Causes of Maternal mortality

World wide over 500,000 mothers die annuaally.

25% Haemorrhage
15% sepsis
12% eclampsia
8% obstructed /prolonged labour

2
Motherhood is NOT Safe in Kenya
MM ratio is estimated at 414/100,000 live births*
About 6,000 Kenyan women die annually from
pregnancy related conditions
Kenyan women face an unacceptable 1 in 20 lifetime
risk of maternal death
ANC coverage 88% (KDHS 2003) down from 92% in
1998
Delivery care by skilled attendants at 41%
Neonatal Mortality Rate: 28/1000 dependent on
quality of maternal services
KDHS 2003
Maternal mortality
women are not dying
because of diseases we
cannot treat. They are
dying because societies
have yet to make the
decision that their lives
are worth saving
Dr M. Fathalla

4
Factors Contributing to Poor
Maternal Health
Poor physical infrastructure and lack of
utilities
Inadequate equipment and supplies
Poor referral Systems
Weak competency and skills of service
providers in Maternal & Neonatal Health
Lack of support supervision
Poor quality services
5
Factors cont
Lack of knowledge of Evidence Based
Standards and guidelines for Safe
Motherhood
Inadequate community mobilization
activities and approaches
Weak health information management
system

What is normal labour?
Labour is physiological process by which the uterus
expels the products of conception.
Starts spontaneously
low risk at the start of labour and remain so
throughout labour and delivery.
The infant is born spontaneously in the vertex
position between 37 completed weeks to 42
weeks of pregnancy.
After birth mother and infant are in good
condition.
7 Normal Labor and Childbirth
Objectives of Care During
Labor and Childbirth
Protect the life of the mother and newborn
Support the normal labor and detect and treat
complications in timely fashion
Support and respond to needs of the woman,
her partner and family during labor and
childbirth
Normal labour is suspected or
diagnosed if the woman has
Painful contractions with a certain regularity,
effacement and or dilatation of the cervix -
progressive.
Pain often associated with blood stained
mucous discharge (show)
Watery vaginal discharge or sudden gush of
fluid (liquor)
True Vs False labour
Feature True labour False Labour
Painful contractions Gradual Increases Irregular
Interval btwn pains shortens

Remains long
Intensity Increases Same
Site of pain L/abd+back Lower abd
Dilatation/effacement
of cervix
Present&progressi
ve
Absent
bulg of Memb Present Absent
Sedation Pain not stopped Relieved
PHASES OF LABOUR
Latent phase- onset of labour to cervical
dilatation of 3cm
Active phase- 3cm cervical dilatation to 10cm
(full dilatation)( rate of at least 1cm per hour)

Stages of labour
Ist Stage :Onset to full dilatation of the cervix
2
nd
Stage :Full cervical dilatation to the expulsion of
the foetus.expected to lasts -one hour.
Passive second stage of labour:
the finding of full dilatation of the cervix prior to or in the
absence of involuntary expulsive contractions.
Onset of the active second stage of labour:
the baby is visible
expulsive contractions with a finding of full dilatation of the
cervix or other signs of full dilatation of the cervix
active maternal effort following confirmation of full dilatation
of the cervix in the absence of expulsive contractions.
Stages of labour cont.
3
rd
Stage : From delivery of the baby to
expulsion of the placenta.last 5-30 minutes
4
th
Stage : One hour after delivery of the
placenta

Position in Labour and Childbirth
Allow freedom in position and movement
throughout labor and childbirth
Encourage any non-supine position e.g.:
Side lying
Squatting
Hands and knees
Semi-sitting
Sitting


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

What is a partogaph
A graphic recording of progress of labour and
salient condition of the mother and the fetus..
The objective of using the partograph is
prevention of prolonged labour and its
sequelae

Why the partograph
Part of global adoption and up-scaling
of evidence-based practices, tools and
materials
Expected outcome Improved quality of
reproductive health care services,
particularly maternal health


Partograph as an early warning system
It assist in early decision on transfer
Augmentation and termination of labour
Improves on quality and regularity of all
observation
Improves on early recognition of problems
18 Normal Labor and Childbirth
Partograph and Criteria for Active
Labor
Label with patient
identifying information
Note fetal heart rate, color
of amniotic fluid, presence
of moulding, contraction
pattern, medications given
Plot cervical dilation
Alert line starts at 4 cm--
from here, expect to dilate
at rate of 1 cm/hour
Action line: If patient does
not progress as above,
action is required
19 Normal Labor and Childbirth
WHO Partograph: Results of Study
All Women Before
Implementation
After
Implementation
p
Total deliveries 18254 17230
Labor > 18 hours 6.4% 3.4% 0.002
Labor augmented 20.7% 9.1% 0.023
Postpartum sepsis 0.70% 0.21% 0.028
Normal Women
Mode of delivery
Spontaneous
cephalic
Forceps

8428 (83.9%)

341 (3.4%)

7869 (86.3%)

227 (2.5%)

< 0.001

0.005
WHO 1994.
20 Normal Labor and Childbirth
Presence of Female Relative
During Labor: Results
Randomized controlled trial in Botswana: 53 women with
relative; 56 without
Labor Outcome Experimental
Group (%)
Control
Group (%)
p
Spontaneous vaginal
delivery
91 71 0.03
Vacuum delivery 4 16 0.03
Cesarean section 6 13 0.03
Analgesia 53 73 0.03
Amniotomy 30 54 0.01
Oxytocin 13 30 0.03
Madi et al 1999.
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.
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

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

Harmful practices
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

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

26 Normal Labor and Childbirth
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 womans choice for position during labor
and childbirth
Provide continuous emotional and physical
support to woman throughout labor