of the corridor 10 Neonatal Asphyxia Intrapartum care to prevent asphyxia

11. 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

12. Alternative positions  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

13. 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 Intrapartum care to prevent asphyxia

14. 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

15. 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

16. 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

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