Transcript Infections in pregnancy: The “so what” factor

Skilled Birth Attendants,
Traditional Birth Attendants
&
Intrapartum Care
Karen Hays, CNM, DNP-c
GH 544
January 6, 2011
Clinical Activities: Maternal-Newborn Care
•
photo of WHO Safe
Motherhood book
WHO 1999.
“A skilled
attendant at
childbirth is
the most
effective
intervention…”
But what is
skilled?
Skilled Birth Attendant (SBA)
W.H.O. Definition
An accredited health professional (e.g., a
midwife, physician, or nurse) who has
been educated & trained to proficiency in
the skills needed to manage normal
(uncomplicated) pregnancies, childbirth,
and the immediate postnatal period, & in
the identification, management, and
referral of complications in women &
newborns.
An Accredited Health Professional…
• Accredited – does that mean licensed? board
certified? registered? graduate of basic training
program?
• What about upkeep of that credential?
3 photos of different types of skilled attendants:
Cambodian nurse/midwife in birth center
Rich-country obstetrician
Trained traditional midwives in Guatemala
…educated & trained to
proficiency in the skills…
• ‘Educated’ & ‘Trained’ – either within
their primary MD, MW, RN program or
as an extra training after graduation
• ‘Proficiency’ – to pass the tests in the
context of the training; rarely any
follow-up in real life work setting
• ‘The Skills’ – see next slide
SBA Skill Set
•
•
•
•
Prenatal Care
Intrapartum Care
Newborn Care
Postnatal Care
SBA skill set is
standardized based
on the country & the SBA’s
scope of practice as defined by
licensure/registration/tradition/hierarchy
Intrapartum Care
•
•
•
•
Infection prevention, patient rapport
Uncomplicated labor, birth, & postpartum
Normal newborn care (breastfeeding & the Warm Chain)
Complication prevention & management
– obstructed labor – partograph, vacuum extraction*
– pre-eclampsia / eclampsia
– postpartum hemorrhage – AMTSL, bimanual
compression, manual vacuum aspiration*
– neonatal resuscitation
– sepsis (mom & baby)
– post-abortion care – manual vacuum aspiration*
*not always included
Rationale for the SBA Skill Set - Moms
Rationale for the SBA Skill Set - Babies
Reproduced from UNICEF ChildInfo website: http://www.childinfo.org/newborncare.html and based on Lawn, JE et
al. ‘4 Million Neonatal Deaths: When? where? why?’ The Lancet, vol. 365, no. 9462, 2005, pp. 891–900.
Skill Set – Infection Prevention
photos of handwashing, gloving, cleaning instruments, etc
Skill Set - Patient Rapport
Mother-Friendly Childbirth Initiative
photos of women laboring alone and
looking forlorn
Lonely women, delivering all over the world….
SBA Skill Set: Uncomplicated Labor
Photos of women and their attendants during labor, in homes & facilities, from
several different countries and resource-levels.
SBA Skill Set: Uncomplicated Delivery
Photos of normal births, at home & in facilities, with different types of
attendants in different countries with different resource levels.
SBA Skill Set: Uncomplicated Postpartum
Photos of placental delivery and moms with their babies soon after birth.
SBA Skill Set: Normal Newborn Care
Photos of babies being cared for in many different countries
SBA Skill Set: Complication Prev & Tx
Photos of BPs being taken, women in trouble, book of PPH management, etc.
Two Trendy Prevention Strategies
1. The Partograph
• Graph to be used during
Active Labor & 2nd Stage
• Charts
–
–
–
–
–
vital signs
contraction pattern
cervical dilation
fetal descent
medications given
• Purpose – to minimize
delays in recognizing
prolonged labor
2. Active Management of the
Third Stage of Labor (AMTSL)
• Protocol for delivery of
the placenta
• Includes
– Use of a uterotonic
medication
– Controlled cord traction
– Abdominal uterine massage
after placenta out
• Purpose – to reduce risk
of postpartum hemorrhage
(PPH)
PARTOGRAPH
Registration No._____________ Name (Last, First)__________________________________ Age_____
Date_______________Gravida/Parity_____/______LMP________EDD_________Gestation (wks)_____
ROM (Time, Date)____/________ Labour Duration (Hrs)_____ Facility/Clinic Name________________
FETAL
HEART
RATE
190
190
180
170
160
150
140
130
120
110
180
170
160
150
140
130
120
110
100
90
80
70
60
100
90
80
70
60
LIQUOR
MOULDING
8
(CM)
Plot X
DESCENT
Plot O
10
A
ct
io
n
9
A
le
rt
10
CERVIX
9
8
7
7
-3
6
6
-2
5
5
-1
4
4
0
3
3
+1
2
2
+2
1
1
+3
0
0
HOURS
HOURS
TIME
5
4
3
2
1
CONTRACTIONS
PER 10 MINS
5
4
3
2
1
Oxytocin U / L
Drops / minute
DRUGS
&
IV FLUIDS
BLOOD
PRESSURE
&
PULSE
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
TEMPERATURE
URINE
Amount
Protein
Acetone
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
AMTSL
• Oxytocin injection
is preferred, but
misoprostol tablets
are okay in places
where injection
skills & equipment
management is not
feasible.
• Early cord clamping
is not required for
AMTSL.
To the right – photo of AMTSL
poster from India
SBA Skill Set: What’s Missing?
Hint: 2 lifesaving medical procedures
SBA Skill Set: What’s Missing?
Blood Transfusion & Cesarean Section
Photo of a C-section and of a woman getting a transfusion
Basic vs. Comprehensive
Emergency Obstetric Care (EmOC)
• Basic EmOC for some health centers & all
hospitals (SBA+ level care)
– antibiotics, oxytocics, anti-convulsants, antihypertensives, manual removal of placenta,
manual vacuum aspiration
• Comprehensive EmOC for hospitals with
surgical capacity (personnel, O.R., anesthesia)
– basic EmOC capabilities
– blood transfusions
– Cesarean section
Why can’t SBAs and EmOC
save more lives?
Reproductive Health Response in Conflict Consortium ©2005
The 3 Delays Model
Photos of transportation difficulties
and a crowded female hospital
ward
• Delay in recognition
of a problem
• Delay in transport
to referral facility
• Delay in proper
treatment at the
facility
Will the SBA reduce mortality
in this setting?
Photo of a midwife in a dreadful facility
Other reasons for under-utilization
of SBAs & EmOC
• Women fear poor treatment due to political, socioeconomic, ethnic, religious, language, etc. problems
• Facility reputation for poor quality services, long waiting
times, exclusion of family, male health care workers
• Cost
• Women unable to travel due to security, poor travel
conditions, no vehicle, or cultural restrictions
• Concerns about privacy, social stigma
• Status of Women – unable to obtain permission from
husband, mother-in-law, patriarch
• Prefer local traditional healers – TBAs, shamans, etc.
• Fatalism, attribute illness & death to supernatural forces
Will the SBA & EmOC reduce
mortality for this woman?
Photo of an emaciated young mother with 2 small babies in a horrible refugee
camp
Is a Traditional Birth Attendant (TBA)
a Skilled Birth Attendant (SBA)?
TBAs have a
different,
overlapping, &
complementary
skill sets
Photos of TBAs from 4 different
countries
.
TBAs are
influential in their
communities & need
to be respected &
included in MCH
activities, even if
non-literate
Integration of TBAs into the Slooow
‘Modernization’ of MCH Services
Recognition & Support
• Education – the 3 cleans
(hands, surface for birth,
cord cutting)
• Incorporate into facility
services, e.g. Doula role
• Organize gatherings
where TBAs can share
knowledge & support
• Recognize ‘Big Picture’
issues before judging or
trying to replace them
Photos of TBAs learning hand washing,
being doulas in hospital, having a
TBA meeting
It’s all so worth it!
Photo of happy mom with brand new baby on her chest.
Websites
• http://www.internationalmidwives.org
• http://www.who.int/reproductivehealth/global_monitoring/skilled_atten
dant.html
• http://www.paho.org
• http://www.midwives.org
• http://www.hesperian.org/index.htm