Download healthy beginnings: guidelines for care during pregnancy

SOGC
C LINICAL P RACTICE G UIDELINES
POLICY STATEMENT
No. 71, December 1998
HEALTHY BEGINNINGS:
GUIDELINES FOR CARE DURING
PREGNANCY AND CHILDBIRTH
This document was written and reviewed by members of the Clinical Practice—
Obstetrics Committee and approved by the Executive and Council of the Society of
Obstetricians and Gynaecologists of Canada (SOGC).
This document supersedes the guidelines published in December 1995.
Principal Authors:
Nan Schuurmans, MD, FRCSC (Past Chair)
Guy-Paul Gagné, MD, FRCSC (Chair)
Ahmed Ezzat, MD, FRCSC
Irene Colliton, MD
Catherine J. MacKinnon, MD, FRCSC
Brenda Dushinski, RN
Robert Caddick, MD, FRCSC
(Edmonton, AB)
(LaSalle, QC)
(Saskatoon, SK)
(Edmonton, AB)
(London, ON)
(London, ON)
(Moncton, NB)
National Office:
André B. Lalonde, MD, FRCSC
Robert A.H. Kinch, MB, FRCSC
Policy Statement: this policy reflects emerging clinical and scientific advances as of the
date issued and is subject to change. The information should not be construed as
dictating an exclusive course of treatment or procedure to be followed. Local
institutions can dictate amendments to these opinions. They should be well
documented if modified at the local level. None of the contents may be
reproduced in any form without prior written permission of SOGC.
Déclaration de principe : le document d’opinions fait état des percées récentes et des
progrès cliniques et scientifiques à la date de publication de celle-ci et peut faire
l’objet de modifications. Il ne faut pas interpréter l’information qui y figure comme
l’imposition d’une procédure ou d’un mode de traitement exclusifs à suivre. Un
établissement hospitalier est libre de dicter des modifications à apporter à ces opinions.
En l’occurrence, il faut qu’il y ait documentation à l’appui de cet établissement.
Aucune partie ne peut être reproduite sans une permission écrite de la SOGC.
HEALTHY BEGINNINGS: GUIDELINES FOR CARE
DURING PREGNANCY AND CHILDBIRTH
TABLE OF CONTENTS
Chapter 1:
Introduction ........................................................................................................................................1
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Chapter 2:
The Human Experience ..........................................................................................................................................................2
Safety Factors ......................................................................................................................................................................................2
Cost Effectiveness ..........................................................................................................................................................................3
References ................................................................................................................................................................................................3
Antepartum Care ..........................................................................................................................4
– Preconceptual Care ......................................................................................................................................................................4
Medical History
Present Medications
Lifestyle Issues
Past Obstetrical History
Folic Acid
Rubella
Infertility Patients
– The First Prenatal Visit ............................................................................................................................................................5
When
Shared Care with Another Physician
Antenatal Record
Previous Obstetrical History
Physical Examination
Laboratory Investigations
– Follow-Up Visits ..............................................................................................................................................................................6
When/How Often?
Further Investigations
Communication with the Patient
Fetal Surveillance/Induction of Labour
– Establishing the Relationship with the Pregnant Woman ..........................................................7
Issues Identified by Patients Regarding Communication
Prenatal Care Plan
“Record of Pregnancy” Diary
Birth Plan
Specific Information Pamphlets
– References ................................................................................................................................................................................................8
– Appendix 2-1: HIV Testing in Pregnancy........................................................................................................9
– Appendix 2-2: Sample Prenatal Care Plan ................................................................................................10
Chapter 3:
Health Education and Lifestyle
Aspects of Prenatal Care ..................................................................................................12
– Prenatal Education ....................................................................................................................................................................12
Review of the Literature
Gaps in the Literature
Recommendations
– Nutritional Counselling ......................................................................................................................................................14
Nutrition Assessment and Counselling
Maternal Weight Gain
Vitamin Supplements
Food Supplements
Supplementary Advice about Nausea and Vomiting
– Work during Pregnancy ......................................................................................................................................................16
– Exercise during Pregnancy ..............................................................................................................................................16
First Prenatal Visit
Exercise Cautions
Exercise Intensity
– Sexuality in Pregnancy..........................................................................................................................................................18
– Stress and Social Support ..................................................................................................................................................18
Social Support
Stress
Some Measures to Assist in Alleviating Stress
– Abuse in the Obstetrical Population ..................................................................................................................19
Incidence
Components of Counselling
The Dos When Abuse is Identified
The Don’ts When Abuse is Identified
– Appendix 3-1: Antenatal Psychosocial Health Assessment (ALPHA) ..................21
– Smoking and Pregnancy ....................................................................................................................................................24
– Alcohol and Pregnancy ........................................................................................................................................................25
– Drug Use and Abuse in Pregnancy ......................................................................................................................26
– Exposure to Infectious Diseases during Pregnancy ........................................................................27
– Education to Recognize Some of the Important Complications of Pregnancy ........27
Preterm Labour and Birth
Risk Factors for Preterm Birth
Signs of Preterm Labour
Preventive Strategies for Preterm Birth
Premature Rupture of Membranes
Antepartum Haemorrhage
Hypertensive Disorders in Pregnancy
Fetal Movement
Summary
– Breastfeeding ....................................................................................................................................................................................31
Benefits of Breastfeeding
Components of Counselling and Patient Education
Some Community Resources
Chapter 3 cont.:
– References ............................................................................................................................................................................................31
– Appendix 3-2: Guidelines for the Management of
Nausea and Vomiting in Pregnancy ......................................................................34
Chapter 4:
Birthing Guidelines ................................................................................................................37
– Philosophy ............................................................................................................................................................................................37
– Hospital Policies and Standards ..............................................................................................................................37
Family-Centred Care
– Facilities ..................................................................................................................................................................................................38
Labour/Delivery/Recovery/Postpartum (LDRP) Rooms
– Staffing ......................................................................................................................................................................................................39
– Alternative Delivery Setting ..........................................................................................................................................40
Home Birth
Alternative Birthing Centre Outside the Hospital
– Strategies to Address Intervention Rates ......................................................................................................40
Implementation of Progressive and Lasting Changes
– References ............................................................................................................................................................................................41
– Appendix 4-1: Family Birthing Centre/Sample Birth Plan ....................................................42
Chapter 5:
First Stage of Labour ............................................................................................................43
– Early Assessment..........................................................................................................................................................................43
First Stage of Labour—Triage
– Management of the First Stage of Labour ..................................................................................................43
Diet/Routines
Pain Relief: Medicinal or Non-Medicinal
Fetal Monitoring
Monitoring Labour Progress
Early Amniotomy
– Labour Support ............................................................................................................................................................................45
Benefits of Labour Support
The Art of Labour Support Techniques
Examples of Labour Support Techniques
Conclusion
Summary of Recommendations
– References ............................................................................................................................................................................................48
– Appendix 5-1: Hydrotherapy ......................................................................................................................................49
– Appendix 5-2: The Partograph ................................................................................................................................51
Chapter 6:
Second Stage of Labour ....................................................................................................52
– When to Push/How to Push ..........................................................................................................................................52
Conclusion
Chapter 6 cont.:
– Maternal Position ......................................................................................................................................................................53
Upright or Semi-Sitting Posture
Left Lateral or Sims’ Position
Squatting Position
Delivery on all Fours
Birthing Chairs or Stools
Water Births
Conclusion
– Duration of the Second Stage ......................................................................................................................................54
– Monitoring Fetal Health ....................................................................................................................................................55
Summary
– Care of Perineum/Delivery ..............................................................................................................................................55
– Shoulder Delivery ........................................................................................................................................................................56
Shoulder Dystocia
– Summary of Recommendations................................................................................................................................57
– References ............................................................................................................................................................................................58
Chapter 7:
Baby Arrives....................................................................................................................................59
– General Philosophy ..................................................................................................................................................................59
– Management at the Time of Birth ........................................................................................................................59
Chapter 8:
The Third Stage of Labour ..........................................................................................61
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Passive Management ..............................................................................................................................................................61
Placental Expression................................................................................................................................................................61
Active Management of the Third Stage of Labour ..........................................................................61
Retained Placenta ........................................................................................................................................................................62
Inversion of the Uterus ........................................................................................................................................................62
Early Clamping and Division of the Umbilical Cord ..................................................................62
Conclusion
– Repair of Perineal Trauma after Childbirth ............................................................................................62
– Summary of Recommendations................................................................................................................................63
– References ............................................................................................................................................................................................63
Chapter 9:
Postpartum Care ........................................................................................................................64
– Management of Postpartum Care ........................................................................................................................64
– Length of Hospital Stay ......................................................................................................................................................64
– References ............................................................................................................................................................................................65
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Chapter 1
INTRODUCTION
The main mission of the Society of Obstetricians and
Gynaecologists of Canada (SOGC) is to promote optimal reproductive care for all Canadians. The Society and
its members are highly involved and interested in the
provision of care during pregnancy and childbirth. This
field is in a state of constant evolution, particularly due
to changing scientific evidence and greater consumers’
involvement in health. As a result, the appropriateness
of some medical practices or hospital policies have been
questioned, particularly when viewing a normal process
such as childbirth.
Pregnancy and birth, as all of us who are health
caregivers and/or parents know, is a unique life event.
As physicians, we are concerned with the physiologic
process—what is normal, what is abnormal and how to
diagnose and treat abnormalities. Our patients seek
medical care because it is also important to them that
all goes well, but in addition, pregnancy and birth for
them is an important life event. As Sheila Kitzinger
says:
There are clearly many opportunities available for promoting and supporting pregnancy and birth as normal events
while maintaining and improving the excellent medical surveillance and care that has contributed to our patients’
favourable perinatal and neonatal outcomes that Canadians
have come to expect.
The cost of health care has also become a prominent
force and should be considered when formulating obstetrical policies. Procedures or policies that have not proven
to be clearly beneficial in improving outcome should be
avoided.
In this context, the Obstetrical Clinical Practice Committee
undertook an extensive review of the scientific and sociologic evidence concerning antepartum, intrapartum and
postpartum care to determine what is essential to the provision of safe and effective care during pregnancy and
childbirth. The committee has considered the provision of
care in obstetrics at three different levels:
1. The human experience;
2. Evidence-based clinical practice;
3. Cost effectiveness.
“Birth is a rite of passage which is not only important in
the developing consciousness of a woman who becomes a
mother, but usually also has special meaning for the father,
the extended family of each, and the wider society within
which birth takes place.”1
To achieve its goal, the committee has extensively
reviewed scientific data available from the Cochrane
Pregnancy and Childbirth Database and from Medline
searches. It also incorporated Clinical Practice Guidelines already completed by other SOGC committees
(e.g. Maternal-Fetal Medicine Committee) and used the
experience and expertise of its members, which reflect
the diversity of obstetrical care across this country (geographic, university, community-based, and general practice and nursing).
The tendency for the medical model to treat pregnancy and childbirth as an illness rather than an expression of health has been criticized by women and their
advocates. As a result of public pressure, there has been
more of an emphasis over the past 20 to 30 years on promoting and enabling the “normal” process within the
medical/institutional setting.
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All recommendations are based on the best scientific data available, and where scientific data are not available, this is clearly stated.
SAFETY FACTORS
Pregnancy and birth are natural, but those with
experience in obstetrical care know the natural outcome
of a pregnancy is not always perfect and sometimes can
even be hazardous. This reality was also recognized in
very ancient religious texts more than two thousand
years ago, when a pregnant woman would not be expected to follow the different religious rites as soon as labour
started because after this time, her life was considered to
be in danger.4 Excluding those people who are ready to
accept any outcome passively as the “Will of God”, the
great majority agree that some form of standardized care
and assistance is desirable for safety during labour and
delivery. Jordan states: “Because of the importance of the
birth event for individuals, for the continuity of families,
the existence of communities and indeed the species, no
society known to us has left the management of birth to
the individual. Rather, people everywhere have regulated the event.” 5 In the last few decades important
advances in medicine, particularly the care of premature
infants and promotion of the education of women during pregnancy, have contributed to a marked reduction
in perinatal mortality.
In addition to these advances, the introduction of
electronic fetal monitoring and ultrasono-graphy have
brought the hope that health care professionals would
be able to control such risks of pregnancy as fetal growth
restriction and intrapartum fetal asphyxia. These
advances may have contributed to a significant rise in
litigation as a result of the population’s attitude that all
adverse outcomes are preventable and someone can be
held accountable when things go wrong. New scientific
data and current experience indicate that these techniques have limitations and they should be indicated
only for specific purposes. Extensive and routine use may
lead to an increase in the intervention rate without an
accompanying advantage in outcome.
It is our responsibility as obstetricians to inform families of these facts and obtain consent to encourage realistic expectations. Medicine is not an exact science. It is
an art. From this perspective, the care of every patient
must be tailored to meet her needs. In every case,
informed consent must be obtained, meaning the couple, particularly the woman, makes the final decision.
When obtaining informed consent, the obstetrician
should present the facts of the case and allow the couple
THE HUMAN EXPERIENCE
In the majority of cases, pregnancy and birth are normal, natural processes. Most births in Canada take place
in hospitals, and it is therefore the responsibility of hospital administrators to provide and to create an environment that supports this important event. In this
context, it is felt that the hospital should be a nonthreatening environment in which the patient can
openly express her preferences without feeling that she
is contradicting hospital policy. The use of a “birth plan”
is also effective and encourages the caregiver to adopt a
more flexible way of working. In the last two decades,
many hospital policies justifiably came under criticism
due to their lack of flexibility, or were deemed unnecessary. The routine use of an enema and perineal shaving at the time of admission and the routine use of an
intravenous line during normal labour are good examples of the latter and should be abandoned.
“The challenge faced by professionals working in maternity
units is firstly to maintain and introduce only those routines
and rules which have been shown, on balance, to do more
good than harm; and secondly, to apply such routine flexibly and in a way which takes the needs of individual child
bearing women into account.”2
“A pre-requisite for moving in the right direction is that
both professionals and women using their services should
be aware of the relevant evidence.”2
Hospital care should also be family-oriented and
encourage the participation of the husband or significant
other and/or family member. Early separation of mother
and baby within the first two hours after birth should be
avoided, as research has demonstrated that this has a
deleterious effect on breastfeeding and maternal affectionate behaviour.3 Both scientific and human factors
must be considered to ensure a successful and gratifying
experience for all involved. Otherwise stated, the feeling of being understood and in control of oneself will
support the experience of joy and growth and favour a
positive outcome, allowing birth to be a celebration of
life and love.2
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to arrive at their own decision. This involves being supportive and non-judgemental of their final decision. For
example, the risk of a miscarriage after an amniocentesis compared with the advantage of an antepartum diagnosis of Down’s Syndrome at a given mother’s age can
be acceptable to the doctor, but considered too high a
risk by the patient. Her final decision should be respected and supported. The same is true for all obstetrical procedures. Objective, informed, compassionate and
personalized care is what brings art into obstetrics.
COST EFFECTIVENESS
All across Canada and the U.S., different projects
like mother and baby care, self-care, cooperative care, as
well as the labour/delivery/recovery (LDR) concept and
the labour/ delivery/recovery/postpartum (LDRP) concept (single-room maternity) have proven to be cost
effective, while at the same time providing a better environment for personal and family-oriented care. Experience has shown that personalized obstetrical care has
increased the tendency towards natural birth with a
reduction in the number of interventions and consequently, a reduction in cost. The consumer’s priorities
for physical facilities include: privacy, the availability of
support people (family or friends), and the possibility of
making choices.
It is our hope that hospital administrators and caregivers in obstetrics will consider these policies which
have been shown to produce proven beneficial outcomes.
REFERENCES
1.
2.
3.
4.
5.
Kitzinger S. Childbirth and society. In: Chalmers I, Enkin
M, Kierse, M, eds. Effective care in pregnancy and childbirth. Oxford University Press. 1989(1991):99.
Chalmers I, Garcia J, Post S. Hospital policies for labour
and delivery. In: Chalmers I, Enkin M, Kierse M, eds.
Effective care in pregnancy and childbirth.. Oxford University Press. 1989(1991): 815-19.
Thomson M, Westreich R. Restriction of mother-infant
contact in the immediate post-natal period. In: Chalmers
I, Enkin M, Kierse M, eds. Effective care in pregnancy and
childbirth. Oxford University Press. 1989(1991):1322-30.
Feldman, Perle. Sexuality, birth control and childbirth in
orthodox Jewish tradition. Can Med Assoc J 1992;146:
29-33.
Jordan B. Sistemi natali etno-obstetrica: Frammenti di
una recerca transculturale. In: Couture del Parto. Milano:
Feltrinelli. 1985:73-84.
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Chapter 2
ANTEPARTUM CARE
The goal of modern prenatal care is to assist the pregnant woman in ways that reduce perinatal mortality and
morbidity, while supporting the woman’s medical, social
and psychological needs. This document is designed to
help physicians offer this kind of care in an effective
manner with a minimum of intervention.
lowest possible risk to the fetus.2 These women should
be stabilized on the new drug regimen prior to attempting to conceive. Some women with epilepsy may be able
to stop their medication, if no seizures have occurred in
the last two years. Comprehensive information about
specific drugs and use during pregnancy is available.3,4
LIFESTYLE ISSUES
PRECONCEPTUAL CARE
Smoking, alcohol use, illicit drug use, nutritional status and general physical fitness should be reviewed and
constructive advice given. Women who abuse drugs,
alcohol or tobacco should be helped to alter their behaviour prior to discontinuation of reliable birth control.
Prescreening for rubella and syphilis may be done and
patients at risk of HIV infection should be offered testing for it and other sexually transmitted diseases.
MEDICAL HISTORY
All women considering conception should be encouraged to discuss this with their physician. When
approached on such a matter, the physician should review
the woman’s medical history for diseases that might influence the pregnancy outcome or which could be adversely affected by the pregnancy. Serious conditions may
require review by pertinent specialists. For example, a
woman with valvular heart disease should discuss her plans
with her cardiologist as well as with her obstetrician or
perinatologist. Women with diabetes should strive for
excellent control in the periconceptual period.1 This may
require intensive monitoring or the aid of a specialist. The
implications of any familial or genetic conditions should
be discussed and referral to a geneticist considered.
PAST OBSTETRICAL HISTORY
A review of the woman’s obstetrical history should
involve a discussion of past complications, such as
intrauterine growth restriction and premature labour, that
may repeat in future pregnancies. Advice on possible need
for hospitalization or the likelihood of perinatal complications may play an important part in the woman’s decision regarding conception. Assessment by an obstetrician,
perinatologist or neonatologist may be helpful.
PRESENT MEDICATIONS
All of the woman’s medications should be reviewed
with regard to the optimal dosage. In some instances a
woman should be advised to discontinue the medication
or switch to another medication that is more appropriate during pregnancy. For example, women should not
continue to take angiotensin converting-enzyme (ACE)
inhibitors for chronic hypertension or coumadin for anticoagulation if they intend to conceive. Consideration
should be given to choosing a medication that will give
epileptic women good seizure control while offering the
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FOLIC ACID
All women should be advised to take a minimum of
0.4 mg of folic acid supplementation or dietary equivalent according to Canada’s Food Guide for Healthy Eating, after discontinuation of reliable birth control and
for 10 to 12 weeks after the last menstrual period
(LMP). Women who have had a previous conception
or baby affected by a neural tube defect should be
advised to take four mg of folic acid daily in this same
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time period. Intermediate risk women include those with
insulin-dependent diabetes, epilepsy treated with valproic
acid or carbamazepine, or women with a first degree relative with a neural tube defect. These women should be
advised to take one to four mg folic acid daily. To achieve
this, extra doses of prenatal vitamins should not be used
as toxicity may occur from other ingredients. Careful
seizure monitoring is necessary in epileptic patients, as folic
acid interacts with many antiepileptic medications. Details
of interactions are provided in the SOGC Policy Statement on the Use of Folic Acid for the Prevention of Neural Tube Defects, published in March 1993.5 Folic acid
supplementation is contraindicated in women with
untreated pernicious anaemia or undiagnosed anaemia.
The physician should advise the woman on how to
discontinue her current birth control and ensure that any
questions regarding conception and pregnancy have been
fully answered. One or two spontaneous menstrual cycles
should occur before the couple attempts conception. Plans
for early pregnancy follow-up should be made.
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offered an early appointment to discuss the available
genetic investigations. Women requesting chorionic villus sampling or amniocentesis should be referred immediately to an appropriate physician or genetics centre.
SHARED CARE WITH ANOTHER PHYSICIAN
If the woman’s usual physician does not attend deliveries, the patient should be informed and opportunities
for shared care with another physician or transfer of care
should be explored. The patient should visit the delivering physician early and plans for subsequent care must
be clearly planned.
ANTENATAL RECORD
At the first prenatal visit, the following should be
recorded on a standardized antenatal form:
– the woman’s past medical history,
– obstetrical and family history,
– use of prescription and non-prescription drugs,
– known drug allergies and present symptoms, and
– physical findings.
This same antenatal form will then be used to record
further progress during pregnancy. Risk factors for
adverse pregnancy outcome should be identified and
clearly highlighted on the antenatal record. The initial
physician should transfer these forms with the patient to
all subsequent physicians and also to the delivery room
the patient expects to attend. If shared care is to occur,
communication between physicians must be accomplished with efficiency and thoroughness.
RUBELLA
At the preconceptual visit, rubella-susceptible women
should be identified and, if not actively attempting to
become pregnant, should be immunised. Screening by
serology at the first prenatal visit is indicated. Rescreening
of serologic-negative women after exposure or with possible rubella infection should be performed. Women who
have negative serology should be immunised postpartum.
INFERTILITY PATIENTS
PREVIOUS OBSTETRICAL HISTORY
The opportunity should be taken with women
undergoing investigation for infertility to advise them
regarding preconceptual care.
Notes from previous pregnancies may need to be
reviewed to assess risk of recurrence of complications.
Ideally, notes from previous Caesarean births should be
reviewed to confirm that the incision was low segment
transverse prior to planning an attempt at vaginal birth.
THE FIRST PRENATAL VISIT
WHEN
PHYSICAL EXAMINATION
Women should be encouraged to inform their physician as soon as pregnancy is suspected and ideally should
be seen within 12 weeks of the last normal menstrual
period. It is especially important that a woman be seen
as soon as possible if a preconceptual visit did not
occur. Teenage women should have their initial visits
earlier and receive more intensive support during their
pregnancies. It is also recommended that women over
the age of thirty-five or with genetic risk factors be
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Physical examination at the first antenatal visit
should include observation of the woman’s:
– height,
– weight,
– blood pressure,
– thyroid,
– breasts,
– chest and cardiovascular findings,
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abdomen,
a Pap. smear if not done in previous six to twelve
months,
– a bimanual examination for uterine size and adnexal findings,
– extremities.
A detailed examination of other body systems may
be necessary in certain cases, depending on the complaints and past medical history.
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Laboratory test results from the initial and all subsequent investigations should be recorded directly on the
antenatal forms with the date they were completed. All
ultrasounds should be compared to the expected gestational age on the basis of the dating established at the
first visit. Alterations in estimated date of confinement
(EDC) should be clearly documented and explained to
the patient.
FOLLOW-UP VISITS
LABORATORY INVESTIGATIONS
WHEN/HOW OFTEN?
If pregnancy is confirmed, the following laboratory investigations should be offered and arranged for all patients:
– haemoglobin level,
– blood group and antibody screen,
– rubella titre,
– hepatitis B surface antigen assay,
– VDRL,
– HIV testing. (See Appendix 2-1: HIV Testing in Pregnancy.)
Visits every four to six weeks are appropriate for the
beginning of pregnancy. After 30 weeks, visits should
occur every two to three weeks and after 36 weeks, every
one to two weeks until delivery. These assessments should
focus on different issues appropriate to the gestational age.
(See Appendix 2-2: Sample Prenatal Care Plan.) At
each visit, blood pressure, uterine size, urine dipping for
protein and glucose, and fetal heart rate should be
recorded. The patient’s weight gain may also be assessed.
Urine microscopy or culture and sensitivity may be
used to detect asymptomatic bacteriuria. Obese women
should be screened for pre-existing diabetes. A full
screening ultrasound at 16 to 20 weeks should be
offered according to the SOGC Policy Statement on the
Performance of Ultrasound.6 Earlier or subsequent scans
should be offered only when medically indicated.
Other investigations are appropriate in certain circumstances, and include:
– cultures for herpes, gonococcus or chlamydia (refer
to Chapter 3);
– hepatitis C screening (refer to Chapter 3);
– toxoplasmosis screening (refer to Chapter 3);
– maternal serum screening for chromosome anomalies and neural tube defects. There is fair evidence
to offer triple-marker screening to women under
35 years of age within a comprehensive screening
and prenatal diagnosis program including education, interpretation and follow-up. However, there
are concerns with regard to these tests related to
limited sensitivity of the screening test, the number of false-positive results, and the number of
women who receive positive results but do not subsequently undergo amniocentesis. 7,8 For women
over 35, the evidence supports offering amniocentesis. Women may choose maternal serum screening as an alternative.
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FURTHER INVESTIGATIONS
Further investigations such as ultrasound may be
ordered if evidence of intra-uterine growth restriction
(IUGR), pre-eclampsia, excessive growth or other abnormalities are identified.
All women who are Rh negative should receive Rh
immune globulin at 28 weeks gestation if there is no evidence of isoimmunization.
The value of routine screening of all pregnant
women for gestational diabetes remains unproven. Until
further data are available, caregivers should maintain a
low threshold for testing for this condition, or consider
testing all patients with a 50 gram oral glucose challenge
test at 24 to 28 weeks gestation, as per the SOGC Committee Opinion on Routine Screening for Gestational
Diabetes Mellitus in Pregnancy.9
Group B Streptococcus (GBS) is a major cause of
morbidity and mortality among newborn infants. Group
B Streptococcus in pregnancy should be discussed with
the patients. There are two acceptable options for
screening (testing) for GBS.10 A doctor may choose to
routinely culture (test) all pregnant women between the
35th and 37th week of pregnancy, and treat the mothers who are GBS colonized (positive) with antibiotics
when labour starts. Alternatively, a doctor may choose
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not to test every woman routinely, but rather to treat
only those mothers who are at risk of passing the bacteria to their babies during the birth process.
The risk factors for which intrapartum chemoprophylaxis is recommended include:
1. Preterm labour (<37 weeks gestation).
2. Term labour (37 weeks gestation) with:
a) Prolonged rupture of membranes. Chemoprophylaxis should be given if labour and/or ruptured membranes is likely to continue beyond 18
hours (neonatal benefits are optimally achieved
if antibiotics are given at least 4 hours prior to
delivery).
b) Maternal fever during labour (>38°C orally).
3. Previous delivery of a newborn with GBS disease,
regardless of current GBS colonization status.
4. Previously documented GBS bacteriuria.
If cultures were not done in the 35th to 37th week of
pregnancy, or if the test results are not available at the
time of delivery, it is essential that women at risk be
treated with antibiotics.
In addition, particularly if the woman has a history
of bladder or kidney infections, a doctor may test a
woman’s midstream urine for bacteria. If bacteria are
found in the urine but not in the vagina or rectum, the
woman is considered colonized (positive) and will still
be treated with antibiotics.
The woman should be made aware of the importance
of regular fetal activity. Fetal movement counts may be
advised routinely or selectively.
COMMUNICATION
WITH THE
–
the physician’s enquiring about possible physical or
sexual abuse and being attentive to indications of
such that may not be directly expressed.
For further details, please refer to the Prenatal Care Plan
(Appendix 2-2), as well as Chapter 3, “Health Education and Lifestyle Aspects of Prenatal Care,” for counselling information.
FETAL SURVEILLANCE/INDUCTION
OF
LABOUR
For patients with an uncomplicated pregnancy up to
41 completed weeks gestation, no special monitoring or
induction of labour is warranted. For women who have
pregnancies complicated by such other risk factors as
hypertension, diabetes mellitus, IUGR, macrosomia,
poly-hydramnios or multiple pregnancy, strong consideration should be given to fetal surveillance or elective
delivery between 39 and 40-6/7 weeks gestation. If the
pregnancy persists beyond 41 completed weeks, delivery
by induction of labour, as described in SOGC guidelines
on Induction of Labour,11 should be offered unless contraindicated. The woman should be informed of the lower
risks of perinatal mortality, neonatal morbidity and Caesarean section associated with induction at this time.12 If
she wishes not to proceed to induction, surveillance of
the fetus should be instituted, consisting of a minimum
of ultrasound assessment of amniotic fluid volume twice
weekly. If fluid volume is decreased, consideration should
be given to immediate delivery. Other forms of monitoring may be added to this, such as fetal movement counts,
biophysical profile scores and non-stress tests.
PATIENT
ESTABLISHING THE RELATIONSHIP
WITH THE PREGNANT WOMAN
Regular communication is important for the patient
to understand her pregnancy fully,make informed decisions and prepare herself for the upcoming labour and
delivery. The woman should be encouraged to ask questions and discuss concerns with her physician. Important
topics may include:
– the role of the baby’s father,
– the patient’s social support network,
– prenatal classes or educational literature,
– exercise,
– diet,
– coitus during pregnancy,
– birth plans of the patient and the views of the delivering physician,
– the philosophy regarding breastfeeding,
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These obstetrical guidelines are based on an extensive literature review and broad-based clinical opinions
that have stressed: (1) the importance that health caregivers view pregnancy and childbirth as a normal, unique
event and allow for patient autonomy and choice; (2)
that clinical practice policies and procedures be evidencebased; and (3) that cost effectiveness is considered.
In addition, the advice on preconceptual counselling, wellness counselling and routines of medical care
emphasizes the need for models of care which enhance
the education of our patients. This will allow them to
possess the necessary knowledge needed to make wellinformed choices about the health and well-being of
their pregnancy. As obstetricians, we believe that the
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first step we can make towards achieving this goal is to
establish good communication channels. Studies which
have examined women’s views of care during pregnancy
and childbirth emphasize the need for improved communications and a caring approach.13
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The patient education booklet—Healthy Beginnings—
Your Handbook for Pregnancy and Birth14— which has
been designed and written as a companion booklet to
this Clinical Practice Guideline, has also been developed
to use both as a source of information and as a diary of
the woman’s pregnancy.
Issues Identified by Patients Regarding Communication:
BIRTH PLAN
– personal care is very important;
– the need for more information than is normally given;
– clinic setting—impression of “business” that makes
questioning difficult;
– ability of women to keep their own records allows them
to feel more “in control” of care;
– importance of being aware of and respecting women’s
family commitments and responsibilities;
– listen to “minor complaints”, as they are not minor to
the women;
– booklets and pamphlets should be readily available for
women.
The concept of a routine “birth plan” needs further
elaboration. The underlying philosophy is one of respect
for the woman’s wishes. If we as caregivers wish to be proactive, and recognize that all our patients have an increasing
interest in a less technological and more flexible approach
to birth, we can use the idea of a routine discussion of a
birth plan. This will provide an opportunity to talk about
the alternatives available, and provide reassurance that the
only interventions taken would be those that are necessary
and of proven value. An example of a birth plan that we
have developed is included in Chapter 4.
Some suggestions for facilitating communication and
promoting healthy choices in pregnancy care include:
– a prenatal care plan,
– a “record of pregnancy” patient diary,
– a birth plan,
– specific information pamphlets or books.
SPECIFIC INFORMATION PAMPHLETS
It is important to suggest readings or other educational materials (in pamphlet or video format) which are
easily accessible to the pregnant woman.
PRENATAL CARE PLAN
REFERENCES
We have developed an outline for prenatal care as
an example of how prenatal care could be managed,
focusing on specific educational and counselling objectives and investigations at appropriate times during the
care of a pregnancy (see Appendix 2-2). We have not
focused on the ideal number of visits, but rather have
given a range of times when each visit would address specific objectives. This may result in fewer visits, longer
visits and fewer “routines”. It would also fit a model
where alternate health care givers participate in some of
the care. This outline could be given to the woman along
with other information to serve as a tool to communicate the plan, answer questions and concerns, and provide comprehensive prenatal information.
1.
“RECORD
OF
2.
3.
4.
5.
6.
PREGNANCY” DIARY
The woman should be encouraged to write down her
concerns for discussion. This is another tool which could
be used to facilitate communication with your patient as
well as making her feel in control of the outcome of her
pregnancy. A simple notebook or journal would be useful.
JOURNAL SOGC
7.
8.
8
Kitzmiller JL, Gavin LA, Gin GD, Jovanovic-Peterson L,
Mann EK, Zigrang WD. Preconceptual care of diabetes.
Glycemic control prevents congenital anomalies. JAMA
1991;265:731-36.
Delgado-Escueta A and Janz D. Consensus Guidelines:
Preconception counselling, management, and care of the
pregnant woman with epilepsy. Neurology 1992;42(5):8-11.
Koren G. Maternal-fetal toxicology. 2nd ed. New York:
Marcel Dekker Inc., 1994.
Briggs G, Freeman RK, Yaffe SJ. Drugs in pregnancy and
lactation. 3rd ed. Baltimore: Williams & Wilkins, 1993.
Society of Obstetricians and Gynaecologists of Canada.
Policy Statement: The use of folic acid for the prevention
of neural tube defects. Journal SOGC 1993;15
(suppl.):41-46.
Society of Obstetricians and Gynaecologists of Canada.
Policy Statement: Guidelines for the performance of
ultrasound examination in obstetrics and gynaecology.
Journal SOGC 1995;17(3):263-66.
Carroll JC. Maternal serum screening. Canadian Family
Physician 1994;40:1756-64.
Dick PT, the Canadian Task Force on the Periodic Health
Examination. Periodic health examination, 1996 update:
1. Prenatal screening for and diagnosis of Down
syndrome. Can Med Assoc J 1996;154(4):456-79.
DECEMBER 1998
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9.
10.
11.
12.
13.
14.
▼
Society of Obstetricians and Gynaecologists of Canada.
Committee Opinion: Routine screening for gestational
diabetes mellitus in pregnancy. Journal SOGC
1992;14(10):85-86.
Society of Obstetricians and Gynaecologists of Canada,
Canadian Paediatric Society. Policy Statement: Statement
on the prevention of early-onset group B streptococcal
infections in the newborn. Journal SOGC 1997;19(7):751-58.
Society of Obstetricians and Gynaecologists of Canada.
Policy Statement: Induction of Labour. Journal SOGC
1997;19(2):155-61.
Society of Obstetricians and Gynaecologists of Canada.
Committee Opinion: Post-term pregnancy. Journal
SOGC 1994;16(4):1581-86. Updated March 1997.
Reid M, Garcia J. Women’s views of care during pregnancy and childbirth. In: Chalmers I, Enkin M, Keirse M, eds.
Effective care in pregnancy and childbirth. Oxford University Press, 1989(1991):131-142.
Adams C, Schuurmans SN. Healthy Beginnings—Your
Handbook for Pregnancy and Birth. Vicars MH, ed. In
press 1998.
▼
are subsequently found to have transmitted the virus to the
fetus/neonate during pregnancy or the neonatal period, the
growing public awareness of the problem, and the increasing rate of seropositivity amongst pregnant women all lend
support to the concept of offering universal testing.
RECOMMENDATIONS
In light of the above, the Maternal/Fetal Medicine
Committee of the SOGC makes the following recommendations:
1. Providers of prenatal care should:
a) be aware of the efficacy of AZT in reducing
vertical transmission to the offspring of pregnant
women who are HIV positive;
b) provide basic information about HIV testing,
including the risks and benefits of finding a positive result, and stressing the success of treatment
in reducing vertical transmission;
c) offer HIV testing for all pregnant women;
d) carry out testing with the agreement of the
woman and with due regard to confidentiality;10
e) document refusal of HIV testing on the patient’s
chart.
2. Women so tested and found to be positive should be
referred to an expert with special training in this area.
3. Pregnant women testing HIV-positive should be offered
treatment with AZT as currently recommended.4
4. Further research on the applicability and cost effectiveness of universal testing in Canada is warranted.
5. A review of existing recommendations on pretest
counselling with respect to HIV testing is warranted
to bring such testing in line with other forms of
prenatal testing.
APPENDIX 2-1
HIV TESTING IN PREGNANCY
This document ws prepared by the Maternal/Fetal Medicine
Committee of the Society of Obstetricians and Gynaecologists of
Canada and was approved by its Council in March 1997. It supersedes the Policy Statement published in the February 1996 issue of
the Journal SOGC and distributed to SOGC Membership under
the Obstetrical Policy Statement No. 17 in December 1995.
INTRODUCTION
The increasing rates of HIV infection in women,1,2 the
potentially devastating effect on the neonate of vertical
transmission from the mother,3 and the proven efficacy of
AZT in reducing vertical transmission4 lend support to the
concept of offering HIV testing to every pregnant woman
during pregnancy. Such a recommendation has been made
by the Infectious Diseases and Immunisation Committee
of the Canadian Paediatric Society,5 the College of Family Physicians of Canada,6 the Canadian Medical Association,7 the American Academy of Pediatrics,8 and the
American College of Obstetricians and Gynecologists.9
REFERENCES
1.
2.
RATIONALE
3.
The prevalence of HIV seropositivity in women of
childbearing age varies throughout Canada (1.13/10,000
in Nova Scotia; 15.2/10,000 in Montreal). Such variation
will affect the acceptability and the cost effectiveness of
universal testing. Nevertheless, the absence of know risk
factors among a significant proportion of those women who
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4.
9
Centers for Disease Control and Prevention. Update:
Acquired Immunodeficiency Syndrome -United States
1992. MMWR 1993;42:547-1, 557.
Ellerbrock TV, Bush TJ, Chamberland ME, Oxtoby MJ.
Epidemiology of women with AIDS in the United States,
1981 through 1990. A comparison with heterosexual men
with AIDS. JAMA 1991;265:2971-75.
Sperling RS, Stratton P, O’Sullivan MJ, Boyer P, Watts
DH, Lambert JS et al. Survey of AZT use in pregnant
women with human immunodeficiency virus infection. N
Engl J Med 1992;326:857-61.
Centers for Disease Control and Prevention. AZT for
prevention of HIV transmission from mother to infant.
MMWR 1994;43:285-87.
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5.
6.
7.
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Canadian Paediatric Society Infections Diseases and
Immunisation Committee. Should there be routine testing form human immunodeficiency virus infection in pregnancy? Can J Infect Dis 1994;5:203-4.
Tobin MA, Chow FJ, Bowmer ML, eds. A comprehensive
guide for the care of persons with HIV disease. College of
Family Physicians of Canada. Module 1—Adults, Women
and Adolescents, 1996.
Canadian Medical Association. Counselling guidelines for
HIV testing, 1995.
APPENDIX 2-2
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8.
American Academy of Pediatrics, Provisional Committee
on Pediatrics AIDS. Perinatal Human Immunodeficiency
Virus testing. Pediatrics 1995;95:303-7.
9. American Academy of Pediatrics, American College of
Obstetricians and Gynecologists. Joint Statement on
Human Immunodeficiency Virus Screening. August 1995.
10. Society of Obstetricians and Gynaecologists of Canada.
Clinical Practice Guidelines for Obstetrical and Gynaecological Care of Women Living with HIV. 1994.
SAMPLE PRENATAL CARE PLAN
Outcomes
Critical Path Time Frame
Preconceptual Visit (Ideal)
All
– Advice about diet, folic acid, exercise, lifestyle, work
– Advice about cigarette smoking, alcohol, drugs
– Complete physical and pelvic examination and selected
investigations as necessary
–
– Health status clear
Where Appropriate
– Advice about medical illness and medication, e.g. epilepsy,
diabetes
– Physical examination and investigations
– Advice about prenatal diagnosis
previous pregnancy
complicated outcome
–
aware of effect of medical illness on pregnancy and of
desired behaviour, e.g. any change in drugs
– Health status clear
–
aware of risks/benefits and reasons for prenatal diagnosis
–
aware of any changes in behaviour to prevent complicated
pregnancy outcome
First Visit (6 to 12 weeks)
– Advice about diet, exercise, lifestyle, work
– Advice about cigarette smoking, alcohol, drugs
– Complete physical and pelvic examinations and selected
investigations as necessary
– Outline prenatal care plan for pregnancy
– Formal Prenatal Record
– Arrange prenatal tests, including routinely offering HIV screening
– Discuss ultrasound
– Prenatal classes information
– Advice about further reading
– Patient Diary
– Social Support
Second Visit (Usually four weeks later)
– Review healthy behaviour counselling and reinforce changes
made
– Limited physical examination—BP, abdominal examination and
FHR determination
– Review results of routine tests
– Action on abnormal tests
– Patient diary review
Visit(s)—16 to 24 weeks
– Review and reinforce—as above
– Specific discussion regarding rest/work, signs and symptoms
of premature labour
– Educational materials re same
– Discuss common symptoms at this stage of gestation
– Limited physical examination—BP, abdominal examination and
SFH, FHR
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aware of effect and reasons for any changed behaviour
–
aware of objective of visits and plan for care
–
–
–
–
–
–
aware of tests, reasons
aware of need for ultrasound
aware of how to enroll in classes
has reading list, pamphlets
has and knows how to use diary
& physician aware of social support and need to access other
social support
–
aware and clear on necessary change
– Health status clear
–
aware of test results and action required
–
voices questions and concerns
–
–
–
aware and clear on necessary change
aware of importance of rest/work
aware of signs and symptoms of premature labour and what
to do
–
aware of significance of same
– Health Status clear
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APPENDIX 2-2 cont.
Outcomes
Critical Path Time Frame
Visit(s)—16 to 24 weeks cont.
– Patient diary or patient’s questions
– Screening ultrasound—if doing routinely
– Other tests—e.g. urine culture
– Maternal Serum Screening (where available as a comprehensive
provincial programme)
Visit(s)—26 to 32 weeks
– Further discussion rest/work, premature labour
– Discussion of common symptoms—3rd trimester
– Fetal movement charting and/or awareness
– Discussion of birth plan (may give written plan)
– Limited physical—BP, abdominal examination, and SFH and FHR
– Cervical examination if concerned about premature labour
– Tests—e.g. glucose screen on selected patients
– Rh immune globulin for Rh-negative patients
– Patient diary
– Discussion of Breastfeeding
Visit(s)—32 to 35 weeks
– Review and reinforce previous visit
– premature labour
– common symptoms during 3rd trimester
– fetal movement
– childbirth preparation report
– Review birth plan
– Limited physical examination—BP, abdominal, SFH, FHR
– Tests
– Patient diary
– Suggest appropriate reading and other education material
– Advice/discussion of childbirth preparation
Weekly Visits—Starting 36-37 weeks to 40 weeks
– Review or reinforce/reassure
– Signs and symptoms of labour and what to do
– Fetal Movement
– Common symptoms review
– Physical examination—BP, abdominal, SFH
– Tests
– Option: Group B Strep. culture
– Birth plan discussion
– Childbirth preparation
– what happens during labour
– monitoring during labour
– pain relief
– delivery
– labour support
– need for episiotomy
– Postpartum
– right after delivery
– hospital stay
– breastfeeding
– discomforts
– Baby care
Post-term Visit(s)—40+ weeks
– Review of significance of postmaturity
– Physical examinations (in addition to usual—cervical examination)
– Discussion of need and method of induction and fetal surveillance
– Fetal movement
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–
–
voices questions and concerns
agrees and understands reason for ultrasound
–
–
–
–
aware of importance of rest/work
aware of signs and symptoms
aware of signs of fetal movement
has discussed and initiated birth plan
– Health status clear
–
–
voices questions and concerns
aware of benefits of breastfeeding
–
aware of these issues
–
aware of signs and relief of edema, backache, abdominal
discomfort
–
voices specific requests
– Health status clear
–
–
–
voices questions and concerns
has access to necessary information
has access to necessary information
–
aware of distinction between true and false labour and quality
of labour pains, rupture of membranes, mucous plug, bleeding
aware of signs and relief of edema, backache, abdominal
discomfort
–
– Health status clear
–
aware of reasons for GBS screening and necessity for
intrapartum Rx if in high risk category
–
aware, raises questions and concerns and has access to
further information/counselling
–
aware and agrees to decisions about management of
postmaturity
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Chapter 3
HEALTH EDUCATION AND LIFESTYLE
ASPECTS OF PRENATAL CARE
PRENATAL EDUCATION
REVIEW
Over the last 20 years, prenatal classes have expanded from focusing mainly on pain and pain relief strategies in labour to include such broader issues as nutrition,
normal infant growth and development, as well as parenting. Prenatal education, both formal and informal,
should foster health of the entire family by clarifying
parental goals and expectations for labour and birth and
providing accurate, current information.1 Today, prenatal classes strive to instill confidence in the family’s ability to cope with this life transition.
Partners, close friends and children of labouring
women often take a more active role through pregnancy, labour, and birth. In some Canadian cities, prenatal
educators have responded to this family-centred philosophy by integrating partners into prenatal classes,
offering dads’ classes, sibling classes and other prenatal
preparation for extended family members. Prenatal classes promote links to the community for women/families,
thereby increasing their support system.
There is little scientific data about the effects of prenatal education. It is difficult to assess the effectiveness
of prenatal classes using an evidence-based model. These
classes vary greatly with regard to the educators (public
health nurses, obstetrical nurses, midwives, physicians
or independent childbirth educators), learning objectives, and philosophy.2 As a result, generalization cannot be made about the effects of formal prenatal
education.
Following an extensive literature review and metaanalysis, Simkin and Enkin2 conclude that the only outcome that has been adequately supported in the
literature is that prenatal education results in reduced
analgesia use. These authors also suggest that increased
patient satisfaction may be another result of prenatal
education, though this effect is more difficult to measure.
Providing women with information may increase their
sense of control over their pregnancy, labour and birth,
thus increasing satisfaction with the experience. In a
small study of 21 women, Crowe and Von Baeyer reported that women most likely to have a positive childbirth
experience felt well-informed and had formal prenatal
preparation.3 It is likely that for many women and families, prenatal classes may increase family knowledge and
participation throughout pregnancy, labour and birth,
thereby contributing to satisfaction.
In a prospective study of 825 women who completed three questionnaires—two before birth and one six
weeks after—Green, Coupland and Kitzinger found that
information and feeling in control during labour and
birth were of great importance to women.4 Therefore,
the provision of accurate information prenatally may
facilitate the woman’s/family’s participation and satisfaction with the birthing experience.
Other effects of childbirth education classes have been
measured with regard to such obstetric outcomes as length
of second stage, operative delivery rate, and medication
use during labour. In one such study, non-significant
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LITERATURE
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differences were noted between 114 women who attended
prenatal classes versus 93 women who had not attended.
However, despite their findings the authors note that the
“results must not be seen as a rebuttal to those who
encourage prenatal classes”.5 Certainly the fact that the
majority of expectant women attend prenatal classes
reflects an interest in this form of prenatal preparation.
Some research has indicated that preterm prevention programmes may decrease the incidence of preterm
birth. In one study, Yawn and Yawn reported that following implementation of a preterm prevention programme, the percentage of women accessing medical
care early enough to receive tocolysis increased from 51
percent to 98 percent.6 In one meta-analysis reviewing
factors that contribute to preterm birth prevention, the
authors found that the current literature supports the
hypothesis that these programmes are effective.7 However, they also reveal that methodological differences
among the studies (e.g., using low risk vs. higher risk populations) have “rendered a final verdict equivocal”.7
It is important to note that these programmes focus
specifically on preterm labour prevention and changing
women’s habits, whereas most general prenatal education classes discuss this topic as part of a broader agenda.
However, prenatal education provides the woman with
information related to the early signs of preterm labour
(excessive mucousy vaginal discharge, premature rupture
of membranes, low back ache, excessive uterine activity)
and the implications, thus enabling her to make
informed choices and seek appropriate, prompt medical
attention.
Classes for expectant fathers are also described. One
example of these “Dads’ Classes” is the Fatherhood Project offered in London, Ontario.8 These classes “focus on
men’s transition to fatherhood and their changing relationship with both their spouse and their new baby”.9
The goal is to facilitate family health by promoting an
active parenting role for fathers.
Prenatal education for siblings has also been
reported.10-12 These classes may prepare siblings for attendance during labour and birth, or simply aim to facilitate
the integration of another child into the family. Children may be assisted in identifying the unique qualities
and value that they add to the family while parents learn
about child growth and development, family interaction
and coping strategies.10 Other classes attempt to prepare
the child(ren) for labour and birth through discussion,
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drawing, videos, engaging in birth demonstrations using
a doll, and other age-appropriate learning.11 Some hospitals in Canada currently welcome children into labour
and birthing suites, but may require a support person
available for each child to attend to their needs (leaving
the birth if desired, for example) in addition to the
woman’s support person.
In a small study examining the short-term effects of
birth on children present for the birth of a sibling, Lumley reported that apart from asking more questions about
the baby, there were no significant differences between
children who had attended a birth and those who had
not.12 It should be noted that this particular centre had
developed a specific programme designed to promote
family participation in labour and birth. Again, the evidence is scarce regarding the effects of sibling preparation classes.
GAPS
IN THE
LITERATURE
Traditionally, formal prenatal education was directed
toward middle-class, educated families. Today, however,
health departments and hospitals have expanded their
target population by offering programmes designed for
adolescent teens and other specific populations.2 Further
research is needed regarding the effectiveness of prenatal classes tailored to single mothers, dads, adolescents,
culturally diverse populations, siblings, and lower income
families.
One retrospective study of 100 pregnant adolescents
compared perinatal outcomes of 50 pregnant teens who
had attended a specialized prenatal education programme using a multidisciplinary team, to 50 pregnant
teens who had not attended.13 The results demonstrate
improved outcomes among the group who attended.
There were lower frequencies of cephalo-pelvic disproportion (CPD), maternal medication use, required
neonatal resuscitation, infection, and respiratory distress
of the infant.
Postnatal classes are another option that may benefit women and their families. These may be offered on
an informal basis, providing new families with an opportunity to share thoughts and experiences and support one
another. In addition, women can be identified and
linked to appropriate resources that may be required for
breastfeeding support, where to find various infant supplies, or counselling. Education related to such issues as
parenting, body image after birth and child growth and
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development can also be implemented by appropriate
educators (nurses, midwives, independent childbirth
educators). In this way, networks are developed as members of the community continue to support one another.
Further research is necessary in order to evaluate the
need for and effectiveness of postnatal education.
family health by addressing a broad range of issues. In
this way, women are better able to make informed choices
throughout pregnancy, labour, birth and early parenthood: “Choice relies on the availability of information:
information about services, options, diagnosis and prognosis. Not having such information can be a serious
impediment to quality decision making.”16 Wegner and
Alexander write that following prenatal education, parents become clear and assertive in sharing their goals
with health care professionals, thus promoting communication.17 These authors also note that most women and
men can identify changes in behaviour that they made
following prenatal classes.
Randomized controlled trials are needed to determine the
benefits and any potential disadvantages to offering population-specific prenatal classes. This may involve a more
qualitative approach to determine the woman’s/family’s
satisfaction with:
1. the content of the education;
2. the programme’s sensitivity to her learning needs;
3. her labour and birth; and
4. confidence in her ability to cope with the challenges of
early parenthood.
Based on the available evidence, the SOGC recommends:
1. That physicians encourage women to participate in prenatal education to promote a positive birthing experience and family health.
Quantitative measures must also be used to identify
any differences in obstetrical outcomes (e.g. forceps/vacuum rates, episiotomy rates, incidence of fetal distress)
between those who attend prenatal classes and those
who do not.
2. That childbirth educators, women/families and their
physicians strive to develop communication between all
parties to facilitate the provision of accurate and current information. (In this way the family is assisted in
developing clear and realistic goals/expectations.)
RECOMMENDATIONS
In one Canadian survey of early hospital discharge,
postpartum women reported a need for such adequate
support in the home as daily visits for one week by a registered nurse and a homemaker, and a 24-hour telephone
service that could offer advice or answer questions.14
Given the current trend of reduced length of stay in
obstetrical units, there will be fewer opportunities for
providing information and listening to the concerns of
the woman/family regarding the newborn. Effective prenatal preparation, along with appropriate follow-up in
the home, may become a pivotal determinant of family
health.15 To be effective in imparting knowledge and a
sense of confidence in expectant families, prenatal education must be both proactive and responsive to the
changing needs of the community resulting from new
trends in the provision of health care.
Given the thousands of Canadian women and families who engage in some form of prenatal preparation
every year, there seems to be a demand for this service.
Perhaps it is because prenatal classes bring together
women and families who are otherwise often isolated
in Western society. The class environment provides an
opportunity for expectant families to share experiences, wisdom and feelings while attempting to promote
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3. That needs assessments occur, as they have in many
cities, regarding the demand for population-specific
classes through focus groups or questionnaires,
thereby including input from women/families of these
populations.
4. That needs assessments for postnatal education and
evaluation of existing programmes occur (to determine
consumer interest in and effectiveness of current post
natal programmes).
5. Ongoing evaluation, both qualitative and quantitative,
of the effects of prenatal education.
NUTRITIONAL COUNSELLING
Good nutrition has a positive influence on pregnancy
outcome, especially birth weight, neonatal morbidity and
mortality, and recovery of the mother. The degree of
effect depends upon the preconceptual nutritional status of the mother.
Ideally, nutrition and education would be discussed
during preconceptual counselling. Advising the use of
folic acid supplementation to prevent neural tube defects
is a good example of this. If nutrition screening did not
occur then, it is important to identify, early in a pregnancy, disordered eating patterns and non-informed vegetarian practices as well as low socio-economic status.
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Women identified as being at potential risk of nutrient deficiency or food insecurity require additional
assessment.
NUTRITION ASSESSMENT
AND
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VITAMIN SUPPLEMENTS
Emphasis should always be placed on improving diet
quality first. However, other women may benefit from
nutrient supplements (e.g. folic acid). Adolescents and
those who have had many births may require vitamin
supplements. Initial prenatal nutritional assessment can
help reveal evidence of poor nutritional status and/or
such dietary practices as non-informed vegetarianism.
Routine iron supplements are not an essential component of early prenatal care for women who are not
anaemic. Maintenance of maternal iron stores is usually
assured if low level iron supplements are provided during the last half of the pregnancy. Measuring serum ferritin levels to evaluate iron stores has been shown to be
a useful screening tool in research projects. Its use in routine assessment of iron stores is questionable.4
COUNSELLING
Nutritional assessment and monitoring should be
part of every prenatal care plan. A dietary history
should be obtained in the first visit, along with measurements of height and weight and screening for
anaemia. Enquiries as to whether the patient chooses
foods from the four food groups, as well as about smoking and her alcohol intake, are necessary. Canada’s
Food Guide to Healthy Eating suggests pregnant and
breastfeeding women need three to four servings of
milk products daily. Non-pregnant women consume
an average of 1,900 to 2,400 calories per day. It is recommended that pregnant women should increase
their energy intake by about 100 calories/day in the
first trimester, by 300 calories/day in the second and
third trimesters, and by 450 calories/day during lactation.1 Meeting calcium, iron and folic acid needs are
special nutritional challenges for pregnant women.
Food sources of these nutrients, such as milk products,
orange and dark green vegetables and fruit, meat and/or
legumes, should form an important part of the diet during pregnancy.
When nutritional risk factors have been identified,
referral to a dietician or prenatal nutrition project targeted to at-risk women would be indicated.
During subsequent prenatal visits, women at nutritional risk should have their nutritional status re-evaluated. Screening for anaemia should be repeated at least
once early in the third trimester.
The Preconception/Prenatal Nutrition National Guidelines2 provide detailed information on counselling pregnant women.
FOOD SUPPLEMENTS
Food supplements may be needed to fill the gaps
between dietary intake and requirements. The choice of
food provided needs to be based on respectful consideration of the woman’s cultural, religious and dietary background. Food supplements and nutrition education
should be available to all pregnant women with low
incomes, especially teenagers. The experience of the
Montreal Diet Dispensary (MDD) shows that the benefits of increased caloric intake and special dietary management during pregnancy are not confined to
chronically malnourished women in developing countries, but can also improve the pregnancy outcomes of
socially disadvantaged mothers in more affluent nations.5
Postpartum maintenance of maternal nutrition will
facilitate breastfeeding. Vitamin and mineral supplements during lactation are not routinely required.
SUPPLEMENTARY ADVICE
VOMITING
MATERNAL WEIGHT GAIN
Optimal maternal weight gain during pregnancy
(varies from 6.8 to 18.2 kg) will depend on the prepregnancy weight. Underweight women and teenagers
can be encouraged to gain at the upper end of the
range. Weight loss by obese women is not recommended during pregnancy.3 It must be acknowledged
that the issue of ideal weight gain during pregnancy is
controversial.
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ABOUT
NAUSEA
AND
Advice is generally given that each patient should
be encouraged to choose for herself the type of food or
beverage which seems to improve her nausea. These
flavours range from salty, bitter, crunchy, sweet, spicy,
hot, cold or thick.6
Smells from various sources (e.g. coffee, perfumes) are
factors contributing to the nausea, especially when high
humidity and higher temperatures prevail.7 If cooking
smells trigger nausea, the partner should do the cooking.
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DECEMBER 1998
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Obviously, smells which increase nausea should be identified and avoided.
Sniffing fresh lemons or ginger, drinking lemonade,
or eating watermelon slices are also recommended.
For further details, refer to Appendix 3-2: Guidelines for the Management of Nausea and Vomiting in
Pregnancy.8
▼
similar Canadian guidelines developed at present, however, the province of Québec has a “Preventative Leave”
programme, where a woman’s workplace can be assessed
and, if it is determined to present any danger to the pregnancy, the woman can be reassigned or given leave with
full pay.
SUGGESTED READING
WORK DURING PREGNANCY
–
In uncomplicated pregnancies, work is not associated with adverse pregnancy outcomes. Strenuous work,
extended work that is more than 40 hours a week, and
shift work may be associated with modest increases in
the rates of low birth weight, prematurity and spontaneous abortions. Women should be asked early in the
pregnancy about their type of work and advised to modify such activities, if possible.
Pregnant women should avoid exposure to chemical
solvents and metal fumes. They should follow current
guidelines available in the workplace for handling antineoplastic agents and exposure to radiation.
To define strenuous work, the American Medical
Association (AMA) Council on Scientific Affairs has
issued guidelines for continuation of various levels of
work during pregnancy.1 These recommended limiting:
repetitive stooping and bending (>10 times per hour),
repetitive climbing of ladders/poles (>3 times/8-hour
shift), repetitive lifting (>23 kg) after 20 weeks gestation; prolonged standing (>4 hours) and lifting 11 to 23
kg at 24 weeks; repetitive stair climbing (>3 times/shift),
intermittent stooping, bending, and ladder climbing after
28 weeks; intermittent heavy lifting after 30 weeks; and
standing over 30 minutes per hour after 32 weeks for otherwise healthy women. These “work during pregnancy
guidelines” are an example of how to gauge strenuous
work in pregnancy.
With these exceptions, employment may be continued to term. In addition, the AMA Council recommends careful evaluation to determine if work should be
continued by women who have a number of medical
conditions or prior adverse obstetrical outcomes or complications. These guidelines are in keeping with the earlier recommendations of both the American College of
Obstetricians and Gynecologists and the National Institute of Occupational Safety and Health,2 and can be
used as a reference when advising women about medical leave from work during pregnancy. There are no
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–
–
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McDonald AD, McDonald JC, Armstrong B, et al. Occupation and pregnancy outcome. Br J Ind Med.
1987;44:521-26.
McDonald AD, McDonald JC, Armstrong B. Fetal death
and work in pregnancy. Br J Ind Med. 1988;45:148-57.
McDonald AD, McDonald JC, Armstrong B, et al.
Congenital defects and work in pregnancy. Br J Ind Med.
1988;45:581-88.
Mamelle N, Munoz F. Occupational working conditions
and preterm birth—a reliable scoring system. Am J Epidermiol. 1987;126:150-52.
McDonald AD, McDonald JC, Armstrong B, et al.
Prematurity and work in pregnancy. Br J Ind Med.
1988;45:56-62.
EXERCISE DURING PREGNANCY
FIRST PRENATAL VISIT
All pregnant women should be given advice about
exercise and physical fitness. During the first prenatal
visit, they should be asked about daily routines, recreational and work related exercises, and plans for changes
during pregnancy. The health care worker should ensure
that there are no contraindications to exercise.
Contraindications include:
– previous obstetrical problems such as an incompetent cervix or a history of preterm labour;
– clinically important cardiopulmonary disorders (e.g.
ischaemic or valvular heart disease, uncontrolled
hypertension, peripheral vascular disease, chronic
obstructive pulmonary disease) which might compromise maternal cardiac output, uterine blood flow
or arterial oxygen saturation;
– serious uncontrolled metabolic disorders (e.g. Type
I diabetes mellitus or thyroid disease);
– infectious diseases (e.g. mononucleosis or hepatitis);
– multiple pregnancy;
– eating disorders, poor nutrition or very low maternal
fat stores;
– medications that may alter maternal metabolic and
cardiopulmonary capacities.
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DECEMBER 1998
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–
–
–
–
sudden swelling of the extremities;
unexplained abdominal pain;
absence or decrease in fetal movement;
persistent uterine contractions suggesting the onset
of premature labour;
– insufficient weight gain;
– other symptoms including persistent headaches,
visual disturbances, dizziness, or general fatigue.
Adequate fluids and dietary intake (particularly carbohydrates) should be maintained. Canada’s Food Guide
suggests ingestion of about 2200 to 2400 calories/day for
pregnant women.1 This should be increased by about 100
calories/day in the first trimester and by 300 calories/day
in the second and third trimesters. However, this may
not be enough for exercising pregnant women. Although
the caloric intake is important, so is the type of food
being taken. Foods high in complex carbohydrates—
such as rice, pasta, potatoes—should make up at least 30
to 40 percent of the total calories taken.
The level of exercise to be continued, or started, during pregnancy will depend on the general fitness of the
woman and her level of exercise prior to pregnancy.
Exercise-related activities should be reviewed during
subsequent prenatal visits.
EXERCISE CAUTIONS
Appropriate 10 to 15 minute warm-ups and stretching of ligaments and muscles are important to prevent
injury. Adequate breast support is advised. The exercise
workout should be 15 to 30 minutes long with a rest
break if necessary and fluid intake during and/or after. A
gradual 10 to 15 minute cool-down is important so as not
to affect the fetal heart rate. Exercises using large muscle groups, particularly those that are rhythmical in
nature, are to be encouraged and include:
– walking,
– swimming,
– stationary cycling,
– low impact aerobics.
The supine position should be avoided. Abdominal
exercises should be modified to use the side-lying or
standing positions. Pregnant women should avoid overstretching ligaments and tendons that may have
increased laxity caused by gestational hormones. Good
posture is important for decreasing back strain and
fatigue. Kegel exercises are recommended to strengthen
the pelvic floor muscles.
Those sports that require increased balance and coordination and those that involve the potential for injury,
falls and blows should be modified or avoided. These
include downhill skiing and mountain climbing. Exercises that strain the lower back and use of Valsalva’s
manoeuvre (such as certain weight-lifting routines)
should be modified or avoided.
Strenuous exercising in warm and/or humid environments should be avoided. Exposure to hot tubs,
saunas and steam should be limited to avoid increases in
core body temperature, which may lead to adverse fetal
outcome. Scuba diving and water-skiing should be
avoided throughout the pregnancy.
Pregnant women should be particularly aware of the
signs and symptoms of common obstetric problems indicating the need to consult their physician. These include:
– evidence of bleeding;
– fluid discharge from the vagina suggesting premature
rupture of membranes;
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EXERCISE INTENSITY
Women should avoid anaerobic exercise or exercising to maximum heart rate. The American College of
Obstetricians and Gynecologists suggests a safe upper
limit of 140 beats per minute.2 For some women this is
too low. Guidelines based on the maternal age, physical
fitness, stage of pregnancy and other individual factors
have been developed by fitness experts and are summarized in the following chart.
Suggested Heart Rate Target Zones for Aerobic Exercise
in Pregnancy*
Maternal Age (Years)
Heart Rate Target Zone
Less than 20
140-155
20 to 29
135-150
30 to 39
130-145
Greater than 40
125-140
* These values apply to most healthy pregnant women. At the
beginning of a new exercise programme and in late gestation,
women should exercise at the lower end of the recommended
heart rate target range.3
The rating of perceived exertion (RPE) scales are recommended for use in addition to pulse target rate. The final
test against overexertion is the “talk test”—that is, they
should be able to carry on a conversation while exercising.
There is agreement that pregnant women should not
increase the intensity or duration of habitual physical
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DECEMBER 1998
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activity prior to the 15th week of gestation, in order to
avoid the possibility of fetal teratogenic effects caused by
exposure to exercise-induced hyperthermia during closure
of the neural tube. It is also unwise to increase maternal
exercise intensity, duration, or frequency after the 28th
week, when fetal demands for nutrition and oxygen delivery are highest. There is good scientific evidence that previously inactive women can safely increase the quantity
and quality of aerobic exercise between approximately the
16th and 28th week of gestation. This should be done gradually and systematically to avoid chronic fatigue.
Medical clearance to exercise should be withdrawn
if serious obstetrical symptoms or problems arise:
– cardiac or pulmonary problems and anaemia;
– vaginal bleeding during pregnancy;
– pre-eclampsia/eclampsia;
– preterm labour;
– multiple gestation;
– abnormal glucose tolerance;
– intrauterine growth restriction (IUGR);
– clinically significant pubic or lower back pain.
Exercises could gradually resume during the postpartum period. Lactation is not a contraindication to
exercise provided there is adequate fluid intake.
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SEXUALITY IN PREGNANCY
This topic should be addressed during the prenatal visits. Where possible, the couple should be seen
and counselled together. Sexual activity should be discussed with both partners, especially if restrictions are
necessary. The promotion of a broad definition of sexuality beyond coitus will help to facilitate open and
honest sexual communication within the couple’s
relationship. The healthy, pregnant woman with an
uncomplicated pregnancy can enjoy her sexuality and
her sexual relationship throughout the pregnancy
without risk to her or her fetus. Advice against coitus
in pregnancy needs to be discussed in some situations
where there is a complication, like threatened abortion, antepartum haemorrhage or threatened preterm
labour. Patients may be informed regarding various
coital positions and pleasuring techniques as well as
information regarding avoiding vaginal insufflation
during oral sex. Safe sexual practices and protection
against sexually transmitted diseases should also be
discussed.
SUGGESTED READING
–
SUGGESTED READING
–
–
–
–
–
–
–
–
Mottola MF, Sloboda D, Weis C, Wolfe LA. Exercise for
two. The Network, Cain.
Wolfe LA, Amey MC, McGrath MJ. Current Therapy in
Sports Medicine, 3rd ed., Chapter on Exercise and Pregnancy:550-54, Mosby, 1995.
Mottola MF, Wolfe LA. Toward Active Living. Chapter 18:
Active living and pregnancy:131-40, Human Kinetics Publishers: Champaign Il, 1994.
American College of Sports Medicine. Pregnancy. In:
Pate RR, Blair SN, Durstine JL, et al. Guidelines for exercise testing and prescription. 4th ed, Philadelphia: Lea &
Febiger, 1991:180-82.
McMurray RG, Mottola MF, Wolfe LA et al. Recent
advances to understanding maternal and fetal responses
to exercise. Med Sci Sports Exerc 1993;25:1305-21.
Wolfe LA, Mottola MF. Aerobic exercise in pregnancy:
An update. Can J Appl Physiol 1993;18:119-47.
Wolfe LA, Brenner IKM, Mottola MF. Maternal exercise,
fetal well-being and pregnancy outcome. Exer Sport Sci
Rev 1994;22:145-94.
Hanton R. Times Two: A prenatal guide for the active
woman. Available from Serious Fun Enterprises, 20 Fulton
Avenue, Ottawa ON, K1S 4Y6. Phone 613-730-5986; fax
613-730-0148.
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Reamy K, White, SE. Sexuality in pregnancy and the
puerperium: A review. Obstet and Gynecol Surv
1985;40(1):1-13.
Thorpe Jr EM, Ling FW. Sex and sexuality in pregnancy.
In: Sciarra, ed. Clinical Obstetrics, Vol. 2, Chapter 20.
Philadelphia: Lippincott. 1992:1-8.
Bray P, Myers RA, Cowley RA. Orogenital sex as a cause
of nonfatal air embolism in pregnancy. Obstet Gynecol
1983;61(5):653-57.
Bernhardt TL, Goldmann RW, Thomas PA, et al. Hyperbaric oxygen treatment of cerebral air embolism from
orogenital sex during pregnancy. Crit Care Med
1988;16(7):729-30.
STRESS AND SOCIAL SUPPORT
SOCIAL SUPPORT
A lack of perceived social support during pregnancy
has been associated with higher levels of maternal
depressive symptoms and adverse health behaviours.1,2
Physicians should use a proactive, holistic approach to
women’s health care preconceptually or prenatally by
assessing the woman’s perception of the quantity and
quality of her social support.
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DECEMBER 1998
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The ALPHA (Antenatal Psychosocial Health Assessment)
form was created to facilitate systematic gathering of this
information.3 Based on a systematic review,4 antenatal
risk factors were chosen for screening which demonstrated association with poor postpartum family outcomes of
woman abuse, child abuse, postpartum depression, marital (couple) dysfunction and increased physical illness.
This tool is recommended because it has been shown to
be useful for health care providers to identify pertinent
new information about women and their families which
can be used to help women make decisions about life situations or obtain support and assistance for psychosocial
problems. Women are comfortable with this form of
enquiry and providers have noted increased rapport with
women following this assessment.5
Some Measures to Assist in Alleviating Stress
1. Rest and relaxation exercises, yoga (audio and video
tapes available in most public libraries or book stores);
2. Exercise;
3. Hobbies;
4. Reading about pregnancy, labour and birth, and using
videos tapes, prenatal classes and consultations with
physician as sources of information;
5. Developing a birth plan that outlines a woman’s intrapartum preferences to enhance communication and
collaboration between the woman and her caregivers;9
6. Counselling, particularly if there are long-standing issues
which require professional help.
The ALPHA form considers the following antenatal
factors, and identifies the associated postpartum outcomes:
– Family Factors
– Maternal Factors
– Substance Use
– Family Violence
Refer to Appendix 3-1: Antenatal Psychosocial
Health Assessment (ALPHA) for a sample of the form,
including questions and outcomes.
When open-ended questions are incorporated into
the preconceptual/prenatal visits in a supportive, nonjudgemental manner, those women requiring further support can be identified and assisted in gaining access to
community resources.
physician should also be aware of available options and
resources that the woman may choose to use.
ABUSE IN THE OBSTETRICAL POPULATION
INCIDENCE
The 1993 Violence Against Women Survey1 found
that in Canada:
– twenty-one percent (21%) of women abused by their
marital partners were assaulted during pregnancy;
– forty percent (40%) of the women who were abused
during pregnancy reported that the abuse began
when they were pregnant;
– the women who were abused during pregnancy were
four times as likely as other abused women to say
they experienced very serious violence (beatings,
chokings, gun/knife threats, sexual assaults);
– just over 100,000 women who were assaulted during
pregnancy suffered a miscarriage or other internal
injuries as a result of the abuse.2-4
A Canadian study5 of 548 prenatal patients that
identified a 6.6 percent rate of abuse during pregnancy
also found that:
– almost 11 percent of the women studied reported
that they had experienced violence before their current pregnancy;
– among the abused pregnant women, 86.1 percent
reported previous abuse;
– almost two-thirds of the abused women (63.9%)
reported that the abuse escalated during pregnancy.
A subsequent Canadian study6 found that 95 percent
of women who were abused in the first trimester of their
pregnancies were also abused in the three-month period
STRESS
Changing self image, fetal well-being concerns and
home/family life are among some of the major antenatal
stressors reported by women.6,7 Stress can also be a sign
of a perceived knowledge deficit. When physicians allow
time for answering the woman’s questions or concerns
regarding the pregnancy, this may decrease her anxiety
and increase her sense of control. Other studies indicate
that maternal anxiety antepartum is negatively correlated with perceived satisfaction with the partner.8 In
addition to validating expressed feelings of stress by
actively listening to the woman’s concerns in an understanding manner, physicians can also recommend various alternatives to promote relaxation and a woman’s
ability to cope.
Through preconceptual/prenatal counselling, the
physician promotes family health by providing a safe environment for the woman to communicate her concerns
and wishes related directly or indirectly to pregnancy. The
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after delivery. For these women, the abuse also increased
after the baby was born.
In view of these sobering statistics, it is important
that health care providers are knowledgeable about and
screen for abuse in all obstetrical patients.
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COMPONENTS
OF
COUNSELLING
The way in which a woman is approached may facilitate the identification of abuse. She may be experiencing feelings of shame about the abusive relationship.9
Physicians should be aware of their own attitudes about
this issue and approach the woman in a non-judgemental manner.9,10 If a woman does choose to confide in her
physician about abuse, it is crucial that she is made aware
in a supportive, non-hurried manner of the full range of
available options and resources.
Physicians should also provide pamphlets and other
literature regarding domestic abuse in such private places
as examination rooms or washrooms, to encourage safe
access to information. Small cards (business-card sized)
can be made available in these locations that include
some facts about woman abuse and local resources. The
size of these cards allows the woman to slip them in her
shoe, concealing them from the abusive partner or the
general public. Some hospitals and shelters in Canada
have already done this and have made arrangements
with cab companies for free transportation to such facilities if needed. In this case, this is also advertised on the
card. Posters that address the issue of violence against
Ask every woman about abuse.
Universal screening means asking every woman about
abuse, not just those whose situations raise suspicions of
abuse. Pregnant women should be asked as early as possible in their pregnancies about abuse.
Screening for abuse should also occur in hospitals
that care for women, particularly in labour and delivery,
postpartum, and emergency wards.
The literature describes numerous (and often interrelated) complications and adverse outcomes associated
with abuse during pregnancy. For professionals there are
many potential “signs” of abuse. Professionals should
keep in mind, however, that no single indicator may be
definitive on its own. It is important to be open to the
possibility that abuse may be occurring.7 A list of some
of the potential signs of abuse during pregnancy follows.
Physical signs that may be indicative of abuse:
– unwanted or mistimed pregnancies;
– termination of pregnancy (including multiple abortions, miscarriages);8
– any injuries or complications during pregnancy,
labour and birth (especially unexplained symptoms);
– low birth weight and preterm births;
– sexually transmitted diseases.
Behavioural signs that may be indicative of abuse:
– smoking or substance abuse during pregnancy (note: this
may be a mechanism for coping with the stress of abuse);
– suicide attempts during pregnancy;
– inadequate or delayed prenatal care;
– frequent visits to hospitals, clinics, doctors’ offices
(with a wide range of injuries or symptoms, often
unexplained);
– poor nutrition and diet;
– parenting difficulties.
Emotional signs that may be indicative of abuse:
– depression (including postpartum), anxiety disorders
and fear.8
THE DOS WHEN ABUSE IS IDENTIFIED11
1. Provide a safe and private environment to discuss the
situation.
2. Build trust by listening and being supportive.
3. Acknowledge the potential danger of the situation.
4. Validate her experiences, feelings and fears.
5. Discuss options and plans for her safety.
6. Explore with her available community resources such as:
– Social Services or Department of Social Work
– Women’s Shelters, Crisis Centres, Help Lines
(phone numbers listed in front pages of most
telephone books)
– Young Women’s Christian Association (YWCA)—
non denominational
– Law Enforcement Agencies
– Multicultural Societies, Intercommunity Health
Agencies for immigrant women from varying cultural backgrounds (may also provide translators
if necessary).
7. Support her choices.
A key warning sign:
8. Let her know that assault/abuse is a criminal offence
punishable by law.
Professionals should be particularly alert to situations in which a
partner appears overly solicitous, answers questions on behalf
of the woman, and is unwilling to allow the woman privacy.
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9. Assist the woman in identifying her internal strengths.10
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APPENDIX 3-1
The Antenatal Psychosocial Health
Assessment Form
Many guidelines have been published stressing the importance of psychosocial assessment in
pregnancy. The Antenatal Psychosocial Health Assessment (ALPHA) Form was developed
by a multidisciplinary team at the University of Toronto. The ALPHA Form is an evidencebased tool to assess psychosocial health in pregnancy. It includes risk factors shown to be
associated with the adverse postpartum outcomes of woman abuse, child abuse, postpartum
depression, couple dysfunction and increased physical illness. The ALPHA Form has been
extensively field tested and found to be acceptable and helpful to both women and health
care providers.
The ALPHA Form is designed to be used by all obstetrical health care providers and to be
used as a systemic guide to assessment of psychosocial health in all pregnant women. It can be
filled out during a single visit or over several visits, usually during the second trimester when
prenatal visits are somewhat quieter. The Form indicates suggested questions for inquiry into
psychosocial areas. It is essential that a woman understands the purpose of the inquiry which is
to help identify both strengths and areas of concern in her psychosocial situation and to assist
her with areas she identifies as problematic.
The ALPHA Form includes a list of suggested resources. Obstetrical care providers should
provide care or referral for identified psychosocial concerns according to their comfort and
expertise.
There are ongoing studies of the effectiveness, reliability and validity of the ALPHA Form as
well as dissemination strategies. Copies of a Guide and Video, giving further details about use
of the ALPHA Form, are available through the Department of Family and Community
Medicine, University of Toronto.
June C. Carroll, MD, CCFP, FCFP
Co-Principal Investigator—Care in Pregnancy Project
Member of the ALPHA Research Group
Associate Professor
Department of Family and Community Medicine
University of Toronto
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Antenatal Psychosocial Health Assessment (ALPHA)
Antenatal psychosocial problems may be associated with unfavorable
postpartum outcomes. The questions on this form are suggested ways
of inquiring about psychosocial health.
Addressograph
Issues of high concern to the woman, her family or the caregiver usually
indicate a need for additional supports or services. When issues of some
concern are identified, follow-up and/or referral should be considered.
Additional information can be obtained from the ALPHA Guide.*
Please consider the sensitivity of this information before sharing it
with other caregivers.
Antenatal Factors
Comments/Plan
Family Factors
Social support (CA, WA, PD)
• How does your partner/family feel about your pregnancy?
• Who will be helping you when you go home with your baby?
Recent stressful life events (CA, WA, PD, PI)
• What life changes have you experienced this year?
• What changes are you planning during this pregnancy?
Couple’s relationship (CD, PD, WA, CA)
• How would you describe your relationship with your partner?
• What do you think your relationship will be like after the birth?
Maternal Factors
Prenatal care (late onset) (WA)
• First prenatal visit in third trimester? (check records)
Prenatal education (refusal or quit) (CA)
• What are your plans for prenatal classes?
Feelings toward pregnancy after 20 weeks (CA, WA)
• How did you feel when you just found out you were pregnant?
• How do you feel about it now?
Relationship with parents in childhood (CA)
• How did you get along with your parents?
• Did you feel loved by your parents?
Self esteem (CA, WA)
• What concerns do you have about becoming/being a mother?
History of psychiatric/emotional problems (CA, WA, PD)
• Have you ever had emotional problems?
• Have you ever seen a psychiatrist or therapist?
Depression in this pregnancy (PD)
• How has your mood been during this pregnancy?
Associated postpartum outcomes
The antenatal factors in the left column have been shown to be associated with the postpartum outcomes listed below.
Bold, italics indicates good evidence of association. Regular text indicates fair evidence of association.
CA—Child Abuse CD—Couple Dysfunction PI—Physical Illness PD—Postpartum Depression WA—Woman Abuse
Antenatal Factors
Comments/Plan
substance use
Alcohol/drug abuse (WA, CA)
• How many drinks of alcohol do you have per week?
• Are there times when you drink more than that?
• Do you or your partner use recreational drugs?
• Do you or your partner have a problem with alcohol or drugs?
• Consider CAGE (Cut down, Annoyed, Guilty, Eye opener)
family violence
Woman or partner experienced or witnessed abuse
(physical, emotional, sexual) (CA, WA)
• What was your parents’ relationship like?
• Did your father ever scare or hurt your mother?
• Did your parents ever scare or hurt you?
• Were you ever sexually abused as a child?
Current or past woman abuse (WA, CA, PD)
• How do you and your partner solve arguments?
• Do you ever feel frightened by what your partner says or does?
• Have you ever been hit/pushed/slapped by a partner?
• Has your partner ever humiliated you or psychologically abused
you in other ways?
• Have you ever been forced to have sex against your will?
Previous child abuse by woman or partner (CA)
• Do you/your partner have children not living with you? If so, why?
• Have you ever had involvement with a child protection agency
(ie Children’s Aid Society)?
Child discipline (CA)
• How were you disciplined as a child?
• How do you think you will discipline your child?
• How do you deal with your kids at home when they misbehave?
Follow-up Plan:
❑ Supportive counselling by provider
❑ Homecare
❑ Additional prenatal appointments
❑ Parenting classes/ parents’ support group
❑ Additional postpartum appointments
❑ Addiction treatment programs
❑ Legal advice
❑ Additional well baby visits
❑ Smoking cessation resources
❑ Children’s Aid Society
❑ Public Health referral
❑ Social Worker
❑ Other: ______________________
❑ Prenatal education services
❑ Psychologist / Psychiatrist
❑ Other: ______________________
❑ Nutritionist
❑ Psychotherapist / marital /
❑ Other: ______________________
❑ Community resources / mothers’ group
family therapist
❑ Assaulted women’s helpline /
shelter / counselling
❑ Other: ______________________
comments:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
__________________________
________________________________
Date Completed
Signature
Copyright © ALPHA Project 1993 Version: May 1998
* The ALPHA Guide is available through the Department of Family and Community Medicine, University of Toronto.
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In Canada in 1990, 28 percent of women over age fifteen reported smoking daily.7 To intervene successfully, one
must first recognize women who are smokers. At the first
prenatal visit, 20 to 40 percent of women will identify themselves as smokers. If few woman seem to admit they smoke
in your practice, you may not be asking the right question.8
There is some controversy as to what method of
smoking cessation is best—“tapering” vs. “cold turkey”.
Some of those who quit will relapse, but these women
will have decreased smoke exposure to their fetuses, if
only for a matters of weeks. Most smokers quit four to
five times before they are permanently smoke free.
The most effective method for reducing smoking
appears to be self-help (how-to) behaviour modification
strategies.9-10 Initially, one should ascertain at the first
prenatal visit the extent to which a woman is smoking,
previous attempts to quit, and how she went about it.
The amount of personal support a woman feels she would
have is also an important factor. This will then delineate
the extent to which a particular patient will benefit from
hand-out materials of “quit tips”. Many of these strategies are included in “Guide your Patients to a SmokeFree Future”, a program of the Canadian Council on
Smoking and Health.11
When counselling women about smoking cessation,
it is important to understand the reasons why women
smoke. For many, smoking is a relief from stress—a cigarette is seen as a reward, a break, a means of calming
oneself down. It is helpful for women to discuss these
issues so they can understand what motivates them to
smoke. Cigarettes can be a relatively affordable and
accessible means of relaxation or escape. It may take
much guided advice and encouragement for women to
seek out other more healthful ways of stress reduction.
Weight control and dieting is another reason many
women smoke, and this concern over weight can also
influence women who are pregnant to continue smoking. It is important to stress the links between smoking
and poor pregnancy outcomes.
Smoking is increasing amongst adolescent girls.12 In
Canada tobacco use is strongly linked to low income and
other signs of social disadvantage. Aboriginal and Inuit
women are more likely to smoke. Low income women
and those with social disadvantage have fewer ways to
try to quit than do women with more resources.4 It is
therefore important for all health care providers to be
sensitive to these types of barriers.
THE DON’TS WHEN ABUSE IS IDENTIFIED
1. Don’t discuss the issue in front of others. Be discreet.
2. Don’t impose solutions on the woman. She needs to
be a part of the problem-solving process.
3. Don’t make judgements or blame the woman. Be
aware of your body language to ensure non-verbal
and verbal communications are consistent.
4. Don’t minimize the seriousness of the situation or her
expressed feelings and concerns.
5. Don’t ignore the admission of abuse. This may be the
only time she admits to the violence and, therefore,
the only opportunity to offer support. Your response
to her can have long-lasting effects.
6. Don’t tell her what to do or that she must leave the
abusive situation. That must be her choice.
women (wife assault), its incidence (so women know
they are not alone), and the fact that it is an unacceptable crime can be displayed throughout patient areas.
As advocates of women and their families, physicians
will continue to promote women’s health by increasing
their own understanding of abuse and the various available resources. Physicians should encourage and participate in education programmes for all health care
professionals within their organizations. Other professionals’ expertise can be used through an interdisciplinary approach.
SMOKING AND PREGNANCY
Clear evidence exists that there is an association
between smoking and pregnancy outcomes. Considerable information has come to light regarding adverse
effects of second-hand smoke on infants and children.
The major problems associated with smoking in pregnancy are prematurity and low birth weight. Increased
risks have also been identified of tubal pregnancy, spontaneous abortion, placenta praevia or placental abruption, hydramnios, premature rupture of membranes,
stillbirth, neonatal deaths, sudden infant death syndrome, congenital defects, and respiratory problems in
babies and young children.1,2
Ideally, women should stop smoking prior to conception. Maximum reduction of risk is felt to occur if
individuals quit smoking by sixteen weeks gestation,
however, quitting smoking at any stage of gestation is
advisable. 3 It appears even reducing smoking can
improve birth outcomes.3-6
JOURNAL SOGC
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“If a woman cannot see an alternative way to cope with
stress in her life, if she lacks support to help her quit, and
if she doesn’t really believe she is worth the effort, quitting is going to be difficult.”4
–
–
–
Besides office counselling about the risks of smoking
and advice to quit, physicians need to be aware of these
factors and be able to refer women to community
resources that can provide women-centred support for
smoking cessation.
–
–
In summary, the three keys to approaching smoking
are:8
1) ASK all pregnant women if they smoke.
–
2) ADVISE all who smoke about the benefits of quitting,
risks of smoking to the fetus, and the effects of secondhand smoke.
–
3) ASSIST/ENCOURAGE all who smoke to reduce or quit.
–
PATIENT RESOURCE MATERIALS
–
–
–
–
The Canadian Cancer Society pamphlets:
– When a Woman Smokes
– Where There’s Smoke…It’s usually second-hand
– Growing Up in Smoke.
Canadian Council on Smoking and Health pamphlet: A
New Start in Life—About pregnancy and smoking.
Health Canada series of booklets on Smoking and Pregnancy. Available through National Clearinghouse on
Tobacco and Health (1-800-267-5234).
Catching our Breath: A Journal About Change for
Women who Smoke. D. Holmberg-Schwartz. Women’s
Health Clinic, Winnipeg, MB 1990(1997).
HEALTH CARE PROVIDER RESOURCES
SUGGESTED READING
–
–
–
–
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AND
ALCOHOL AND PREGNANCY
All women should be questioned about alcohol use
and should be encouraged to avoid alcohol and unnecessary drugs during pregnancy. It is important to
increase the awareness of the public to the hazards of
alcohol taken during pregnancy. Women substance
abusers should be encouraged to seek treatment. The
risks of alcohol consumption must be stressed during
preconceptual counselling. Identification early in pregnancy of women who abuse alcohol, and referral to supportive agencies for treatment, should improve
outcomes.
Fetal Alcohol Syndrome (FAS) is a pattern of
abnormalities observed in children born to women with
a history of alcohol consumption in pregnancy. Features
of this syndrome include:
Smoking Interventions in the Prenatal and Postpartum
Periods. Ottawa: Health Canada, 1995:
– Smoking and Pregnancy: A Woman’s Dilemma
– Tobacco Resource Material for Prenatal and
Postpartum Providers—A Selected Inventory
– The Effects of Tobacco Smoke and Second-Hand
Smoke in the Prenatal and Postpartum Periods—A
Summary of the Literature
– Tobacco Reduction in Prenatal and Postpartum
Programs for High-Priority Families—Results of a
Cross-Canada Survey
– Smoking Interventions in the Prenatal and Postpartum
Periods
– Smoking and Pregnancy—Selected Program Profiles.
Available from: Women and Tobacco Reduction
Programs, 4th Floor Jeanne Mance Building, Tunney’s
Pasture, Ottawa ON, K1A 1B4. Fax (613) 952-5188.
JOURNAL SOGC
Taking Control: An Action Handbook on Women and
Tobacco. Canadian Council on Smoking and Health 1989.
Act Now. National Working Group on Women and Tobacco.
ACOG. Healthy Moms, Healthy Babies, Healthy
Families—Helping Your Patients Quit Smoking.
ACOG. Smoking Cessation and Your Patients: How You
Can Make a Difference. Sept. 1997.
Saskatchewan Institute on Prevention of Handicaps.
Prevention Resources: Second-Hand Tobacco Smoke
(Includes patient resource pamphlets). 1319 Colony
Street, Saskatoon SK, S7N 2Z1. Fax (306) 655-2511;
Phone (306) 655-2512.
Tobacco, Alcohol and Drug Use During Pregnancy.
Research and Program Review. Capital Health/Community
Care and Public Health, Edmonton AB, 1996.
Prochaska JO, DiClemente CC, Norcross JC. In Search of
How People Change—Applications to Addictive Behaviors. American Psychologist, 1992;47(9):1102-14
Biener L, Abrams DB. The Contemplation Ladder: Validation of a Measure of Readiness to Consider Smoking Cessation. Healthy Psychology, 1991;10(5);360-65.
Hartmann KE, Thorp JM, Pahel-Short L, Koch MA. A randomized controlled trial of smoking cessation
intervention in pregnancy in an academic clinic. Obstet
Gynecol 1996;87(4):621-26.
Stotts AL, Diclemente CC, Carbonari JP, Dolan Mullen P.
Pregnancy smoking cessation: A case of mistaken identity.
Addictive Behaviors 1996;21(4):459-71.
Wright LN, Pahel-Short L, Hartmann K, Kuller JA, Thorp
Jr. JM. Statewide assessment of a behavioral intervention
to reduce cigarette smoking by pregnant women. Am J
Obstet Gynecol 1996;175:283-88.
Windsor RA, Lowe JB, Perkins LL, et al. Health education
for pregnant smokers: Its behavioral impact and cost
impact. Am J Public Health 1993;83(2):201-206.
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growth restriction,
central nervous system involvement,
characteristic facial abnormalities.
A child must present with abnormalities in all three
categories for the diagnosis to be confirmed.1,2 Alcohol
Related Birth Defect (ARBD) is a term used to refer to
anatomical or functional abnormalities attributed to prenatal exposure to alcohol. Fetal Alcohol Effect (FAE) is
an ambiguous term most commonly used to encompass
a milder form of FAS, or a situation where not all the criteria of the Syndrome are met. There are five factors
which account for the form and intensity of alcoholrelated birth defects:
– quantity of alcohol consumed,
– gestational timing of the consumption,
– the mother’s ability to metabolize alcohol,
– nutritional status and smoking habits of the mother,
– individual fetal susceptibility (genetic factors).
Fetal alcohol syndrome is more likely to occur following fetal exposure to continuous or heavy maternal
intake of alcohol, but it remains unclear as to what
quantity of alcohol consumption can be regarded as safe
during pregnancy. On the basis that excessive or persistent alcohol intake has been associated with fetal alcohol syndrome, a prudent choice for women who are or
may become pregnant is to abstain during pregnancy. A
review of the literature suggests that occasional intake
of alcohol during pregnancy is unlikely to cause problems for the fetus. Women who are concerned about the
effect of occasional or inadvertent alcohol intake on
fetal development and subsequent performance can be
reassured.
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Ideally, adequate counselling regarding drug use and
abuse should occur prior to conception. It is recommended that a drug history be obtained during the first
prenatal visit. Women who are currently taking prescribed medication need to be evaluated for possible risks
during pregnancy. Current available data should be
reviewed with the patient. Dose modifications may also
be required. Patients should be encouraged to consult
their physician prior to starting new prescribed or overthe-counter medication.
Risk assessment regarding drug abuse and pregnancy
should also be undertaken early in prenatal care. Women
who abuse drugs are frequently poly-drug abusers, and
are at higher risk of HIV infection if they or their partners are intravenous (IV) drug users.1 Drug abuse is often
associated with other sexually transmitted diseases as
well, and these need to be screened for and treated. A
toxicology screen may be indicated if multiple drug use is
suspected, or if history is vague, in order to identify the specific drugs used. Referral to a drug treatment programme for
further drug history, diagnosis and treatment may be necessary. It is important to note that maternal withdrawal and
detoxification from some drugs involves risk of fetal withdrawal, possibly resulting in death. A multi-disciplinary
approach to risk reduction is very important.
Much more research has been done on fetal than
maternal drug effects. For instance, marijuana has been
linked to impaired fetal growth and decreased gestational
length. Cocaine has been linked to poor fetal growth, malformation and impaired neurobehavioural development.
Maternal heroin use has been related to low birth weights
and neonatal abstinence syndrome (NAS). Other possible effects of illegal drug exposure in general include sudden infant death syndrome, developmental delays and
learning disabilities, speech disorders, attention deficit disorder, and aggressive behavioural tendencies.2
Fetal alcohol syndrome, from awareness to prevention—
Government Response to the Fifth Report of the Standing Committee of the House of Commons on Health,
Welfare, Social Affairs, Seniors and the Status of Women.
Government of Canada, Dec. 1992.
Fetal alcohol syndrome—A preventable tragedy. Government of Canada, June 1992.
Bray DL, Anderson PD. Appraisal of epidemiology of fetal
alcohol syndrome among Canadian Native peoples. Can
J of Pub Health 1984;80:45.
Clarke S. Alcohol Consumption and Fetal Abnormalities
(FAS). AADAC Position paper, Edmonton, AB,
1993.
Clarren SK, Smith DW. Fetal alcohol syndrome. N Engl J
Med 1978;298(19):1063-67.
JOURNAL SOGC
Day NL, Richardson GA. Prenatal alcohol exposure, A
Continuum of Effects. Seminars in Perinatology.
1991;15(4):271-79.
Ernhart CB, Sokol RJ, et al. Alcohol teratogenicity in the
human: A detailed assessment of specificity, critical period and threshold. Am J Obstet Gynecol 1987;156:33-39.
Loock CA. Fetal alcohol syndrome and fetal alcohol
effects: Common, expensive, and preventable. Report on
the Symposium on Fetal Alcohol Syndrome and Fetal
Alcohol Effect, Health and Welfare Canada, 1992.
DRUG USE AND ABUSE IN PREGNANCY
SUGGESTED READING
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Educational and support pamphlets should be readily available in washrooms.
List of Resources for Drug Abusing Women
Canadian Centre on Substance Abuse
75 Albert Street
Suite 300
Ottawa, ON
K1P 5E7
General Info. # (613) 235-4048
Info. on Fetal Alcohol Syndrome: # 1-800-559-4514
SUGGESTED READING
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Canadian Council on Smoking and Health
170 Laurier Avenue West
Suite 1000
Ottawa, ON
K1P 5V5
Info. # (613) 567-3050
–
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Canadian Institute of Child Health
885 Meadowlands Dr. East
Suite 512
Ottawa, ON
K2C 3N2
Info. # (613) 224-4144
–
Health Canada
Family and Child Health Unit
Jeanne Mance Bldg
Tunney’s Pasture
Ottawa, ON
Info. # (613) 957-3436
–
Behnke M and Eyler FD. The consequences of prenatal
substance use for the developing fetus, newborn and
young child. Int J of Addictions 1993;28:1341-91.
Briggs, Freeman, Yaffe. A Reference Guide to Fetal and
Neonatal Risk, Drugs in Pregnancy and Lactation. 3rd edition, 1990.
Koren G, ed. Maternal-Fetal Toxicology, a Clinician’s
Guide. 2nd edition. Marcel Dekker Inc., 1994.
Boyd S. Women and illicit drug use. Int J of Drug Policy
1994;5:185-89.
Finkelstein N. Treatment issues for alcohol and drugdependent pregnant and parenting women. Health and
Social Work 1994;18:7-15.
Jarvis MAE and Schnoll SH. Methadone use during pregnancy. NIDA Research Monograph 149, 1995:
Medications development for treatment of pregnant
addicts and their infants.
Teoh SK, Mello NK, Mendelson JH. Effect of drugs of
abuse on reproductive function in women and pregnancy.
Drug and alcohol abuse reviews, 1994;5:437-73.
EXPOSURE TO INFECTIOUS DISEASES
DURING PREGNANCY
Motherisk Programme
Division of Clinical Pharmacy
The Hospital for Sick Children
555 University Avenue
Toronto, ON
M5G 1X8
Info. # (416) 813-6780 or 1-800-436-8477
Exposure to an infectious disease during pregnancy
is a source of marked anxiety both for the couple and the
health care workers. A prenatal care plan should outline
the following guidelines:
Planned Parenthood Federation of Canada
1 Nicholas Street
Suite 430
Ottawa, ON
K1N 7B7
Info. # (613) 241-4474
EDUCATION TO RECOGNIZE SOME OF
THE IMPORTANT COMPLICATIONS OF
PREGNANCY
The prenatal care plan should include health education to enable the pregnant woman to recognize early
some of the complications of pregnancy and instigate
treatment where appropriate.
La Leche League of Canada
P.O. Box 29
18-C Industrial Drive
Chesterville, ON
KOC 1H0
General Info. #(613) 448-1842
Breastfeeding Referral #1-800-665-4324
PRETERM LABOUR
AND
BIRTH
Preterm birth is a major financial burden because of
the need for neonatal intensive care and care for children with handicapping conditions. Risk scoring has met
with limited success due to its relative inability to predict preterm birth in primigravida women. Previous
preterm birth is the most important risk factor for recurrence. Effective prevention and treatment of preterm
labour have yet to be developed. General measures have
To obtain publications:
Health Canada,
Division of Publications
Brooke Claxton Bldg, RM 0913 A
Tunney’s Pasture
Ottawa, ON
K1A 1BA
Info. #(613) 957-1100
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Disease
Recommendation
Chicken pox
(Varicella-zoster)
Routine screening is not indicated. Pregnant women exposed to chicken pox (varicella-zoster
virus) should first be tested to determine immunity before being given varicella-zoster
immune globulin (VZIG), since about 80 percent of women with no history of chicken pox
infection are in fact immune, and the cost of the immune globulin is about 16 times the cost
of the immune status test.1 Because the risk of complications of chicken pox in pregnant
women may be greater than in other adults, VZIG should be given to exposed susceptible
pregnant women. Treatment of the newborn from a mother with recent active chicken pox
with varicella-zoster immune globulin is indicated.
Chlamydia
Caregivers should offer screening to women felt to be at increased risk. This would include
those in areas of high prevalence, women <20, and those with multiple sexual partners (or a
partner with multiple sexual partners) or history of sexually transmitted diseases. There is fair
evidence to support routine screening of pregnant women for chlamydia.2
Cytomegalovirus
No pregnancy screening is indicated. The potential public health effect of preconception
screening remains to be determined because of the possibility of recurrent infections.
Gonorrhoea
Screening of high risk populations (as for chlamydia) by cervical culture at first visit and if
symptomatic (i.e. cervicitis).
Group B Streptococcus
Until the results of Canadian studies are available, the SOGC recommends the following:
1. The strategy for decreasing early-onset GBS infection in the neonate should be
considered an area where there is an urgent need for research in Canada.
2. Until more specific information is available, identification and management of women
whose newborns might be at increased risk of GBS disease are acceptable by either of
two methods:
a) Universal screening of all pregnant women at 35 to 37 weeks gestation with a single
combined vaginal-anorectal swab and the offer of intrapartum chemoprophylaxis to all
GBS-colonized women.
b) No universal screening but intrapartum chemoprophylaxis for all women with identified risk factors. This strategy should also be used in cases where universal screening
is the policy but either was not done or the test results are not available.3
Hepatitis B
All women should be screened for Hepatitis B surface antigen at the preconception visit
or during pregnancy. Treatment of all infants of surface antigen-positive mothers with
Hepatitis B immune globulin and immunisation is indicated. At the preconception or during the first prenatal visit, women at high risk for acquiring hepatitis because of habits or
work situation may be screened for antibody status and, if not immune, immunisation is
appropriate.
Herpes
Routine prenatal screening by culture is not indicated for those with a positive history. A
single culture to confirm diagnosis is indicated when lesions are present. Delivery by
Caesarean section is indicated only in the presence of clinically active lesions in the lower
genital tract.
HIV
The SOGC recommends that providers of prenatal care:
a) be aware of the efficacy of AZT in reducing vertical transmission to the offspring of
pregnant women who are HIV positive;
b) provide basic information about HIV testing, including the risks and benefits of finding
a positive result, and stressing the success of treatment in reducing vertical transmission;
c) offer HIV testing for all pregnant women;
d) carry out testing with the agreement of the woman and with due regard to
confidentiality;
e) document refusal of HIV testing on the patient’s chart.
Mycoplasma
No prenatal screening is indicated.
Rubella
(German measles)
At the preconception visit, women at risk for rubella should be identified
and, if not actively attempting to become pregnant, should be immunised. Screening by
serology at the first prenatal visit is indicated. Rescreening of serologic-negative women
should be performed after exposure or if they have a possible rubella infection. Women
who have negative serology should be immunised postpartum.
Refer to Appendix 2-1 for full details.
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Disease
Recommendation
Rubeola
(Red measles)
If a pregnant woman has been exposed to measles and her immunity status is in doubt,
she should be tested for measles antibodies. Immune globulin (0.25 ml/kg for a healthy
adult; 0.5 ml/kg if immuno-compromised) is recommended within six days of the last
exposure to measles if patient is immuno-compromised or if measles immune status is
unknown/questionable and measles IgG serology is either negative or can’t be obtained
before 6 days from the last exposure. Immune globulin is not recommended if the woman
was born before 1957, has had documented natural measles, or has had two doses of
vaccine a minimum of one month apart.4
Syphilis
Screening by serology at the preconception and/or early pregnancy visit is indicated as per
provincial regulations. For women at risk, a repeat test in the third trimester is indicated.
Toxoplasma
An educational programme at the preconception and/or first pregnancy visit is appropriate. Screening by serology at the first pregnancy visit may be appropriate, but only for
those known to be at risk (have a new or outside cat or eat raw meat), with a repeat test at
16 to 20 weeks. Converters may be referred to a tertiary centre for percutaneous fetal
blood sampling and culturing and, if positive, treatment or termination. Due to the high
prevalence and seriousness of maternal infection and prenatal transmission, a potential
health benefit to routine preconception screening exists. The presence of antibodies provides reassurance about immunity. The absence of antibodies underscores the need for
education and vigilance.
Tuberculosis
Screening by skin testing should be performed only in women at high risk for the disease
or in high-risk populations or in endemic areas.
included counselling about diet, smoking cessation and
improving antenatal care. Advice regarding the reduction
of strenuous work has also been pursued (see page 24).
Rest has not been proven to be beneficial, however, it
may be recommended for those considered in a high risk
category. Education regarding the recognition of some
of the early signs of preterm labour, including excessive
mucousy vaginal discharge and/or excessive uterine
activity, may be useful.
PREVENTIVE STRATEGIES
FOR
discussed those interventions which have shown some
promise.1
PREMATURE RUPTURE
OF
MEMBRANES
The possibility of premature rupture of membranes
should be discussed with pregnant women during prenatal care, along with advice regarding immediate reporting
of this occurrence. Patients with suspected premature rupture of membranes should be evaluated as soon as possible, whether this happens at term or preterm.
PRETERM BIRTH
ANTEPARTUM HAEMORRHAGE
Prevention of preterm birth continues to be the subject of ongoing research. In a recent review, Moutquin
The prenatal care plan should include discussion
regarding vaginal bleeding during pregnancy. Pregnant women need to be informed
Risk Factors for Preterm Birth
that any bleeding during pregnancy is
abnormal and should to be brought to the
Established risk factors:
– Black race
– Placental abnormalities
attention of her physician immediately.
– Single marital status
– Gestational bleeding
The significance of abdominal pain in preg– Low socio-economic status
– Cervical and uterine anomalies
nancy, especially if associated with tender– Previous LBW or preterm delivery
– In utero diethylstilbestrol exposure
– Multiple second-trimester
– Multiple gestations
ness of the uterus, may be discussed.
spontaneous abortions
– In-vitro fertilization pregnancy
– Cigarette smoking
HYPERTENSIVE DISORDERS
PREGNANCY
Probable risk factors:
– Urogenital infections
– Cocaine use
– No prenatal care or inadequate
– Seasonality
prenatal care
– Employment-related physical activity – Psychosocial stress
JOURNAL SOGC
IN
The desire to improve the poor pregnancy outcome associated with hypertension was responsible for the development
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The problem of hypertensive disorders in pregnancy
should be discussed with pregnant women. In the
majority of cases, this disease is essentially asymptomatic.
Taking blood pressure values before conception or during early prenatal visits may provide important information about existing conditions, such as chronic
hypertension, and provide base-line values—useful for
comparison later in the pregnancy. Failure to demonstrate a normal decline in blood pressure during the second trimester may be used to predict the risk of
pre-eclampsia.
Evaluation for protein in the urine may be useful in
some prenatal visits. Some patients with pre-eclampsia
have severe proteinuria with minimal hypertension,
whereas in others, hypertension is more prominent.
Edema is the third clinical sign traditionally evaluated
when considering the diagnosis of pre-eclampsia. Edema,
even of the hands and face, is such a common finding in
pregnant women that if present by itself, it is not an
important diagnostic clue nor a reason for treatment.
Pregnant women with mild hypertensive disease or
chronic hypertension should be counselled about the
possible deterioration of the disease and some of the
associated symptoms, which include: frontal headaches,
visual upsets, and/or epigastric pain.
Signs of Preterm Labour
Any one or more of:
– regular contractions or tightening of the uterus
– increase or change in vaginal discharge (watery,
mucousy, or bloody)
– menstrual like cramps or low dull backache
– feels like the baby is pushing down in the pelvis
– an unusual need to urinate urgently or often
– abdominal cramps, with or without diarrhea
Actions for a woman to take if these signs occur:
– lie down on left side and rest for one hour
– drink two or three glasses of juice or water
– if the symptoms go away after one hour, begin light
activity
– inform health care provider at next prenatal visit
– if the symptoms do not go away after one hour of rest,
or if they return, call health care provider
When to immediately call health care provider or go
to the hospital:
– if the symptoms get worse during the one hour rest
– if there is fluid leaking from the vagina
– if she is concerned about what is happening
For practical purposes, and in the context of routine prenatal care, the following strategies may be effective in
reducing prematurity:
1. Treat such infections as asymptomatic bacteriuria, urinary tract infection, bacterial vaginosis.
FETAL MOVEMENT
2. Identify high-risk patients and monitor closely (see Risk
Factors).
Part of prenatal care should include education about
fetal movement patterns during the second half of the
pregnancy. Observing them is a non-invasive, inexpensive and universally available tool for fetal surveillance in which the pregnant mother may actively
participate. It is a valid method for assessing fetal health
and well-being. A decrease and/or cessation of fetal
movements may be indicative of possible fetal hypoxia,
and should be evaluated further.
3. Educate all patients in the second trimester about
signs and symptoms of premature labour.
4. Enquire about type of work and provide adequate
leave from work for all those in strenuous occupations
(see page 24).
5. Enquire about stress, social support, domestic abuse
(see pages 28-32).
6. Counsel on cigarette smoking cessation (see pages
33-35).
SUMMARY
of much of the prenatal care system as we now know it.
Hypertensive disease occurs in six to eight percent of
pregnancies. Associated risk factors include low socioeconomic and educational status, poor nutrition, and
primigravid status. It occurs more frequently in association with other conditions, including chronic hypertension, diabetes, renal disease, multiple gestation and
polyhydramnios. It is one of the major causes of maternal mortality.
JOURNAL SOGC
Health education during pregnancy should be promoted for all pregnant women and their partners. This
may include:
1. Counselling to promote and support healthy behaviour (for example, nutrition, exercise, stress reduction, and smoking cessation).
2. General knowledge of pregnancy, fetal growth and
development, labour and delivery, parenting, as well
as possible complications of pregnancy.
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DECEMBER 1998
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3. Information on the proposed prenatal and birthing
care plans.
Physicians, as important members of the health care
team, should encourage patients to participate in health
education and prenatal classes.
Counselling and Patient Education
1. Facilitation of exclusive breastfeeding for four to six
months, which should be initiated and supported in
hospital by:
– not giving artificial feeds of water (only breast
milk);
– breastfeed on demand (usually 8 to 12 times in
24 hours);
– do not use bottles or pacifiers because this can
encourage poor sucking technique.
BREASTFEEDING
BENEFITS
OF
BREASTFEEDING
1. Improved newborn immunity while breastfeeding
will lower the frequency of infant respiratory and gastrointestinal problems.1,2
2. Unlike cows’ milk protein found in many formulas,
breast milk lowers the incidence and severity of allergic responses.2,3
3. Breastfeeding is a less expensive alternative than
formula feeding, with no preparation time
required.4,5
4. Breast milk is more easily digested and its nutrients
more readily absorbed by the infant.3
5. Breastfeeding promotes mother-infant bonding.6
6. Only breast milk contains Omega 3 fatty acids which
are vital for brain development.
COMPONENTS
EDUCATION
OF
COUNSELLING
AND
2. Dispel such breastfeeding myths as:4,7,8
– expression of colostrum antenatally;
– nipple preparation or breast massage
antenatally;
– routine application of creams or ointments to
the nipple.
3. Promote early initiation of breastfeeding:
– within one hour post-vaginal birth;
– within 30 minutes of the mother’s ability to
respond to her newborn post-Caesarean section.
based on the woman’s learning needs. UNICEF and the
WHO recommend the following approach:7
Physicians can promote breastfeeding by increasing
their understanding about the benefits of breastfeeding
and then passing this information on to women. Physicians should be familiar with the various community
resources for breastfeeding mothers for those women who
choose to seek access to further support. Breastfeeding
mothers should be encouraged to contact their physician, midwife or a certified lactation consultant immediately if they encounter difficulty with infant feeding.
PATIENT
The prenatal counselling process provides a wonderful opportunity for the physician to offer the woman
accurate, updated, and consistent information. The
woman is thus assisted in making informed choices
about breastfeeding. Using such effective communication skills as listening and asking open-ended questions, the physician encourages the woman to express
her understanding of breastfeeding. The Canadian
Paediatric Society states, “the best food source for the
first six months of life is breast milk…”.6 Similarly,
the World Health Organization (WHO) together with
the United Nations Children’s Fund (UNICEF) recommends that infants should be exclusively breastfed from birth to four to six months of age. 7 The
rationale behind counselling is to assist a woman in
making an informed decision, and should include discussions of the benefits and common myths about
breastfeeding.
First, the woman’s knowledge level and beliefs (such
as cultural beliefs) about breastfeeding should be assessed.
Following this assessment, teaching should be begun
JOURNAL SOGC
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Some Community Resources:
– Certified Lactation Consultants (may be located in
hospital, or through Yellow Pages)
– LaLeche League Canada Breastfeeding Referral Service
(Tel. 1-800-665-4324)
– Public Health
– INFACT Canada
10 Trinity Square, Toronto, Ontario M5G 1B1
(Tel:. 416-595-9819)
REFERENCES
PRENATAL EDUCATION
1.
2.
31
Pridham KF, Schultz ME. Parental goals and the birthing
experience. JOGNN 1983;8(1):50-55.
Simkin P, Enkin M. Antenatal Classes. In: Chalmers I,
Enkin M, Keirse M, eds. Effective care in pregnancy and
childbirth. Oxford University Press, 1989(1991):318.
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Crowe K, Von Baeyer C. Predictors of a positive childbirth
experience. Birth: Issues in Perinatal Care 1989;16(2):59-63.
Green JM, Coupland VA, Kitzinger JV. Expectations,
experiences, and psychological outcomes of childbirth: A
prospective study of 825 women. Birth: Issues in Perinatal
Nursing 1990;17(1):15-24.
Sturrock WA, Johnson JA. The relationship between
childbirth education classes and obstetric outcomes.
Birth: Issues in Perinatal Nursing 1990;17(2):82-85.
Yawn BP, Yawn RA. Preterm birth prevention in a rural
practice. JAMA 1989;262(2):230-33.
Alexander GR, Weiss J, Hulsey TC, Papiernik E.
Preterm birth prevention: An evaluation of programs
in the United States. Birth: Issues in Perinatal Care
1991;18(3):160-69.
Rosenkrantz O. Welcome to fatherhood: A new program
helps first-time dads. Today’s Parent 1995;April:50-55.
Campbell NR, Brown J, Freeman T. The transition to
fatherhood. Ontario Medical Review 1993;October:63-64.
Spadt SK, Martin KR, Thomas AM. Experimental classes for
siblings-to-be. Maternal-Child Nursing 1990;15:184-86.
MacLaughlin SM, Johnson KB. The preparation of young
children for the birth of a sibling. J of Nurse-Midwifery
1984;29:371-76.
Lumley J. Preschool siblings at birth: Short-term effects.
Birth: Issues in Perinatal Care 1983;10(1):11-16.
Slager-Earnest SE, Hoffman SJ, Beckman CJ. Effects of a
specialized prenatal adolescent program on maternal and
infant outcomes. JOGNN 1987;16(6):422-29.
Rush R, Valaitis RK. Postpartum care: Home or hospital?
Canadian Nurse 1992;88(5):29-31.
Evans CJ. Description of a home follow-up program for
childbearing families. JOGNN 1991; 20(2):113-18.
Cole MP. A parent’s view of quality health care. MaternalChild Nursing 1990;15:371-73.
Wegner GD, Alexander RJ, eds. Readings in family nursing. Philadelphia: JB Lippincott Company, 1993.
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6.
7.
8.
WORK DURING PREGNANCY
1.
2.
2.
3.
4.
5.
1.
2.
3.
Canada’s Food Guide. Nutrition Program Unit, Health Programs & Services Branch, Health Canada, Ottawa, 1993.
American College of Obstetricians and Gynecologists.
Exercise during pregnancy and the postpartum period.
ACOG Technical Bulletin 1994;189:2-7.
Pre- and postnatal fitness guidelines. Fitness Ontario
Leadership Program, 1992.
STRESS
1.
2.
3.
Health and Welfare Canada. Nutrition recommendations:
The report of the scientific review committee. Ottawa:
Supply and Services Canada, 1990.
Health Canada. The Preconception/Prenatal Nutrition
National Guidelines. Ottawa: Health Canada, draft, June
1996.
Institute of Medicine. Nutrition during pregnancy: Weight
gain and nutrient supplements. Washington D.C.: National Academy Press, 1990.
Thomsen JK, Prien-Larsen JC, Devantier A, Fogh-Andersen N. Low dose iron supplementation does not cover
the need for iron during pregnancy. Acta Obstet Gynecol
Scand 1993;72(2):93-98.
Higgins AC, Moxley JE, Pencharz PB, Mikolainis D,
Dubois S. Impact of the Higgins Nutrition Intervention
Program on birth weight: A within-mother analysis. J Am
Diet Assoc 1989;89:1097-1103.
JOURNAL SOGC
American Medical Association Council on Scientific
Affairs. Effects of pregnancy on work performance.
JAMA 1984;251:1995-97.
American College of Obstetricians and Gynecologists and
the National Institute for Occupational Safety and Health.
Guidelines on Pregnancy and Work. DHEW; 1978.
EXERCISE DURING PREGNANCY
NUTRITIONAL COUNSELLING
1.
Erick, M. The Morning Sickness Report. Fit Pregnancy,
Spring 1995.
Erick, M. Hyperolfaction and Hyperemesis Gravidarum:
What is the Relationship? Nutrition Grand Rounds, October 1995;289-95.
de la Ronde S, Thirsk J for: Society of Obstetricians and
Gynaecologists of Canada. Committee Opinion: Guidelines for the Management of Nausea and Vomiting in
Pregnancy. November 1995.
4.
5.
6.
7.
32
AND
SOCIAL SUPPORT
Zuckerman B, Amaro H, Bauchner H, Cabral H. Depressive
symptoms during pregnancy: Relationship to poor health
behaviors. Am J Obstet Gynecol 1989;160:1107-11.
McAnarney ER, Stevens-Simon C. Maternal psychological
stress, depression and low birth weight. Am J of Diseases
of Children 1990;144:789-92.
Midmer D, Biringer A, Carroll JC, Reid AJ, Wilson L,
Stewart D, Tate M, Chalmers B. A reference guide for
providers: The ALPHA form—Antenatal Psychosocial
Health Assessment Form. 2nd edition, 1996. Toronto:
University of Toronto, Faculty of Medicine, Department
of Family & Community Medicine.
Wilson L, Reid A, Midmer D, Biringer A, Carroll J, Stewart
D. Antenatal psychosocial risk factors associated with
adverse postpartum family outcomes. Can Med Assoc J
1996;154(6):785-99.
Midmer D, Biringer A, Carroll J, Reid A, Wilson L,
Stewart D, Tate M, Chalmers B. A reference guide for
providers: The ALPHA form—Antenatal Psychosocial
Health Assessment Form, 2nd ed. Toronto: University
of Toronto, Department of Family and Community
Medicine, 1996.
MacMullen N, Dulski LA, Pappalardo B. Antepartum
vulnerability: Stress, coping, and a patient support group.
Journal of Perinatal and Neonatal Nursing 1992;6(3):15-25.
Affonso DD, Mayberry LJ. Common stressors reported by
a group of childbearing American women. Health Care
for Women International 1990;II:331-45.
DECEMBER 1998
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8.
9.
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Kemp VH, Hatmaker DD. Stress and social support in
high-risk pregnancy. Research in Nursing and Health
1989;12:331-36.
Carty EM, Tier T. Birthplanning: A reality-based script for
building confidence. Journal of Nurse-Midwifery
1989;34(3):111-14.
ABUSE
IN THE
SMOKING
Statistics Canada. The violence against women survey.
November 1993.
2. Rodgers K. Wife assault: The findings of a national survey.
Juristat Service Bulletin, Canadian Centre for Justice Statistics, March 1994.
3. Statistics Canada. The violence against women survey,
Shelf Tables 1-25. November 1993.
4. Johnson H. Dangerous domains: Violence against
women. Toronto: Nelson Canada. 1996.
5. Stewart DE, Cecutti A. Physical abuse in pregnancy. Can
Med Assoc J 1993;149(9):1257-63.
6. Stewart DE. Incidence of postpartum abuse in women
with a history of abuse during pregnancy. Can Med Assoc
J 1994;151(11):1601-04.
7. Jamieson W, Hart L. Responding to abuse during pregnancy: A handbook for health and social service professionals. In press May 1998.
8. Warshaw C, Ganley AL, Salber PR. Improving the health
care response to domestic violence: A resource manual
for health care providers. Family Violence Prevention
Fund, 1993.
9. Parker BP, McFarlane J. Identifying and helping battered
pregnant women. Maternal Child Nursing
1991;16(3):161-64.
10. Limandri BJ. The therapeutic relationship with
abused women. J of Psychosocial Nursing 1987;
25(2):9-16.
11. WomanKind. 8 steps to support and safety. Fairview
Health System, Minneapolis, MN, 1994.
2.
3.
4.
5.
IN THE
McFarlane J. Battering during pregnancy: Tip of an
iceberg revealed. Women and Health 1989;15(3),
69-79.
Fact sheet on wife assault in Canada. Education Wife
Assault, Toronto, 1985. In: Ontario Women’s Directorate
on Wife Assault, 1992.
Bullock L, McFarlane J. The birth weight-battering
connection. Am J of Nursing 1989; 89:1153.
Ribe J, Teggatz J, Harvey C. Blows to the maternal
abdomen causing fetal demise: Report of three cases and
review of the literature. J of Forensic Science
1993;38:1092-96.
Campbell J, Poland M, Waller J. Correlates of battering
during pregnancy. Research in Nursing and Health
1992;15:219-26.
JOURNAL SOGC
PREGNANCY
Edwards P and Neudorf C. Tobacco reduction in prenatal and postpartum programs for high priority families: Results of a cross-Canada survey. Ottawa: Health
Canada, 1995.
2. Hartmann KE, Thorp JM, Pahel-Short L, Koch MA. A randomized controlled trial of smoking cessation
intervention in pregnancy in an academic clinic. Obstet &
Gynecol, 1996;87:621-26.
3. Challot-Traquet C. Women and Tobacco. Geneva: World
Health Organization, 1992.
4. Chomitz VR, Lieberman E, Cheung L. Healthy Mothers—
Healthy Beginnings. A White Paper. Centre for Health Communication, Harvard School of Public Health, May 1992.
5. Hebel JR, Fox NL, Sexton M. Dose-response of birth
weight to various measures of maternal smoking during
pregnancy. J Clin Epidemiol 1988;41:483-89.
6. Peacock JL, Bland JM, Anderson HR, Brooke OG. Cigarette smoking and birth weight: Type of cigarette
smoked and a possible threshold effect. Int J Epidemiol
1991;20:405-12.
7. Focus on Women and Tobacco. National Clearing House
on Tobacco and Health. Fact Sheet developed with and
supported by the Tobacco Programs Unit, Health Canada. Sept. 1993.
8. Levitt C, Hammond M, Hanvey L, Continelli A. Approaching smoking in pregnancy—A Guide for Health
Professionals. The College of Family Physicians of Canada, Health Canada 1997.
9. Lumley J, Astbury J. Advice for Pregnancy. In: Chalmers I,
Enkin M, Keirse M, eds. Effective care in pregnancy and
childbirth. Oxford University Press, 1989(1991):242-47.
10. Lumley J. Strategies for reducing smoking in pregnancy.
In: Enkin M, Keirse M, Renfrew M, Neilson J, eds. Pregnancy and childbirth module. Cochrane database of systematic reviews: Review No. 03312, 2 October 1993.
Published through Cochrane Updates on Disk, Oxford:
Update Software. 1994, Disk Issue 1.
11. Guide Your Patients to a Smoke-Free Future. A program
of the Canadian Council on Smoking and Health.
Endorsed by the College of Family Physicians and Canada and the Canadian Medical Association, 1993.
12. Bertecchi CE, MacKenzie TO, Schrier RW. The Global
Tobacco Epidemic. Scientific American 1995;May:44-51.
1.
1.
AND
1.
OBSTETRICAL POPULATION
ADDITIONAL REFERENCES—ABUSE
OBSTETRICAL POPULATION
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ALCOHOL
1.
2.
33
AND
PREGNANCY
Sokol RJ, Clarren SK. Guidelines for use of terminology
describing the impact of prenatal alcohol exposure on
the offspring. Alcohol Health & Research World
1989;13(4):597-98.
Olson HC, Burgess DM, Streissguth AP. Fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE): A lifespan
view, with implications for early intervention. Zero to
Three/National Center for Clinical Infant Programs,
1992;13(1):24-29.
DECEMBER 1998
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DRUG USE
1.
2.
AND
ABUSE
IN
▼
8.
PREGNANCY
Vourakis C. Drug abuse problems among women.
In: Ingram Fogel C and Fugate Woods N, eds.
Women’s health care. Thousand Oaks, CA: Sage.
1995:497-515.
Tobacco, Alcohol and Drug Use During Pregnancy.
Research and Program Review. Capital Health/
Community Care and Public Health, Edmonton, AB.
1996.
2.
3.
4.
GUIDELINES FOR THE MANAGEMENT OF
NAUSEA AND VOMITING IN PREGNANCY
This Committee Opinion was prepared by the Clinical Practice—
Obstetrics Committee of the Society of Obstetricians and Gynaecologists
of Canada and approved by its Council in June 1995.
Rouse DJ, Gardner M, Allen SJ, Goldenberg RL. Management of the presumed susceptible varicella (chickenpox)exposed gravida: A cost-effectiveness/cost-benefit
analysis. Obstet & Gynecol 1996;87(6):932-36.
Davies HD, Wang EEL. Periodic health examination, 1996
update: 2. Screening for chlamydial infections. Can Med
Assoc J 1996;154(11):1631-43.
The Society of Obstetricians and Gynaecologists of Canada, Canadian Paediatric Society. National Consensus
Statement on the Prevention of Early-Onset Group B
Streptococcal Infections in the Newborn. Journal SOGC
1997;19(7):751-58.
Demeter S. Measles and Pregnancy—Public Health
Advice. Personal communication, April 29, 1997.
The SOGC wishes to acknowledge Dr. Sandra de la Ronde of Calgary
as the principal author and Dr. Jayne Thirsk, R.D., PhD, Foothills
Hospital, Calgary, for her contribution on nutritional information.
Nausea and vomiting affect at least fifty percent of
pregnant women. Traditionally, these symptoms have
been called “morning sickness” and are most common
in the first and early second trimesters. However, the
symptoms may be present throughout the day and may
last for the entire pregnancy. While nausea and vomiting are considered to be a “normal” part of the pregnant state, their effects on the pregnant patient’s sense
of well-being have probably been underestimated. A
descriptive study by O’Brien and Naber showed that
eighty-three percent of women felt that these symptoms
had affected their ability to perform usual activities, and
in one-third they were severe enough to affect the
woman’s ability to function in family, social, and occupational spheres.1
Hyperemesis gravidarum occurs in about one percent
of pregnancies and is defined as vomiting severe enough
to produce weight loss, dehydration, acid-base disturbances, ketonuria, and electrolyte imbalances. Each year,
a significant number of women are admitted for hyperemesis gravidarum and may require such interventions
as total parenteral nutrition. Early recognition and management could therefore have a significant effect on the
quality of life during pregnancy, as well as a financial
impact on the Health Care System.
EDUCATION TO RECOGNIZE SOME OF
IMPORTANT COMPLICATIONS OF
PREGNANCY
THE
1.
Moutquin JM, Milot-Roy V, Irion O. Preterm birth prevention: Effectiveness of current strategies. Journal SOGC
1996;18:571-88.
BREASTFEEDING
1.
2.
3.
4.
5.
6.
7.
Porro E, Indinnimeo L, Antognoni G, Midulla F, Criscione
S. Early wheezing and breastfeeding. J of Asthma;
30(1):23-28.
Burr ML, Limb ES, Maguire MJ, Amarah L, Eldridge BA,
Layzell JCM, Merrett TG. Infant feeding, wheezing, and
allergy: A prospective study. Arch Dis Child
1993;68:724-28.
Tully MR, Overfield ML. Breastfeeding Counselling
Guide. 1984.
Breastfeeding management and promotion in a babyfriendly hospital. UNICEF/WHO, 1993.
Jaroez L. Breastfeeding versus formula: Cost comparison.
Hawaii Medical J; 52:14-17.
Feeding babies: A counselling guide on practical
solutions to common infant feeding questions. Ottawa:
Health and Welfare Canada, 1986.
Protecting, promoting and supporting breastfeeding:
The special role of maternity services. World Health
Organization (A joint WHO/UNICEF statement), Geneva,
1989;13-9.
JOURNAL SOGC
The MAIN Trial Collaborative Group. Preparing
for breastfeeding: Treatment of inverted and nonprotractile nipples in pregnancy. Midwifery 1994;10:
200-14.
APPENDIX 3-2
EXPOSURE TO INFECTIOUS DISEASES DURING
PREGNANCY
1.
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MANAGEMENT
Management of this problem is multi-faceted. It
includes early recognition, dietary and lifestyle advice,
as well as pharmaceutical and alternative forms of therapeutic interventions.
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any drug even when the drug has been proven to have
no harmful effects on the fetus. They may, however, be
amenable to alternative forms of treatment.
The Cochrane Pregnancy and Childbirth Group
(CPCG) reviewed three controlled trials studying the
effect of acupressure at the P6 (Neiguan) point. This
point is located on the inner aspect of the wrists, just
proximal to the flexor crease. A randomized double-blind
cross-over trial comparing placebo using bands with pressure and blunted points showed a significant reduction
in the symptoms of nausea and vomiting.2 The CPCG
concluded there was a significant positive effect and that
acupressure was safe.3 Currently, Sea-Bands are available
for patients who wish to try this form of therapy.4
The effects of ginger (Zingiber officinale) on nausea
and vomiting have been studied in patients with hyperemesis gravidarum. A double-blind randomized cross-over
trial compared placebo and 250 mg q.i.d. of powdered ginger root and found a significant beneficial effect on symptoms.5 However, there is insufficient information about the
effects of larger doses of ginger on the fetus, and until further trials are completed, ginger cannot be recommended
as a treatment for nausea and vomiting in pregnancy.6
Vitamin B6 (pyridoxine) has also been studied as a
treatment of nausea in pregnancy. The CPCG reviewed
one available trial and found a positive effect.7 More trials are needed.
b) Pharmacological
Doxylamine Succinate 10 mg, in combination with
Pyridoxine Hcl 10 mg (Diclectin), were approved for use
in the treatment of nausea and vomiting in pregnancy
by the Health Protection Branch of Health and Welfare
Canada in 1990. To date, this formulation is the only
anti-nauseant approved for such use.
Health practitioners and pregnant women who are
concerned that this drug has the same formulation as Bendectin, which was withdrawn from the market in the USA
in 1983 after several unsuccessful lawsuits against it, should
know that in spite of the most vigorous testing of any drug
in pregnancy, no evidence of teratogenicity has been
found. In fact, the Australian obstetrician who originally
stated the drug was a teratogen has been found guilty of
scientific fraud in his experiments related to the drug.8
Multiple studies have reviewed Debendox (Bendectin) and concluded that the drug is a safe, effective
treatment for nausea and vomiting of pregnancy and that
there is no evidence that it is a teratogen.9,10
EARLY RECOGNITION
Careful questioning of the patient, early in the pregnancy, about the frequency and intensity of the symptoms of nausea and vomiting allows the practitioner to
intervene with diet and lifestyle adjustments as well as
medication, with the aim of preventing progression to
hyperemesis. Too often, patients are seen after the worst
of the symptoms have subsided or intervention is not
offered until they are already quite severe.
DIET
Traditionally, women with nausea and vomiting of
pregnancy, especially hyperemesis, have been told to eat
frequent small meals consisting of dry, bland foods. Patients
admitted with severe symptoms have been starved and
given intravenous fluids. When they can eat, they have
been given clear fluids only. More recent recommendations suggest that, as soon as they are hungry, women
should be encouraged to eat frequent small amounts of
whichever foods appeal to them. Emphasis is placed on
intake rather than content until the symptoms have subsided. Suggestions for foods which appeal to pregnant
women because of taste and texture are listed in Table 1.
LIFESTYLE
Fatigue seems to exacerbate nausea and vomiting.
Women should be encouraged to increase their rest
while they are symptomatic and to seek assistance in
such daily activities as child care.
Pregnant women seem to have an increased sensitivity to odours, probably due to the effect of increased
levels of estrogen on the area postrema in the brain.
Consequently, aromas of cooking food as well as odours
in the workplace may initiate nausea (e.g. perfume,
smoke). The partner should be encouraged to cook.
It would, therefore, seem appropriate for health care
providers to adopt a liberal attitude towards providing
letters for leaves-of-absence from work. Such a policy
will ultimately shorten the time lost from outside
employment.
THERAPEUTIC INTERVENTION
a) Non-pharmacological
Current public information cautions pregnant
women to limit the use of all medications except vitamins. Hence, many pregnant women are hesitant to use
JOURNAL SOGC
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5.
Fischer-Rasmussen W, Kjaer SK, Dahl C, Asping U. Ginger
treatment of hyperemesis gravidarum. European Journal
of Obstetrics and Gynecology and Reproductive Biology
1991;38(1):19-24.
6. Jewell MD. Ginger treatment for hyperemesis
gravidarum. In: Enkin M, Keirse M, Renfrew M,
Neilson J, eds. Pregnancy and Childbirth Module,
Cochrane Database of Systematic Reviews: Review
No. 06812, 30 April, 1993. Published through
“Cochrane Updates on Disk”. Oxford: Update
Software, 1994, Disk Issue 1.
7. Jewell MD. Vitamin B6 (pyridoxine) for nausea in
pregnancy. In: Enkin M, Keirse M, Renfrew M, Neilson J,
eds. Pregnancy and Childbirth Module, Cochrane Database of Systematic Reviews: Review No. 07703, 30 April
1993. Published through “Cochrane Updates on Disk”.
Oxford: Update Software, 1994, Disk Issue 1.
8. Fortin CF, Lalonde, AB. The bendectin affair (of legal and
general interest). Journal SOGC 1995;17(1):61-63.
9. Jewell MD. Debendox (Bendectin) for nausea in pregnancy. In: Enkin M, Keirse M, Renfrew M, Neilson J, eds.
Pregnancy and Childbirth Module, Cochrane Database of
Systematic Reviews: Review No. 03351, 30 April 1993.
Published through “Cochrane Updates on Disk”. Oxford:
Update Software, 1994, Disk Issue 1.
10. Einarson TR, Leeder JS, Koren G. A Method for metaanalysis of epidemiological studies. Druf Intelligence and
Clinical Pharmacy 1988;22:813-24.
11. Tufts University Diet & Nutrition Letter 1994;11(11):6-7.
Doxylamine Succinate 10 mg, in combination with
Pyridoxine Hcl 10 mg (Diclectin) is a delayed release
tablet. Most women experience their symptoms in the
morning. Therefore, it is recommended that they should
start with two tablets at night before bed. If symptoms
are not relieved, one tablet in the morning and another
in midafternoon can be added. The dosing regimen can
also be tailored to fit each woman’s peak of symptoms.
CONCLUSION
Nausea and vomiting are frequent symptoms in pregnant women which can affect their quality of life significantly. It is recommended that all health practitioners
should question women early in their pregnancies about
the presence of these symptoms and offer intervention
with advice about DIET, LIFESTYLE adjustment and
MEDICAL treatment.
TABLE 111
SUGGESTIONS FOR FOODS WHICH APPEAL TO PREGNANT
WOMEN BECAUSE OF TASTE AND TEXTURE
Salty
Chips, Pretzels
Tart/Sour
Pickles, Lemonade
Earthy
Brown Rice, Mushroom Soup
Crunchy
Celery Sticks, Apples
Bland
Mashed Potatoes
Soft
Bread, Noodles
Sweet
Cake, Sugary Cereal
Fruity
Juices, Fruity Popsicles
Wet
Juice, Seltzer
Dry
Crackers
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REFERENCES
1.
2.
3.
4.
O’Brien B, Naber S. Nausea and vomiting during
pregnancy: Effects on the quality of women’s lives. Birth
1992;19(3):138-43.
De Aloysio D, Penacchichi P. Morning sickness control in
early pregnancy by Neiguan point pressure. Obstet
Gynecol 1992;80(5):852-54.
Jewell MD. P6 acupressure to treat nausea. In: Enkin M,
Keirse M, Renfrew M, Neilson J, eds. Pregnancy and
Childbirth Module, Cochrane Database of Systematic
Reviews: Review No. 06520, 4 May 1993. Published
through “Cochrane Updates on Disk”. Oxford: Update
software, 1994. Disk Issue 1.
Sea-Band Canada, Kinatin International Holdings Inc.
M.P.O. Box 2549, Vancouver, B.C. V6B 3W8.
JOURNAL SOGC
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Chapter 4
BIRTHING GUIDELINES
This document is a step towards this goal of updating guidelines to reflect current evidence while promoting family-centred practice.
PHILOSOPHY
The great majority of births in Canada take place in
hospitals, and the perinatal mortality rate has steadily
improved in all provinces in the last two decades. A rate
at or below 10/1000 births has been achieved in all
provinces. This highlights the effectiveness of the medical community at working together in a regional team.
In 1994, Health and Welfare Canada, with representatives from many national organizations—including
the Society of the Obstetricians and Gynaecologists of
Canada—undertook a revision of its recommended
Standards for Maternity and Newborn Care, and published the updated Family-Centred Maternity and Newborn Care: National Guidelines in 1998.1 This document
promotes a change from the traditional rigid and routinely organized hospital setting towards a more consumer-oriented one, where the family receives highly
individualized and personalized care. Obstetrical units
are advised to abandon their routines and practice family-oriented, evidence-based medicine.
A report issued by the Canadian Institute of Child
Health on routine maternity care policies and practices in
Canadian Hospitals showed that the guidelines are widely
used.2 However, they are implemented differently across
Canada, where surprising inter- and intra-provincial variations, as well as variations based on hospital size, still exist.
These findings indicate the need to adopt specific implementation policies to influence and perhaps define the provision of obstetrical care across Canada more uniformly.
JOURNAL SOGC
HOSPITAL POLICIES AND STANDARDS
FAMILY-CENTRED CARE
Hospital policies should favour a family-centred
approach because this concept is central to meeting the
needs of everyone concerned with the childbearing experience.3,4 When this philosophy is successfully applied,
the parents will have a fulfilling experience of labour
and delivery, free from unnecessary interventions. The
hospital will become user-friendly and, barring unforeseen
problems, will allow maximum flexibility and freedom of
choice to the family regarding procedures, settings, labour
and delivery positions, and selection of techniques for pain
reduction. There will also be acceptance of the wide variation of religious and cultural differences, an important
consideration in our multiethnic country.
Applying this philosophy will allow women and
their families to feel not as though they are done “to”,
but “with.” The following quote is indicative of how people may feel if this is not attended to:
“I felt increasngly more ‘managed.’ I knew what I was
doing; my husband had it all down, too. Labour, push,
baby, suction, oxygen, placenta, nurse, clean up. Birthing
in eight easy steps. Physically it was the best yet, but
emotionally? Poof. I was stunned. No quite time for quiet
reflection. I missed it.” 5
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DECEMBER 1998
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The objectives that we hope to achieve with family-centred
care are to:
▼
For the successful operation of maternity and newborn care units, it is essential that written policies and
guidelines be established. These should clearly reflect
the family-centred approach described above and such
policies should be regularly reviewed and revised in view
of evolving or changing knowledge about perinatal care.
– Improve the safety of childbirth for the mother and the
quality of the human experience for herself and the
members of the family.
– Increase the prognosis for survival of all children and
the development of their full potential.
– Promote the development of a healthy family relationship.
These written policies and guidelines should address:
1. The roles and objectives of the unit, including a statement of philosophical objectives and population to be
served by the unit.
– Reduce the rates of medical intervention (and therefore
the risk and the cost) by offering only those interventions
which have been clearly shown to improve outcome.
2. The administrative structure, including the chain of
command and the relationship between different levels
of responsibility within the unit, including medical,
nursing and/or midwifery.
– Provide parents with educational programmes based on
their needs.
– Provide and maintain a regionalized network of care that
can address the need of high risk mothers and infants
requiring special diagnostic and therapeutic techniques.
3. A list of the policies and procedures that should
include criteria for admission, medical coverage,
responsibilities of unit staff, guidelines for recommended or mandatory consultation, guidelines on the writing of orders (including policies that would keep standing orders to a minimum), guidelines for the operation
of a quality assurance programme, a means to regularly evaluate the outcomes of services provided, and all
other aspects of the unit operation that deserve to be
defined in a procedure manual.
– Establish communication between the members of the
health care team within a given region or community to
ensure coordination and continuity of care.
– Provide CME activity for health care professionals which
places emphasis on the new technical advances, but
also considers the effects of any change on the birth
experience for the parents.
FACILITIES
It is well understood that the age and capacity of all
obstetrical units in Canada vary greatly. It is therefore
difficult to make specific guidelines regarding facilities.
It is clear that the widely accepted advantage of familycentred care has to be supported not only by the people,
but also by a proper environment for care.
A hospital with a family-centred approach should encourage and facilitate:
– Partner labour support as well as professional labour
support by trained nurses or midwives.
– Appropriate contact between the mother, her partner
and the infant from the prenatal period throughout
birth and into the postpartum period.
LABOUR/DELIVERY/RECOVERY/POSTPARTUM
(LDRP) ROOMS
– Early sibling access, which implies flexible visiting hours.
– Breastfeeding.
In the last two decades, the design of the birth suite
for the safe monitoring and coaching of labour and birth
has undergone a dramatic transition. It is clear that separating labour, birth and recovery rooms is a thing of the
past and should be abandoned, if at all possible. The traditional obstetrical theatre should be used only for Caesarean delivery or complicated vaginal deliveries such as
breech or twins, because of the immediate availability of
general anaesthesia and advanced resuscitation equipment. The concept of labour/delivery/recovery/ postpartum (LDRP) rooms offers total care of the mother from
the time of her admission. Different kinds of special labour
and delivery beds are available which facilitate the first
and second stages of labour and promote the philosophy
– Rooming-in with baby and close family members.
– The assignment of one nurse or midwife to each family
unit intrapartum and postpartum.
– Integration in each perinatal care network by fostering
communication and collaboration between all participating institutions and professionals in the day-to-day
work, in clinical research, and in organizing continuous
medical education activities. (The perinatal care network is composed of a group of level I, level II and level
III institutions within the same geographic area, as
defined in the National Guidelines for Family-Centred
Maternity and Newborn Care.)1
– Effective communication with consumers by routinely
asking them about their satisfaction, and also by establishing a proper mechanism for complaints.
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experiencing medical complications and/or by special request. The observation of the normal newborn
must also take place in the mother’s room to ensure
maximum contact with the family during these very
important moments after birth. Traditionally, the
newborn nursery has been considered “cleaner” than
the mother’s room. However, when an infant stays
in the same room as the mother, the mother does
most of the handling. In the nursery, the infant is
handled by many different nurses, all of whom may
be handling other infants as well. Despite guidelines
regarding hand washing, the potential for infections
is probably greater in the nursery.7
When these three points are taken into account, in addition to the desire of consumers for greater privacy, comfort, and the ability to make choices, the labour/
delivery/recovery/ postpartum (LDRP) room seems to be
a logical evolution for the design of future facilities or for
those facilities undergoing major renovation. This concept includes the postpartum period into the same private labour/delivery/recovery (LDR) rooms common in
many facilities today.
The LDR and LDRP concepts associated with the
family-centred approach to care seem to be the way of
the future in obstetrics. Numerous studies have demonstrated these facilities are cost-effective,8 however, this
does not completely prevent the traditional setting from
being used with a family-centred approach. In fact, the
philosophy of a unit is carried more by the people than
by the facilities themselves, but it should be understood
that adequate physical plant will be necessary when
implementing a corresponding policy or philosophy.
of low intervention rates and individualized care. Experience shows that the use of variable positions during
labour and delivery and not limiting the second stage of
labour results in a reduced incidence of operative deliveries and episiotomies. In addition, such an approach
increases patient satisfaction. If necessary, operative
deliveries and other emergency obstetrical procedures
can also be safely accomplished in these beds.
It is believed that most obstetrical units can expand
or convert to the LDRP concept without major renovations. In order that the LDRP concept achieve the full
potential of family-centred care, it must ideally be integrated in facilities that also permit the following:
– Adequate triage area: Trained nurses or midwives
can evaluate the situation and decide if the patient
should be admitted to the active labour area, discharged, or sometimes kept in a separate lounge
where the patient and her family can experience the
latent phase of labour in a quiet environment without medical intervention and under the discreet
supervision of the triage personnel. This special
lounge should be available for women who live far
enough away that they cannot be sent home.
Adequate triage at the time of admission could help
solve the problem of the high rate of primary Caesarean sections being done during the latent phase
of labour. In 1994 the Alberta Perinatal Audit and
Education Programme assessed results of an educational strategy that focused on management of the
latent phase of labour. The percentage of low-risk
primigravida who underwent Caesarean sections for
stage 1 arrest at <4cm dilation decreased from 36.1
percent to 24.6 percent following implementation of
the educational programme.6 Triage is also useful to
identify other risk factors as well as medical or social
problems, thus allowing the design of a personalized
care plan for each family.
– Facilities should provide enough privacy for rooming in with the baby. Families and family members
should be welcomed at all times at the mother’s discretion, taking into account privacy and consideration for other patients. When appropriate, fathers
should also be able to room in. Maternity hospital
rooms should be designed and furnished so as to
ensure that families are comfortably accommodated.
– The well baby nursery can be considerably downsized to accommodate only the babies from mothers
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STAFFING
The actual trend in the provision of care in normal
obstetrics is to move away from technology and bring
back people who can offer human support and understanding to the family.
Many studies addressing labour support by trained
professionals, and recent guidelines by SOGC on assessing fetal well-being in labour,9 favour a one-to-one ratio
of nurse or midwife to mother and fetus during labour.
This ratio was shown to reduce intervention rates and
improve outcome.
Although there is no objective study available measuring the cost of the one-on-one care against the potential economies produced by the reduced intervention rate
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and hospital stay, it is conceivable that this measure is
cost-effective and could be implemented after revision of
the traditional duties, with a minimum increase in staff.
To ensure consistency and continuity of care, it is
also recommended that the same nurse take care of
mother and baby.
drawn criticism of “medical-based care”, and strategies
to reduce their risks have been extensively addressed in
the current literature. There is no single reason for these
high intervention rates.
The following is a set of strategies to reduce intervention rates in hospital.
1. Eliminate the routines. Many routines in hospitals
were established out of necessity to establish policies
and procedures in an institutional setting. With the
exception of such things as mandatory administration of Rh gamma globulin to Rh-negative mothers
with negative Coombs’ test, and rubella immunisation for a non-immune mother, nothing should be
automatic. It should be possible for a woman with a
normal, low-risk pregnancy to come into hospital,
deliver normally and leave having had no intravenous,
no medication, and no blood tests during her stay.
2. Avoid “worst case” philosophy. Many hospital policies prefer to keep the mother fasting during labour
in case of an emergency, which is based on a “worst
case” philosophy.10 The same applies for routinely
starting an intravenous on every patient during
labour. General policies based on such reasoning
should be avoided and decisions on every case should
be made on an individual basis. It is certainly advisable to learn from unfavourable experiences and
these should represent an opportunity to ensure that
all national guidelines and standards are reasonably
met. In so doing, policies should be modified in order
to decrease intervention rates.
3. Provide adequate professional labour support by
nurses or midwives. This point will be discussed subsequently in the document; however, there is evidence that such support may contribute to improved
outcomes.11,12
4. If possible, move away from routine electronic fetal
monitoring for normal, uncomplicated labour.9
5. Provide adequate physical facilities. It is strongly
believed by the authors that LDR and LDRP concepts are very effective when associated with the
other intervention-reducing strategies. They allow
for personalized management of the first and second
stages of labour, which may directly influence the
incidence of operative delivery and episiotomy.
6. Make an official policy for accepting birth plans.
Initially, it is difficult to adapt to change and it may
take time for professionals to learn to modify their
ALTERNATIVE DELIVERY SETTING
HOME BIRTH
The Society of Obstetricians and Gynaecologists of
Canada resolved In June 1981, and reiterated in September 1997, that it strongly disapproves of home births
because they are not in the best interest of optimal
maternal-fetal health care. The Society agrees with
and encourages the establishment of hospital programmes by hospital obstetrical departments which will
promote, in every possible way, the development of
close, normal family relationships and enhance parentchild contact without jeopardizing the safety of either.
With the increased emphasis on family-centred delivery, the move towards early discharge and the availability
of postpartum home care, there should be reduced requests
for home delivery. Health care providers who choose to
carry out home deliveries must adopt strict screening procedures, easily accessible physician consultation, and rapid
transport availability in the event of an emergency.
ALTERNATIVE BIRTHING CENTRE OUTSIDE
HOSPITAL
THE
There has been discussion of the concept of freestanding “birthing centres” in Canada. These centres
may not be as cost effective in urban centres as larger volume hospital units that can offer the same personalized
and family-oriented care, in addition to the rapidity of
intervention in case of emergencies. Small birthing centres may be useful in some areas where, for geographic
reasons, it is necessary to separate normal low-risk mothers from their family for an extended period around the
expected date of confinement. In these situations, proper selection of patients and the availability of emergency
transportation is crucial.
STRATEGIES TO ADDRESS
INTERVENTION RATES
The rates of Caesarean section and other obstetrical
interventions (e.g. episiotomies, forceps or vacuum) have
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routines, thus offering a more personalized service.
Birth Plans are discussed in Appendix 4-1. It has
been the experience of some centres that when birth
plans are accepted they can become an important
instrument in changing attitudes towards tolerance
and personalized care.13 The effect is still important
even when the birth plan is not extensively used.
7. Establish special specific programmes and make
them known to the public. This does not refer to
costly new technologies, but rather certain areas of
obstetrical care that are already accepted but may not
yet be fully implemented in a given centre. The most
commonly used are VBAC and vaginal breech birth
programmes that address special obstetrical challenges. Others are more specific to the needs of a particular population—for example, the natural birth
programme that is aimed at balancing the home
delivery trend or programmes aimed at serving different ethnic or linguistic minorities.
These programmes are useful for implementing
progressive but lasting changes in a given unit.
IMPLEMENTATION OF PROGRESSIVE
LASTING CHANGES
will run by itself without the need of a specific person in charge of publicity.
It is advisable that a promotional flyer/brochure be
created and distributed to interested groups. This
pamphlet should include information about the different procedures available. It is important for the
patient to be well-informed concerning the risks, but
also the advantages must be stressed.
4. Be consumer-oriented. The satisfaction of the family members during their experience of birth should
be a high priority in any obstetrical unit. The degree
of satisfaction can be monitored by regularly questioning the consumers. As mentioned earlier, consumers’ demands are often what initiate change. This
is especially true when they feel they have the ability to make choices.
REFERENCES
1
Family-centred maternity and newborn care: National
Guidelines. Ottawa: Heath Canada, 1998.
2. Levitt C, Hanvey L, Avard D, Chance G, Kaczorowski J.
Survey of routine maternity care and practices in Canadian hospitals. Health Canada and Canadian Institute of
Child Health, 1995.
3. Interprofessional Task Force on the Health Care of
Women and Children. Joint position statement on the
development of family-centred maternity/newborn care
in hospitals. Chicago: American College of Obstetricians
and Gynecologists, 1978.
4. Post, S. Family-centred maternity care: The Canadian picture. Dimensions in Health Service, 1981;6:25-31.
5. Chisholm Julie. Ontario Midwifery Report Card. In: The
Compleat Mother—Spring 1998:16.
6. Demianczuk N, Lange I, Jennissen B, Yee J. Alberta perinatal audit/education program—Results of the strategies
to decrease obstetrical interventions. Presented at FIGO,
XIV World Congress of Gynecology and Obstetrics, Montreal, Québec, Sept. 1994.
7. Rush J, Chalmers I, Enkin M. Care of the new mother and
baby. In: Chalmers I, Enkin M, Kierse M, eds. Effective
care in pregnancy and childbirth. Oxford University Press.
1989 (1991):1333-46.
8. Phillips C. Single room maternity care for maximum costefficiency. Perinatalogy-Neonatalogy. 1988; March/April:4.
9. Society of Obstetricians and Gynaecologists of Canada.
Policy Statement: Fetal Health Surveillance in Labour.
Journal SOGC 1995;17(9):859-901.
10. O’Reilly, SA. Oral intake and emesis in labour. Journal of
Nurse-Midwifery 1993;38:4:225-35.
11. Sosa Roberta et al. The effect of a supportive companion
on perinatal problems, length of labour and motherinfant interaction. N Engl J Med 1980;303(11):597-600.
AND
This is a gradual process which may be summarized
as follows:
1. Make somebody responsible for reviewing the existing literature and guidelines on the subject. This person should demonstrate a vested interest and would
eventually be responsible for the planning of the
change to be implemented.
2. Involve all levels of professionals concerned with the
development and implementation of the new policy
or programme, ensuring that all team members agree
with the final draft .
3. The implementation plan should include a presentation of the policy to all members of the unit. A
question and answer period must be included. The
presentation should also include publicity to the consumer. This can easily be achieved through prenatal
courses and physicians’ offices. It is also very effective to use alternative non-professional routes like
the local newspaper or alternative birthing associations. This will ensure the enrolment of very motivated patients, which in turn will increase the chance
of success during the initial stages of the programme.
It is to be expected that eventually, the programme
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12. Kennell J, Klause M, McGrath S, Robertson S, Hinkley C.
Continuous emotional support during labor in a U.S. hospital. A randomized controlled trial. JAMA
1991;265(17):2197-201.
13. Pridham KF and Schutz ME. Parental goals and the
birthing experience. JOGNN 1983; Jan-Feb.:50-55.
All interventions will be performed only if they are
medically indicated and will be well explained to the
couple in advance.
The hospital stay varies between 24 hours and three
days, depending on the circumstances. Such special programmes as vaginal birth after Caesarean section (VBAC)
and vaginal breech births are available. It is also possible
to leave the hospital immediately after the birth, but this
must be discussed with the treating physician.
APPENDIX 4-1
FAMILY BIRTHING CENTRE
DESCRIPTION
OF THE
UNIT
The birthing unit for the family is comprised of __
private rooms fully equipped to deal with the labour,
delivery, recovery and postpartum stay. Rooming-in 24
hours a day for the baby and the significant other is
included.
PHILOSOPHY
OF THE
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SAMPLE BIRTH PLAN
We encourage you to write down your wishes and desires
for the birth and to discuss these with your physician. (Use
additional sheet, if necessary)
Your support people: ________________________________
____________________________________________________
UNIT
The unit favours a familial, natural and individual
approach in which the medical personnel—nurses and
others—work towards making the birthing and postpartum experience a positive and enriching one for the
family.
In order to accomplish this, there are very few preestablished routines and care should be tailored to each
individual’s needs. All hospital resources will be made
available. In order that the philosophy of the family
birthing centre is maintained, other technical resources
will be used only when absolutely necessary.
Your preferences about pain control: __________________
____________________________________________________
____________________________________________________
Medical interventions during labour: __________________
____________________________________________________
____________________________________________________
Second stage and delivery: __________________________
____________________________________________________
____________________________________________________
Most important issues: ______________________________
____________________________________________________
____________________________________________________
LABOUR
–
–
–
Admission to a birthing room with therapeutic bath.
No shaving, no enema.
Fetal monitoring for the first 15 to 20 minutes and if
all is normal, further monitoring is done either intermittently or at regular intervals.
– Freedom to walk about at all times during labour and
ability to use the therapeutic bath as needed.
– Intravenous line used only for special or high risk
cases.
– Choice of positions for the delivery.
Full participation from the patient, her partner
and/or other family member is encouraged. The baby is
immediately placed on the mother’s abdomen after the
birth and the primary care and observation of the baby
will be done in the room with the couple and other family members. Rooming-in is available 24 hours a day.
JOURNAL SOGC
Concerns or fears: __________________________________
____________________________________________________
____________________________________________________
Infant feeding: ______________________________________
____________________________________________________
____________________________________________________
Newborn Procedures: ______________________________
____________________________________________________
____________________________________________________
THIS BIRTH PLAN HAS BEEN REVIEWED AND DISCUSSED
WITH ME.
Patient’s signature: __________________________________
Doctor’s signature: __________________________________
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Chapter 5
FIRST STAGE OF LABOUR
EARLY ASSESSMENT
For active labour to be confirmed, cervical dilation
should be 3 to 4 cm and 80 to 90 percent effaced in
primigravidas, or 3 to 4 cm and 70 to 80 percent effaced
in multiparous women.
Labour and birth are both normal physiological events.
However, for many women, labour may be a time of fear,
uncertainty, excitement and anxiety as well as anticipation. Caregivers of labouring women must always bear in
mind that women’s perceptions and memories of this
experience remain with them throughout a lifetime.1 In
order to facilitate a positive experience, the SOGC recommends a philosophy of care that emphasizes respect
for individual family choices and needs, flexibility in the
provision of care, and collaboration between the family
and the health care team. This family-centred approach
should guide the management of all labouring women.
If active labour is confirmed, arrangements may be
made for admission to an LDR or LDRP room. If the
woman is found to be in the latent phase of labour, she
and her partner will need to be reassured about the health
of the pregnancy and informed as to the current situation.
Relaxation techniques may be reviewed and advice given
about comfort measures that may be taken after returning
home. If necessary, the patient may remain in the triage
area or appropriate lounge for reassessment in several
hours, or discharged home with specific instructions.
Women who have confirmed rupture of membranes
but who are not yet in active labour may be offered a choice
of induction or planned reassessment in a few hours time.
The triage assessments may be done by qualified personnel in communication with the attending obstetrician, family physician or midwife.
Women presenting in suspected labour at term
should be greeted in an early assessment room. If possible, this unit should use rooms other than those allocated for actively labouring patients. The initial assessment
should include a brief review or familiarization with the
woman’s past medical and obstetrical history and the history of this pregnancy, as well as a record of the presenting problem and vital signs.
Details of the current situation, such as onset time
of contractions, the pattern of their development, and
the history and time of spontaneous rupture of membranes, should be recorded on a partogram (see Appendix 5-2 for example). Unless otherwise contraindicated,
a cervical examination should be performed in triage and
membrane status confirmed by speculum examination.
The couple’s birth plan should be reviewed once the
examination has been completed.
Latent and active phases of the first stage of labour
should be diagnosed using the criteria set out in the
SOGC Dystocia Guidelines.2
JOURNAL SOGC
MANAGEMENT OF THE FIRST STAGE
OF LABOUR
Ideally, all women with uncomplicated term pregnancies should have access to labour/delivery/ recovery
room facilities with continuous professional support.
Unfortunately, such facilities may not always be available. In using other facilities, the caregivers should hold
as top priorities the woman’s need for privacy, the need
for her to be able to move freely to different positions
during her labour, as well as the ability to provide safe
and continuous professional care in the presence of support people of the woman’s choosing.
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relief. Many non-pharmacological approaches
have proven benefits for women in labour.
Available services should include continuous
Inital Assessment:
professional labour support using such meth– past medical history
ods as breathing and relaxation techniques,
– past obstetrical history
massage, positioning and comforting touch.
– history of this pregnancy
– Continuous professional support by care– present vital signs
givers dedicated to helping women achieve
– develop partogram
an unmedicated birth is imperative to the
– confirm membrane rupture
success of this process. Further information
– confirm latent/active labour
on specific techniques can be found in the
subsequent section on Labour Support.
–
Water
Therapy: Aside from labour supLatent labour and
Active labour
Latent labour and
port, there is good evidence for water
confirmed rupture
✔ cervical dilation 3
no rupture of
of membranes
to 4 cm, plus
membranes
therapy as a method of pain relief in
✔ 80-90% effaced
labour. Showers, Jacuzzis and tub baths
(primigravidas) or
are all effective in increasing the likeli70-80% effaced
hood of unmedicated birth and may proMay offer choice of
✔ Reassure patient
(multiparas)
induction or
✔ Advise of current
mote satisfaction with the birthing
planned reassesssituation
experience. The literature indicates that
ment in a few hours
✔ Review relaxation
tub baths and Jacuzzis facilitate the first
techniques
stage of labour by promoting relaxation
and decreasing the woman’s pain perception, due to the buoyancy that the heatSend home with
Keep and reassess
instructions
in a few hours
ed water provides while supporting tense
muscles.1,7 Water therapy can and should
be used in conjunction with other labour
DIET/ROUTINES
support techniques and has been found to be most
A woman in active labour should be offered a light
beneficial when women are in the active phase of the
or liquid diet according to her preference. Some of the
first stage of labour. More information on the adminnutrients should contain glucose and the woman should
istration and safety of hydrotherapy can be found in
be encouraged to maintain a good fluid intake. Routine
Appendix 5-1. Caregivers should encourage upright
use of intravenous fluids is discouraged; however, certain
postures and ambulation during the first stage of labour
situations such as epidural use or oxytocin administration
as this appears to promote progress, relieve maternal
may require intravenous rehydration or an access site.
discomfort, and reduce the requirement for analgesia.2
There is no evidence to support the routine use of
Women may also choose a medication to ease the pain
3-6
shave preparations, enemas, and catheters. Caregivers
of labour and birth. If the woman makes this choice, it
are encouraged to develop a flexible approach to assistis important that labour support measures and philosoing a woman with her labour—an approach which reacts
phy not be abandoned.
not only to the need for safe, effective care, but also to
– Narcotic Analgesia: The use of narcotic analgesia,
the preferences of the woman and her family. Supportgiven either intramuscularly or intravenously, has
ive care that avoids imposing routines leads to higher
been shown to be effective therapy for pain of labour.
patient satisfaction and lowers the need for intervention.
However, these drugs are associated with a higher
risk of lowering the Apgar score.8,9 Physicians should
PAIN RELIEF: MEDICINAL OR NON-MEDICINAL
familiarize themselves with the pharmacokinetics of
Each centre caring for labouring women should offer
each agent they use and always bear in mind the
both medicinal and non-medicinal methods of pain
effects on both the fetus and the mother.
FIRST STAGE
OF
LABOUR—TRIAGE
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Regional Anaesthesia: Regional anaesthesia techniques have been used for many years for pain relief
in the first stage of labour. Epidural analgesia is the
most popular and effective method.10 Although the
safety of epidural anaesthesia is well documented,11,12
it is important to recognize the effect it has on the
progress of labour.13,14 Centres should use relatively
low concentrations of local anaesthetics in attempts
to minimize motor blockade while maintaining good
pain control. This philosophy should allow the
woman more freedom of movement in the first stage
and eliminate the routine use of supine positioning.
Women requesting epidurals should be partners in a
thorough discussion of the procedure, its risks and
benefits and the expected outcome.
Findings should be recorded on a partogram which,
when well designed, will permit the assessment of the
progress of labour at a glance. (See Appendix 5-2: World
Health Organization Partograph.)
Slow progress in labour is not uncommon.
The SOGC Dystocia Guidelines2 suggest that a diagnosis
of dystocia be considered when less than one-half centimetre of change in cervical dilation per hour occurs over
a four hour period.
Since there is considerable variation in the normal
rate of progress in labour, and because the intra- and
inter-observer errors in cervical assessments are also
large, a reasonable length of time must be allowed in
which to make this diagnosis. Approaches to the management of slow progress in labour include: continuous professional support, upright postures in the first
stage, cervical ripening prior to induction of labour,
the use of low dose epidurals and oxytocin, and
amniotomy.2
FETAL MONITORING
As suggested in the SOGC Policy Statement on Fetal
Health Surveillance,15 monitoring of the fetus during the
active phase of the first stage of labour should be done with
intermittent fetal auscultation with a Doppler device every
15 to 30 minutes for one full minute following a contraction.
EARLY AMNIOTOMY
This document suggests reserving the use of continuous electronic fetal heart rate monitoring to situations
of non-reassuring auscultation, prolonged labour, and
labour which is induced or augmented. Fetal scalp sampling should be used in conjunction with electronic monitoring to resolve the interpretation of non-reassuring
patterns. Routine use of continuous electronic monitoring has been shown to lead to higher intervention rates
and to date, no improvement in outcome for the neonate
has been demonstrated.
Early amniotomy may be performed if the woman is
in agreement and the fetal head is well applied to the
cervix and not ballotable. The benefit of early amniotomy appears to be only that of shortening the labour.
Although variable decelerations may be more common
after amniotomy, these are usually well tolerated by a
well-grown fetus at term.2
LABOUR SUPPORT
Professional caregivers of labouring women (nurses,
midwives and physicians) are able to provide effective,
positive labour support better when labour and birthing
suites accept and practise a philosophy of care that
emphasizes:
1. respect for family choices and individual needs;
2. freedom for women to define who they consider as
family and who they would like to participate in
their care (may involve nurses/midwives and physicians working in partnership with family members,
close friends, or doulas/patient-paid labour support);
3. collaboration between health care professionals and
the woman/family in the planning and implementation of care;
MONITORING LABOUR PROGRESS
The progress of labour should be monitored at regular intervals. The caregivers should time the frequency and duration of contractions often and assess the
intensity by palpation. When the labouring woman is
using epidural anaesthesia, cervical examinations
should be performed at least every two to four hours
throughout the labour. In unmedicated labours, the
need for and timing of cervical assessments may be
based on the woman’s behaviour. If a woman experiences an overwhelming desire to bear down, an assessment should be made to determine the feasibility of her
starting to push.
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4. flexibility in the provision of care (freedom to question traditional routines seeking evidence-based
rationale, increasing alternatives and options offered
to labouring women).
BENEFITS
OF
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encouragement, and the demonstration of knowledge
have been reported by postpartum women as helpful
nursing behaviours.20,21 The perception of social support
from nurses enhances a woman’s coping efforts and
positive feelings about her labour experience.20,22
LABOUR SUPPORT
Augmented psychological support in labour appears
to have a wide range of benefits to women and can
reduce the rate of negative outcomes.16 Such an approach
will promote labour progress and decrease the use of
analgesia/anaesthesia, incidence of perineal trauma (>1°
laceration or episiotomy), rate of operative birth, maternal fever, postpartum depression, and negative ratings of
childbirth experience.16,17 Most of these studies have been
conducted in countries other than Canada, in settings
that vary greatly from Canadian labour and birthing
suites, and/or using lay women or doulas as labour support personnel.18
One study conducted in Canada using the continuous presence of self-employed “birth attendants/labour
coaches” or “lay midwives” also identified some
improved maternal outcomes.19 These authors recommend a rethinking of nursing priorities, emphasizing the
need for more such traditional care as the provision of
psychological support. Such recommendations are
applicable to Canadian models of obstetrical care where
nurses and midwives are the trained professionals already
at the bedside of labouring women.
In addition, the SOGC Policy Statement on fetal
health surveillance in labour states: “…intermittent
auscultation of the fetal heart would appear to be the
method of fetal health surveillance of choice, particularly
with regards to spontaneous labour that is progressing
normally.”15 In response to these recommendations, nurses and midwives will have to be more readily available
to women during active labour for fetal health surveillance and should be offering continuous supportive care
at the same time. Therefore, Canadian obstetrical models of care will provide a greater opportunity to offer various skill sets (both supportive and technical) by the
same nurse or midwife, decreasing fragmentation of care
while increasing continuity of holistic care. This varies
from the studies that required the use of lay people for
labour support.
Other studies have found that nursing care is a
key element in influencing satisfaction of women.20 Personalized care, respect for the mother’s/family’s opinion,
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Based on the evidence, the continuous presence of a
nurse or midwife to provide emotional, psychological,
and physical comfort measures is recommended as a key
component of all intrapartum care.
THE ART
OF
LABOUR SUPPORT TECHNIQUES
Labour support is more than simply implementing a
variety of physical comfort measures. It involves using
effective interpersonal skills and a commitment to promoting a satisfying birthing experience for the woman
and her family. What works for a woman at one point of
labour may not work at others. It is vital to assess continually the effectiveness of the various techniques and
the woman’s receptivity through observation and open
communication. Given the emphasis on interpersonal
skills throughout nursing and midwifery education, nurses and midwives are ideal professionals to be providing
labour support alongside the woman’s family. Ongoing
education and training should become a priority for
nurses and midwives offering care to labouring women.
This education should be evidence-based and involve
“hands-on” practice and the sharing of experience/techniques with one another. This can be readily achieved
through a workshop environment.
Physicians should promote a balance of “high-tech” care
and “high-touch” care by developing an understanding
of labour support and its benefits and by making women
aware prenatally about the availability of labour support
offered by nurses and midwives in Labour and Birthing
Suites.
EXAMPLES
OF
LABOUR SUPPORT TECHNIQUES
Vocalization:
Vocalization during labour is not a negative coping
mechanism. Some women find moaning or chanting to be
a way of relaxing and coping with the pain of labour. Ritual routines and repetition which women may initiate on
their own (e.g. rocking, moaning, etc.) can be an effective
means of dealing with pain and should not be interrupted
if the woman is comfortable coping in this manner.23
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Patterned Breathing:
– often used in conjunction with relaxation techniques;
– enhances relaxation;
– may provide the woman with a sense of control over
her own behaviour;
– effective comfort measure.
First Stage (Active labour, 3-7 cm)
It is important first to identify and facilitate breathing patterns that the woman may have practised prenatally. If these measures are not effective according to the
woman’s perspective, then the following breathing patterns may be encouraged.
a) Slow Breathing: Patterned breathing varies depending on the stage of labour and what works best for
the woman, which can change from time to time.
The first stage of labour usually involves slow, rhythmic breathing which tends to calm the woman while
diverting her attention somewhat away from uterine
contractions.23 Women are encouraged to take a
deep breath in through the nose or mouth then allow
the slow release of exhalation (usually at a rate of 12
breaths per minute). With every breath out she is
instructed to “blow the contraction away” and allow
her muscles to relax (useful to use in conjunction
with relaxation and visualization).
b) Light/Accelerated Breathing: Women with intense,
frequent uterine contractions may feel more comfortable with light breathing patterns. She begins
with a slow breathing pattern, then shortens and
lightens her breaths as the contraction intensifies.23
At the peak of the contraction, she is breathing
lightly through her mouth with silent breaths in and
blowing sounds out (rate of 30 to 120 breaths per
minute). As the contraction subsides, she gradually
slows down the breathing rate until the contraction
is over. In between contractions she can be encouraged to use slow breathing to maintain her energy
and promote relaxation.
Transition (7-10 cm)
This pattern of breathing is often used during transition, when the woman is experiencing the most intense
moments of labour and is no longer able to use slow
breathing. Here she may be feeling an increase in perineal/rectal pressure and a strong desire to push despite
a non-fully dilated cervix. Transitional breathing refers
to a “pant-pant-blow” pattern.23 By guiding her to take
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one deep breath in, breaking the exhalation with two
short pants followed by a longer blow to empty her lungs,
she is able to feel some release of pressure while avoiding pushing on the cervix (of particular concern in primiparous women).
Visualization (Guided and Self-Guided Imagery):
– decreases anxiety;
– promotes a feeling of security and comfort;
– provides a distraction;
– promotes relaxation.
Guided imagery involves assisting the woman to visualize herself in a different situation, away from the experience of labour (e.g. at a beach, in a forest, climbing a
mountain). She is walked through the image and assisted
to imagine the sights, sounds, and smells of the scene. Selfguided imagery occurs when the woman imagines a place
or time personal to her that brings with this memory positive, peaceful feelings. Here she guides herself through
this experience. She may imagine her cervix slowly opening or the descent of the fetus.24 Encouraging women to
listen to their body cues and “tune into the baby” can be
a liberating experience.25 Women may vary as to which,
if either, type of imagery is useful to them. Visualization
can be implemented together with touch and other techniques to promote relaxation (may be useful between or
during contractions).
Relaxation:
Relaxation is the common goal of most support techniques. It provides the woman with an opportunity to reenergize and gain a sense of control over her body and
mind. Progressive muscle relaxation can be effective in
achieving this goal. This is done by encouraging the
woman to take a deep breath in and as she exhales, letting all of the muscles in her face “go limp” and relaxed,
then the neck, shoulders, arms, and so forth down to her
toes. This occurs over a period of several contractions
while focusing on new muscle groups with each contraction. The Roving Body Check can also be incorporated into muscle relaxation by focusing on specific areas
of tension, such as the neck and shoulders, with the
woman’s support person(s) putting light pressure on
these areas, allowing the woman to “let go” either
between or during contractions.23
Touch and Massage:
Touch is a universal way of communicating. Touch
can convey caring, acceptance, support, comfort, and
competence.26 It may range from a gentle pat, stroking a
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lock of hair, light massage (sometimes called effleurage)
to a tight embrace. Studies have shown that women find
touch helpful in coping with labour.27
Other Labour Support Techniques:
– Hydrotherapy—showers, Jacuzzis, tub baths (see
Appendix 5-1);
– Counterpressure (often over lower back);
– Body positioning (the woman chooses positions most
comfortable to her);
– Hot/Cold Packs to lower abdomen/groin or perineum (hot packs are not recommended if the
woman has an epidural);
– Transcutaneous Nerve Stimulation (positioned on
abdomen and/or back);
– Music Therapy;
– Birthing Ball (a rubber ball of 65 cm diameter, available through most physiotherapy catalogues at a cost
of about $30.00). The woman sits on this ball in a
supported squatting position with minimal counterpressure to the perineum (much like sitting on a toilet). Her support person is placed in a chair either
behind or facing the labouring woman while she is
free to rock back and forth or bounce gently. This
assists in promoting rhythmic movement, distraction, relaxation, and may improve the dimensions of
the pelvis (increasing the pelvic diameters), thus promoting labour progress and fetal descent.
▼
focusing education and time solely on the technical
aspects of labour, nurses and midwives must continue to
develop their abilities to provide expert labour support
alongside the woman’s family. This does not simply
involve implementation of various techniques, but must
also follow a philosophy of respect for the woman/family, flexibility in routines, and emotional and physical support through the ongoing presence of a nurse or midwife.
Summary of Recommendations
1. Based on the demonstrated improved outcomes, the
continuous presence of a nurse or midwife to provide
psychological support and comfort measures should
be a key component of all intrapartum care.
– May require an increase in nursing staff or flexibility
of staffing, increasing the availability of nurses at
peak periods.19
2. Ongoing education and training of existing health
care professionals (nurses, midwives and physicians)
regarding the benefits of labour support and various
comfort measures and options that should be offered
to labouring women.
–
Involves a shift in focus of care from “high tech” to
“high touch”, leading to greater balance of care.
–
Must have the support of administrators and
physicians throughout this ongoing process.
3. The provision of a supportive environment that
embraces and practises a family-centred philosophy
and approach to care outlined earlier in this document.
COMMON MEASURES USEFUL IN OFFERING
LABOUR SUPPORT
– Needs to be developed using a collaborative, interdisciplinary approach with consumer representation.
– Patterned Breathing – Body Positioning
– Visualization
– Hot/Cold Packs
– Relaxation
– Transcutaneous Nerve Stimulation
– Hydrotherapy
– Music Therapy
REFERENCES
– Counterpressure
– Birthing Ball
1.
2.
Note: Psychological/emotional support must accompany all physical labour support.
3.
CONCLUSION
As technology has rapidly progressed throughout
health care, so has the emphasis on “high-tech” aspects
of care. Nursing priorities often reflect this trend, as evidenced by the frequency of monitoring and epidurals.
When the beneficial outcomes of continuous labour support are considered, the need for nurses to reprioritize
and balance their care must be recognized.19 Rather than
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4.
5.
6.
48
Bennett VR, Brown LK, eds. Myles textbook for midwives,
11th ed. New York: Churchill Livingston, 1989.
Society of Obstetricians and Gynaecologists of Canada.
Policy Statement: Dystocia. Journal SOGC
1995;17(10):985-1001.
Romney ML, Gordon H. Is your enema really necessary?
Br Med J 1981;282:1269-71.
Drayton S, Rees C. They know what they’re doing. Nursing Mirror. 1984;159:4-8.
Kantor HI, Rember R, Tabio P, Buchanon R. Value of shaving the pudendal-perineal area in delivery preparation.
Obstet Gynecol 1965;25:509-12.
Johnston RA, Sidall RS. Is the usual method of preparing
patients for delivery beneficial or necessary? Am J Obstet
Gynecol 1992;4:645-50.
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7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
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Reeder S, Masroianni L, Martin L, Fitzpatrick E. Maternity
Nursing, 13th ed. New York: JB Lippincott, 1976.
DeKornfeld TJ, Pearson JW, Lasagna L.
Methotrimeprazine in the treatment of labour pain. N
Engl J Med 1964;270:391-94.
Cullhed S, Lofstrom B. Obstetrics analgesia with
pethidine and scopolamine. Lancet 1961;1:75-77.
Harrison RF, Shore M, Woods T, Mathews G, Gardiner J,
Unwin A. A comparative study of transcutaneous electrical nerve stimulation (TENS), entonox, pethidine + promazine and lumbar epidural for pain relief in labour. Acta
Obstet Gynecol Scand 1987;66:9-14.
Reynolds F. Epidural analgesia in obstetrics. Br Med J
1989;299:751-52.
Noble AD, Craft IL, Bootes JAH, Edwards PA, Thomas
DJ, Mills KL. Continuous lumbar epidural analgesia using
bupivicaine: A study of the fetus and newborn child. Br J
Obstet Gynaecol 1971; 78:559-63.
Paterson CM, Saunders N St.G, Wadworth J. The characteristics of the second stage of labour in 25,069 singleton
deliveries in the North West Thames Health Region in
1988. Br J Obstet Gynaecol 1992;99:377-80.
Howell C, Chalmers I. A review of prospectively
controlled comparisons of epidural with non-epidural
forms of pain relief during labour. Int J Obstet Anaesth
1992;93(1):110.
The Society of Obstetricians and Gynaecologists of Canada. Policy Statement: Fetal health surveillance in labour.
Journal SOGC 1995;17(9):859-901.
Hodnett ED. Support from caregivers during childbirth.
In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP,
eds. Pregnancy and Childbirth Module, Cochrane
database of systematic reviews: Review No. 03871, 12
May 1993. Published through Cochrane Updates
on Disk, Oxford: Update Software, 1993,
Disk Issue 2.
Keirse M, Enkin M, Lumley J. Social and professional support during childbirth. In: Chalmers I, Enkin M, Keirse M,
eds. Effective care in pregnancy and childbirth. Oxford
University Press. 1989(1991):805-19.
Klaus MH, Kennell JH, Klaus PH. In: Mothering the mother.
New York: Addison-Wesley Publishing Company. 1993.
Hodnett ED, Osborn RW. Effects of continuous
intrapartum professional support on childbirth outcomes.
Research in Nursing and Health 1989;2:289-97.
Field PA. Maternity nurses: How parents see us. International Journal of Nursing Studies 1987; 24(3):191-99.
Bryanton J, Fraser-Davey H, Sullivan P. Women’s perceptions of nursing support during labour. JOGNN
1993;23:638-43.
Simkin P. Just another day in a woman’s life? Women’s
long term perceptions of their first birth experience. Part
1. Birth 1991;18:204-10.
Simkin P. The birth partner. Boston: The Harvard
Common Press. 1989.
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24. Cassidy J. A picture-perfect birth. Registered Nurse
1993;6:45-46.
25. Northrup C. Women’s bodies, women’s wisdom. Toronto: Bantam Books. 1994:403.
26. Weaver DF. Nurse’s views on the meaning of touch in
obstetrical nursing practice. JOGNN 1990;19(2):157.
27. Birch ER. The experience of touch received during
labour. Journal of Nurse-Midwifery 1986; 31:270-76.
APPENDIX 5-1
HYDROTHERAPY
Aside from providing support, there is good evidence
of the beneficial effect from showers, Jacuzzis, and tub
baths. Types of tub baths range, depending on the facility, from regular Jacuzzi baths similar to home Jacuzzis to
larger tubs that allow the woman greater mobility and
choice of positions.
The bath water is maintained at approximately 37
degrees Celsius to minimize vasodilation and dehydration.1 Fluid intake or sucking ice chips should be encouraged to compensate for the increased diuresis noted with
tub use. Length of labour does not seem to be affected by
the use of tub baths. It has been suggested that a
decreased perception will lead to decreased adrenaline
production, allowing oxytocin and endorphin levels to
rise.1-3 The result may be increased comfort and a more
(coordinated) regular uterine contraction pattern. Some
authors report that the frequency of uterine contractions
may decrease in some women when Jacuzzis are used during latent labour. This option is generally encouraged
once active labour is established.1 This approach should
be individualized for each woman based on her preference, pattern and stage of labour. Syntocinon and
administration of prostaglandin during hydrotherapy
have not been adequately studied. However, one centre
considers syntocinon a contraindication for tub baths
due to a potential risk of hyperstimulation.1 This same
centre does allow tub use for women being induced with
prostaglandin E2 gel once the fetus has been monitored
for two hours following insertion of the gel.
THE BATHS: MATERNAL/FETAL INFECTIONS
Maternal and fetal infections have also been considered in the literature about tub baths. The potential
sources for infection of the uterus and/or fetus are organisms originating from the woman herself, or from previous users of the tub. Such organisms might migrate up
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into the reproductive tract.4 Of all the studies reviewed,
none have reported an increase in maternal or fetal
infections directly related to use of Jacuzzis in labour,
regardless of membrane integrity.2-6 It is likely that the
length of time with ruptured membranes is of greater
importance than the use of tubs in labour.4 In one Canadian randomized, controlled trial of Jacuzzi use in labour,
the authors reported no increased incidence of maternal
or fetal infections in the group with ruptured membranes
and they recommend this pain relief option.5
CLEANING
OF
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Other strategies for helping women in labour include
labour support techniques (see section on other labour
support techniques), including various positions for
labour and birth, and physical support. All options
should be made available in all birthing facilities.
REFERENCES
1.
2.
TUBS
3.
Because the types of Jacuzzis/tubs found in each facility may vary, so too will the appropriate method of cleaning. Labour and birthing suites can collaborate with
Infection Control Departments within their centre to
determine methods of cleaning and tracking infection
rates related to the use of tubs. One article describes the
cleaning of tubs at their facility.1 The tubs are 3-1/2 feet
by 2 feet and 20 inches deep. They are filled with water
until the jets are covered and then one cup of chlorine
bleach is added and the jets are turned on. Water is circulated through the plumbing for several minutes. Next,
the tub is drained and surface cleaned with a nonabrasive cleanser. Finally, the tub is rinsed and labelled
“clean”. Weekly cultures taken from their tubs showed
no increased organism count.
The literature indicates a slight increase in maternal
temperature and fetal heart rates for approximately fifteen to thirty minutes after tub use.2 Maternal vital signs
should be assessed and recorded prior to entry into the
Jacuzzi and about thirty minutes following use. The fetal
heart can be auscultated during the first stage using a
hand held Doppler or fetoscope. The woman must lift
her abdomen out of the water by either standing, sitting
on the edge of the tub or tilting (lifting) her abdomen
out of the water.
4.
5.
6.
7.
Aderhold KJ, Perry L. Jet hydrotherapy for labour and postpartum pain relief. Maternal Child Nursing 1991;16:97-99.
Schorn MN, McAllister JL, Blanco JD. Water immersion
and the effect on labour. Journal of Nurse Midwifery
1993;38:336-42.
Lenstrop C, Schantz A, Feder E, Roseno H, Hertel J.
Warm tub bath during delivery. Acta Obstet Gynecol
Scand 1987;66:709-12.
Waldenstrom U, Nilsson C. Warm tub bath after spontaneous rupture of membranes. Birth: Issues in Perinatal
and Neonatal Nursing 1992;19(2):57-63.
Rush J, Burlock S, Lambert K, Loosley-Millman M, Hutchison B, Enkin M. Cochrane Data Base: Effects of whirlpool
baths in labour, 1995.
Odent M. Birth under water. Lancet 1983;2:1476-77.
Milner I. Water baths for pain relief in labour. Nursing
times 1988;6:84.
Conclusion
The use of tub baths during labour appears to enhance
relaxation and provides another pain relief option for
women. The choice should be an informed one with
appropriate teaching by the physician, nurse or midwife
regarding the importance of fluid intake and continued
fetal health surveillance. Tub therapy can be used in conjunction with various other labour support measures such
as touch, visualization and patterned breathing.
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APPENDIX 5-2
▼
▼
PARTOGRAPH
Name
Date of admission
Gravida
Time of admission
180
170
Fetal 160
heart 150
rate 140
130
120
110
100
Liqour
Moulding
10
Para
Hospital no.
Ruptured membranes
hours
Active Phase
9
8
t
er
Al
7
Cervix (cm)
[Plot X]
6
n
tio
Ac
5
4
3
Descent
of head
[Plot 0]
Latent Phase
2
1
Hours 0
1
2
3
4
5
6
7
8
9 10
11 12 13 14 15 16 17 18 19 20
21 22 23 24
Time
5
4
3
2
1
Oxytocin U/L
drops/min
Contractions
per 10 mins
Drugs given
and IV fluids
180
170
160
150
140
130
120
110
100
90
80
70
60
Pulse
and
BP
o
Temp C
{
protein
WHO 93503
Urine
acetone
volume
Source: Maternal Health and Safe Motherhood Programme—Division of Family Health, World Health Organization, Geneva, 1994
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Chapter 6
SECOND STAGE OF LABOUR
The definition of the second stage of labour has traditionally been a simple anatomic one and as such,
includes the period of time from full cervical dilation to
the birth of the baby. This definition has perhaps been
artificial and if strictly adhered to, may result in unnecessary intervention. It does not take into account the fact
that labour is a process and that the progress of labour
must be viewed as a continuum. When the evidence is
examined for effective care during the second stage, particularly focusing on birth as a physiologic event, a definition of the second stage emerges which additionally
takes into account the onset of the spontaneous urge to
push and the station of the presenting part of the infant.1
Because these conditions vary from patient to
patient, individualized management of the second stage
becomes essential. It thus becomes important for
providers to be responsive to cues from the woman rather
than providing arbitrary routine directions, while at the
same time being knowledgeable and aware of the parameters of maternal and fetal safety and best practice. This
section will attempt to outline what is known about
these considerations and thus provide a guide for individualized and optimal care. The concepts already outlined for first stage management—that of provision of
caring, responsive professional support—are obviously
also the foundations for care during the second stage.
researcher on physiologic second stage) recommends not
to encourage pushing until the presenting part is at 0 to
+1 station.2 Others recommend using such upright positions as squatting or sitting on the toilet to encourage
the bearing down reflex if none is experienced within 10
to 20 minutes.3 If there is an irresistible urge to push, the
woman may be “permitted”, although not encouraged,
to push if the cervix is soft, 8 to 9 cm, and the fetal position (occipito-transverse or occipito-anterior) seems
favourable for descent. These conditions are particularly
applicable to multiparous women.
In general, pushing with cervical dilation less than
eight to nine cm and occipito-posterior (OP) position of
the fetus, and especially in primigravida, should be discouraged as this may lead to cervical injury. Measures
should be taken (knee-chest position, transitional
breathing, improved analgesia) to alleviate the parturient’s distress if the urge is irresistible.
In an observational study of women allowed to follow spontaneous bearing-down efforts without instruction, Roberts has shown that they exhibited three to five
relatively brief (four to six second) bearing-down efforts
with each contraction, with the number of bearing-down
efforts increasing as second stage progressed. Most of
these efforts (75 percent) were accompanied by the
release of air and with several breaths between efforts.2
This is in contrast to the sustained bearing-down efforts
involving the Valsalva manoeuvre which are commonly
encouraged in most obstetrical units.
The evidence from controlled trials comparing these
two methods of pushing shows a slightly longer duration
of second stage for the “physiologic” pushing in two of
three trials, with the difference ranging from 12 to 19 minutes greater.4 Nevertheless, studies of cord blood gas results
showed higher pH values for the group of women whose
WHEN TO PUSH/HOW TO PUSH
The urge to bear down occurs spontaneously in most
births and is thought to be due to the Ferguson reflex.
This reflex is triggered when the fetal presenting part distends the pelvic floor, stimulating stretch receptors and
the release of oxytocin. It may not always be associated
with full dilation of the cervix. If the cervix is fully dilated and there is no urge to push, Roberts (a prominent
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bearing-down efforts did not exceed six seconds than those
who were accompanied by sustained breath holding.5,6
These results, while not statistically significant, imply a
trend consistent with observations that show that the Valsalva manoeuvre, particularly in combination with supine
position, may alter cardiovascular dynamics which could
compromise fetal oxygenation. Other factors which may
make the “physiologic” method of pushing more beneficial may be that allowing the woman to follow her body’s
spontaneous urges helps her to feel in control and more
satisfied with the accomplishment of the birth.
Some women may also experience a phenomenon of
“holding back” at the beginning of the second stage
which can be related to fears and ambivalence about this
transition to new motherhood. The birth attendants
should be aware of this “holding back behaviour,”
acknowledge it and allow the woman to express her fears
or ambivalence.7 This recognition will allow the woman
to proceed to the completion of the birth process with
strength and confidence.
Although specific coaching for pushing is often helpful, especially for primigravida and patients with epidurals, caregivers should be sensitive about being too
directive or overbearing in their attitude and allow the
woman space to summon her own resources.
fetal and maternal points of view. Most trials show a
modest decrease in the length of second stage for an
upright versus recumbent position, likely related to
improved uterine contractility. Mean umbilical arterial
pH has been shown to be higher in babies born to
women who had used the upright posture for delivery.4
In addition, upright postures favour descent and have
been shown to result in improved efficiency of pushing.
Mothers themselves also prefer this position as being
more comfortable, and facilitating bonding.
The traditional lithotomy position commonly used
in obstetric units can certainly be modified to obtain a
semi-sitting posture and hence achieve the benefit
derived from the upright position. This can be facilitated readily with currently available models of birthing
beds which allow individualization of posture and foot
placement. Older style beds can also be adapted for this
purpose by using specially constructed wedges. Strapping
women’s legs in restrictive stirrups in the supine position
is to be avoided.
LEFT LATERAL
Supporting a woman in physiologic pushing (3-5
shorter [4-6 second] bearing-down efforts per contraction) has some definite advantages from a psychological perspective, as well as possible advantages for
fetal well-being. It may result in a marginally longer
second stage but this in itself is not detrimental and
may in fact have advantages of allowing slower, steadier distension of the pelvic floor with decreased risk of
tears or episiotomy.
Pushing should not generally be encouraged until
the cervix has reached full dilation and the presenting
part has reached a station of 0 to +1 and/or there is a
strong urge to push. Second stage management is therefore individualized depending on these factors.
The squatting position has two advantages. First, it
maximizes bearing-down efforts by allowing the uterus
to fall forward with the force of gravity, thereby straightening the longitudinal axis of the birth canal and facilitating the descent of the fetus.9 Squatting has also been
shown radiographically to increase the pelvic outlet measurements by 0.5 to 1.5 cm.10 Flexing the thighs against
the abdomen also contributes to increasing the diameter of the pelvis in the sagittal plane and thus the sitting,
SEMI-SITTING POSTURE
There is clear evidence that adopting an upright or
semi-sitting posture for delivery is advantageous from
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SIMS’ POSITION
SQUATTING POSITION
MATERNAL POSITION
OR
OR
The left lateral or Sims’ position also avoids the
adverse haemodynamic effects of the supine position and
results in the delivery of less acidotic babies. Irwin, in a
presentation of his own experiences of 102 deliveries
using the left lateral position, reports that “the delivery
technique is easily mastered, most easily applied for spontaneous or uncomplicated outlet forceps, of special
advantage in breech deliveries, congestive heart failure,
hip joint restriction and leg varicosities; and well accepted by women looking for less restricted and more natural delivery experience.”8 He gives some specific and
practical advice in this paper for those interested in
working with this position.
CONCLUSION
UPRIGHT
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semi-sitting and exaggerated lithotomy positions retain
some of these mechanical advantages, although the last
of these loses the added benefits of the upright position.
Squatting for delivery has been perceived as inconvenient for birth attendants, and uncomfortable for North
American women unused to assuming this position.
Nevertheless, recent adaptations of standard birthing
beds with squatting bars, as well as other practical techniques for adapting hospital obstetrics to this position,
have been described.10,11
DELIVERY
ON
occur in the water, it is imperative that the baby’s head
is lifted out of the water as soon as it is born. Deaths of
babies (in a home setting) have been reported when the
baby was kept submerged for many minutes because of
the mistaken impression that if the umbilical cord is pulsating, fetal oxygenation was still occurring.16
CONCLUSION
Women should be free to choose a position that is
comfortable for them and enhances pushing efforts and
delivery. Upright (semi-sitting, squatting) and left lateral postures have many points in their favour, and
should be encouraged. In contrast, the traditional lithotomy position has distinct disadvantages and should
therefore be reserved for cases of operative delivery.
The lithotomy position can often be modified to a semisitting position for most purposes to avoid the adverse
haemodynamic consequences of supine position and to
benefit, at least in part, from a more upright posture.
ALL FOURS
“Delivery on all fours” is another choice of delivery position. This approach is popular practice among
midwives, and may be a reasonable option for some
women. The effects on duration of second stage and fetal
well-being have not been studied, however, some birth
attendants believe that the position may be particularly
useful in facilitating spontaneous rotation of persistent
OP position. “When a gravid woman is placed in a
hands-and-knees posture, the heaviest part of the fetus
or back is in a superior position to other fetal parts. If
gravitational and buoyancy forces are sufficient, the fetal
body will rotate.”12 Although not of proven benefit, this
may be a useful position to try.
BIRTHING CHAIRS
OR
DURATION OF THE SECOND STAGE
Historically, the upper limits of the second stage
have been set at two hours for primigravida and one hour
for multigravida. The reason for setting such limits has
been the association between prolonged second stage
with such undesirable outcomes as perinatal mortality
and maternal morbidity from postpartum haemorrhage
and infection. However, the question remains: in the
absence of any indication of fetal or maternal problems, is it necessary to curtail the length of second stage
to an arbitrary time limit? The results of two trials indicate that limiting the length of time of the second stage
can result in overall higher cord artery pH, probably
because of the normal decline with time over the course
of labour.17,18 It has also been shown that the duration of
“bearing-down period” plays a more important role in
influencing fetal outcome than the duration of the whole
second stage of labour.19 This fact is particularly pertinent to patients with epidurals and others who, because
of insufficient fetal descent in the presence of full dilation, may not have been encouraged to push at the onset
of “defined” second stage. Length of second stage and
fetal condition at the time of birth could also be influenced by the method of bearing down and maternal position. In studies with pushing as related to epidurals, there
seems to be no advantage to mother or baby in encouraging a policy of bearing down early in the second stage.
STOOLS
Birthing chairs or stools have been developed
because of the known benefits of the upright position,
but these devices have been shown to be associated with
an increased risk of postpartum haemorrhage,13-15 probably secondary to perineal trauma (prolonged use results
in excessive perineal edema). Use of a birthing chair is
not the recommended way of adopting an upright position in labour.
WATER BIRTHS
Water births have become a choice for a number
of women in some hospitals in Europe, England and
North America. Pools for this purpose range from simple portable pools filled and emptied with hose pipes to
built-in Jacuzzi-style baths. They are large enough for the
woman to move around and the water is about three feet
deep so she can submerge herself. There is evidence that
such baths promote relaxation and result in a decreased
need for analgesia.16 Water temperature is best maintained at about 37°C. If the birth itself is allowed to
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prognostic significance of variable decelerations
described “atypical variables as predictive of a high incidence of fetal acidosis and low Apgar scores. Prognostically, unfavourable decelerations with features indicative
of fetal hypoxia include: slow return of FHR to baseline,
loss of variability during and between the deceleration,
loss of initial and/or secondary acceleration, persistence
of secondary accelerations (over-shoot), continuation of
the FHR at a lower level and biphasic deceleration.”23
It has been shown that a longer duration of a non-reassuring fetal heart rate tracing is more predictive of acidosis. In one study, only 16 percent of patients with
non-reassuring tracings (severe late or variable decelerations) had an initial pH in the acidotic range. The remaining cases showed a remarkably low incidence of acidosis
in the first 120 minutes of abnormal tracing. The incidence of acidosis reported associated with an abnormal
FHR (severe late or variable decelerations) varies between
30 and 60 percent. When only cases of FHR lasting for
more than 120 minutes were analyzed, the incidence of
acidosis was found to be 78 percent.24 This emphasizes the
importance of confirming abnormal tracings with fetal
scalp pH measurements and repeating this test every 20
to 30 minutes if non-reassuring fetal monitor tracings persist. It is speculated that in the majority of situations in
which the fetus is exposed to hypoxic stress, the levels are
mild enough for compensatory mechanisms to maintain
acid-base homeostasis, while at the same time exhibiting
changes in the fetal heart rate pattern. With the passage
of time—and this amount of time is variable depending
on the pre-existing state of the fetus—these compensatory mechanisms will be overwhelmed and acidosis will
develop. A term low-risk fetus can be expected to withstand a longer period (90-100 minutes in this study) of this
stress than a fetus who may be compromised by IUGR or
prematurity.24 It should be noted that the limited correlation between fetal metabolic acidosis and immediate
and long-term morbidity commonly reported is not surprising and indeed desirable, indicating the fetal hypoxia
has been identified at an early stage before fetal compromise has occurred. On the other hand, these are at-risk
infants in whom, if the pathophysiological process is
allowed to continue, morbidity or mortality will result.25
An arbitrary time limit for the second stage is not necessary. Maternal status, fetal status and rate of descent
should be the basis of individualizing delivery management. Failure of descent and fetal distress are indicators
for intervention. Second stage durations that fall out of
the normal range should cause the practitioner to be
especially alert to the diagnosis of a problem of disproportion or malposition. Interventions would depend on
the clinical situation and include position change, augmentation with oxytocin, episiotomy, forceps delivery or
vacuum extraction, or Caesarean section. If progress is
being made and in the absence of evidence of fetal compromise there is no necessity for intervention.
MONITORING FETAL HEALTH
As stated in the SOGC Fetal Health Surveillance
document,20 the preferred method of fetal health surveillance for low risk women during labour in birthing
units with one-to-one nursing is intermittent fetal auscultation using either stethoscope or hand-held Doppler.
Such auscultation should occur immediately after a contraction for a full minute and be performed and documented every 15 to 30 minutes in the active phase of the
first stage of labour and every five minutes in the second
stage of labour once the patient has begun pushing.
If the auscultated fetal heart rate (FHR) gives cause
for concern, then a continuous record of FHR should be
obtained using electronic fetal monitoring (EFM). A
reduction or absence of amniotic fluid before labour and
the appearance of meconium are indications for continuous FHR monitoring during labour. Fetal scalp blood
sampling will be appropriate if the EFM record also causes concern.
Although a non-reassuring FHR tracing is a sensitive indicator that there is a problem with the fetus, the
predictive value of such tracings has been low because of
a large number of false positive results. “Fetal heart rate
tracings that are most likely to be associated with fetal
acidosis are marked patterns of total decelerations (i.e.
>30 percent of contractions are associated with a deceleration) and moderate and marked patterns of late decelerations.”21 Variable decelerations often occur in the
presence of normal fetal acid-base state. There is evidence that as the frequency of variable decelerations
increases, a correlation with fetal hypoxia may appear.
This might be anticipated in view of the relationship
between cardiac rate and cardiac output in the fetus.22
One study which analyzed fetal heart rate tracings for
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CARE OF THE PERINEUM/DELIVERY
Minimizing trauma to the perineum is important in
order to reduce early postpartum discomfort and thus
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supported or refuted by any satisfactory methodological
studies.4
Summary
Routine monitoring by direct auscultation for one minute
should be done every five minutes following contractions
in the second stage when pushing and every 15 to 30
minutes when not pushing. If there are non-reassuring
findings on the basis of auscultation or other factors, continuous EFM is recommended. In case of non-reassuring
tracings, a fetal blood sample should be obtained to evaluate acid-base status. Non-reassuring patterns in the second stage include late decelerations, severe “atypical”
variable decelerations and/or a marked total pattern of
decelerations (>30 percent of contractions associated
with decelerations).
“There is no evidence for the advantage of routine
episiotomy.”4
The general philosophy described in these guidelines has espoused a more physiologic approach to second stage management. This philosophy of intervening
only for clear maternal and fetal indications will tend
to minimize perineal trauma during childbirth. Adopting more upright position, “physiologic” pushing, no
definite time limits on the second stage, and an unhurried, gentle delivery of the head (short pushing efforts
with periods of panting) will allow the tissues to relax
and distend and therefore be much less likely to sustain
injury.
Time is an important factor—while a healthy term fetus
can withstand some hypoxic stress over a brief period of
time, acidosis will develop with prolonged hypoxic stress.
allow the new mother to devote her energies to her
infant and to reduce long term perineal discomfort which
can give rise to sexual dysfunction. Other factors which
are of concern are damage to the anal sphincter and rectum, and damage to the muscles of the pelvic floor. Liberal use of episiotomy had been advocated since the
1900s in order to prevent such problems. In order to
address this issue, there have been three randomized controlled studies comparing restricted use of episiotomy to
routine or liberal use.26-28 In the large trial by Sleep, liberal use of episiotomy (51 percent) was not shown to
reduce the rate of serious perineal (3rd or 4th degree
tears) or vaginal trauma from the restricted episiotomy
group (10 percent episiotomy rate). Klein concluded that
“preserving the perineum intact conferred benefits in
perineal trauma prevention, perineal pain reduction,
improved sexual functioning and in avoidance of pelvic
floor relaxation. The liberal or routine use of median episiotomy fails to prevent the trauma or the pelvic floor
relaxation that it was designed to prevent.”28 In addition,
there was no difference in evidence of trauma to the fetal
head, rates of genital prolapse or long term urinary
incontinence (in restricted vs. routine use).
Temporary urinary incontinence is common postpartum and persists in many individuals. There is evidence that this is related to damage to the perineal
branch of the pudendal nerve. There is no logical reason
or evidence to show why liberal use of episiotomy should
affect this, but it is possible that pelvic floor exercise preand post-delivery could make a difference.4 The effect of
perineal massage, oil, and hot compresses has not been
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SHOULDER DELIVERY
Delivery of the shoulders occurs after they have
internally rotated to the anterior posterior (AP) diameter of the pelvis. When the mother is half-sitting, the
anterior shoulder may deliver first. In the squatting,
kneeling or left lateral position, the posterior shoulder is
often delivered first.
S H O U L D E R D Y S T O C I A 29
Shoulder dystocia is defined as impaction of the
anterior shoulder above the symphysis or inability to
deliver shoulders by usual methods. Following delivery
of the head, there is an impaction of the anterior shoulder under the symphysis pubis in the AP diameter, in
such a way that the remainder of the body cannot be
delivered. There may be a sucking back of the head
against the maternal buttocks, known as the “turtle sign”.
There may be no restitution.
Incidence increases from one in 1000 for babies
weighing less than 3500 grams to over 16 in 1000 for
babies over 4000 grams. Despite numerous studies
attempting to identify factors predicting this problem,
more than 50 percent of cases occur without anticipation or warning. Maternal obesity and post-term pregnancy are the most important risk factors.
Brachial plexus injury (Erb’s palsy) of varying degree
is common, but rarely results in permanent damage. Fractures of the clavicle (and sometimes the humerus) can
occur following overzealous manoeuvres. Most worrisome
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Adapted from SOGC’s Advances in Labour and
Risk Management (ALARM) course.
In the presence of shoulder dystocia, the following
mnemonic is helpful advice:
A Ask for help (mother, partner/coach, nursing,
colleague, anaesthesia, paediatrics)
L Lift the legs and buttocks (McRobert’s manoeuvre)
A Anterior disimpaction (suprapubic pressure)
Adduction of accessible shoulder
R Release posterior arm
M Manoeuvre of Wood’s 180°
SUMMARY OF RECOMMENDATIONS
1. The definition of start of the second stage should consider factors such as position of the presenting part
and the presence of the urge to push, in addition to
complete cervical dilation.
2. If the cervix is fully dilated and there is no urge to
push, waiting and encouraging pushing only when the
presenting part is at 0 to +1 station is recommended.
is the potential for fetal asphyxia resulting in permanent
neurological damage or even death.
Episiotomy may facilitate performance of these
manoeuvres. The physician should enlist the cooperation of the mother and her labour support partner—tell
them what you are doing and what they need to do (i.e.
hyperflex both legs). Suprapubic pressure should be
applied from the posterior aspect of the anterior shoulder to dislodge that impacted anterior shoulder into the
oblique position. The posterior arm may be released by
flexing it at the elbow by exerting pressure in the antecubital fossa, and sweeping the hand across the chest
by grasping the wrist. On occasion, fracturing the
humerus may be necessary, but this injury is preferable
to fetal asphyxia.
Cord compression is common in shoulder dystocia.
In the fetal monkey model the fetal pH drops by 0.04 per
minute when the cord is totally occluded. If all has been
well up to that time, you have seven minutes and the pH
will drop by only 0.28, which is reassuring.
Avoid the 4 Ps:
3. Women should push when they have the urge to bear
down if the cervix is fully dilated and should be allowed
to push at eight to nine cm if the cervix is soft and conditions for descent ideal (OA, 0 to 1+ station). This is
particularly the case for multipara.
4. Physiologic bearing down (several short pushes without
breath holding), while resulting in a slightly longer second stage, may result in improved maternal-fetal gas
exchange and maternal satisfaction with her birth
experience. Discussion of this type of pushing should
occur antenatally.
5. Mothers should be allowed to choose their preferred
position for second stage and delivery. Upright postures (semi-sitting, squatting) confer many benefits
including a shorter, more comfortable second stage
and improved cord artery pH values of newborns, and
should be encouraged and taught antenatally.
6. The length of the second stage should not be arbitrarily defined but should be individualized so that if there
is evidence of progress and the mother’s and the
baby’s conditions are satisfactory, there is no need for
intervention. Abnormal descent, which should be suspected but not necessarily present with excessive duration of second stage (>2 hour primigravida, >1 hour
multigravida), and fetal distress are indications for
intervention.
1. Don’t pull
2. Don’t push
3. Don’t panic
4. Don’t pivot.
7. Routine monitoring in the second stage as described in
the SOGC Fetal Health Surveillance document.20 Fetal
blood sampling is recommended if non-reassuring
heart rate tracings or other factors (meconium, oligohydramnios) indicate the need to evaluate fetal acid-base
status. If the fetal acid-base status is normal, repeat
measurements should be taken every 30 minutes if
non-reassuring fetal heart rate patterns persist.
If nothing works and all the procedures have been
tried again, then some have suggested:
1. Deliberate fracture to clavicle;
2. Symphysisiotomy;
3. Zavenelli (reversing the cardinal movements of
labour). So:
rotate
flex
rotate
push up
disengage.
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8. Episiotomy should be used only to expedite delivery in
the case of fetal compromise or maternal distress and
lack of progress.
9. In order to minimize perineal trauma, delivery of the
head should be unhurried and gentle, over the course
of several contractions, in order to allow the tissues to
relax and distend.
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21. Low et al. Intrapartum fetal asphyxia: Clinical characteristics, diagnosis and significance in relation to pattern of
development. Am J Obstet Gynecol 1977;129:857.
22. Low et al. Intrapartum fetal heart rate profiles with and
without fetal asphyxia. Am J Obstet Gynecol
1977;127:729-37.
23. Krebs et al. Intrapartum fetal heart rate monitoring: Atypical variable decelerations. Am J Obstet Gynecol
1983;145:297.
24. Fleischer A et al. The development of fetal acidosis in the
presence of an abnormal fetal heart tracing. I. The average for gestational age fetus. Am J Obstet Gynecol
1982;144:55.
25. Adamson K, Myers RE. Late deceleration of the fetal
monkey to intrapartum asphyxia. Am J Obstet Gynecol
1977;128:893.
26. Sleep J, Grant A, Garcia J, Elbourne D, Spencer J,
Chalmers I. West Berkshire perineal management trial. Br
Med J 1984;289:587-90.
27. Harrison RF, Brennan M, North PM, Reed JV, Wickham
EA. Is routine episiotomy necessary? Br Med J
1984;288:1971-75.
28. Klein MC, Gauthier RJ, Robbins JM, Kaczorowski J, Jorgensen SH, Franco ED, et al. Relationship of episiotomy
to perineal trauma and morbidity, sexual dysfunction and
pelvic floor relaxation. Am J Obstet Gynecol
1994;171:591-98.
29. Adapted from: Society of Obstetricians and Gynaecologists of Canada. Advances in Labour and Risk
Management course, 1997.
REFERENCES
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Cosner K, deJong E. Physiologic second stage labor.
MCN Jan/Feb 1993;18:38-43.
Roberts D. Analysis of involuntary bearing down efforts
during the expulsive phase of labour. J Obstet Gynecol
Neonatal Nurs 1987;16:48-55.
Mahan CS, McKay S. Are we over managing second
stage labour? Contemp Obstet Gynecol 1994;24:37-63.
Sleep J, Roberts J, Chalmers I. Care during the second
stage of labour. In: Chalmers I, Enkin M, Kierse M, eds.
Effective care in pregnancy and childbirth. Oxford University Press, 1989(1991): 1129-36.
Caldeyro-Barcia. The influence of maternal bearing down
effects during second stage on fetal well being. Birth Fam
J 1979;6:17-22.
Martinez-Lopez. Comparison of two methods of bearing
down during second stage. Paper presented at the 31st
meeting of the Society for Gynecologic Inv. 21-24 March
1984.
McKay S and Barrows T. Holding back: Maternal
readiness to give birth. MCN Sept/Oct. 1991;16.
Irwin H. Practical considerations for the routine application of left lateral Sims position for vaginal delivery. Am J
Obstet Gynecol 1978;131:129.
Liu Y. Position during labour and delivery: History and
perspective. Journal of Nurse Midwifery 1979;24(3):2326.
Loomis RJ, Taylor BI. Squatting in childbirth—A new look
at an old tradition. JOGNN Sept/Oct. 1985;406-11.
Kurokawa J, Zilkoski M. Adapting hospital obstetrics to
birth in the squatting position. Birth Summer 1985;12:2.
Andrews CM, Andrews EC. Nursing, maternal postures
and fetal position. Nursing Res. 1983; 32:336-41.
Waldenström U, Gottvall K. A randomized trial of birthing
stool or conventional semirecumbent position for
second-stage labor. Birth 1991;18(1):5-10.
Stewart P, Hillan E, Calder AA. A randomized trial to evaluate the use of a birth chair for delivery. Lancet
1983;1:1296-98.
Turner MJ, Romney ML, Webb JB, Gordon H. The
birthing chair: An obstetric hazard? J Obstet Gynecol
1986;6:232-35.
Kitzinger, S. Sheila Kitzinger’s letter from England. Birth
Sept. 1991;18(3):170-71.
Wood C, Ng KH, Hounslow D, Benning H. Time—an
important variable in normal delivery. J Obstet Gynecol
Br Commnwlth 1973;80:295-300.
Katz Z, Lancet M, Dgani R, Ben-Hur H, Zalel Y. The beneficial effect of vacuum extraction on the fetus. Acta
Obstet Gynecol Scand 1982;61:337-40.
Roberts J. Alternative positions for childbirth—Part II:
Second Stage of Labour. J of Nurse-Midwifery 1989;25:5.
Society of Obstetricians and Gynaecologists of Canada.
Policy Statement: Fetal Health Surveillance in Labour.
Journal SOGC 1995;17(9):859-901.
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Chapter 7
BABY ARRIVES
continuity and consistency of care. This philosophy
would translate into minimal separation of the mother
and baby and integration of the care and teaching given.
GENERAL PHILOSOPHY
Promotion of family-centred maternity care can be carried
out by viewing the mother-newborn as an inseparable unit.
Disruption of the close mother-child relationship during the
crucial few hours following birth is to be avoided, and
direct physical contact is strongly encouraged. The initial
mother-infant bond is the wellspring of all the infant’s subsequent attachments and is formative in the child’s sense
of security. This issue is one of attachment. Early events
have long-lasting effects. The benefit to the mother cannot
be underestimated, as this early prolonged contact with
the baby affirms her sense of accomplishment and starts to
confirm her own beliefs in her power as a mother.
MANAGEMENT AT THE TIME OF BIRTH
As the head delivers, the baby starts to clear its own
secretions because of the pressure of the vagina on the
baby’s thorax. At this point, suction is of proven benefit
only if particulate meconium is present in the amniotic
fluid, and should be abandoned in other situations. Prolonged early contact is to be strongly promoted. This may
be achieved by placing the dried newborn on the mother’s abdomen or alternatively, placing the newborn in an
infant warmer which is in close physical proximity to the
parents. The parents need to have an unobstructed view
of their newborn and to be able to touch their baby.
Cord clamping has been extensively investigated. Proponents of delay suggest the infant receives additional oxygen in the first minutes after birth. Those in favour of early
clamping suggest the increase in blood volume may aggravate jaundice in the newborn period. More study is needed
to make a strong recommendation in this regard.
The baby should be dried, whether on the mother’s
abdomen or in the infant warmer. The basic principles
of neonatal resuscitation are Dry, Stimulate, and Evaluate. The blankets surrounding the baby need to be
changed so as to be warm and dry. Handling of the baby
should be gentle, with support of the baby’s head.
Apgar scores have been a common measurement
index in the first minutes following birth. The oneminute Apgar correlates with the need for resuscitation,
but is not predictive of long-term outcome. The fiveminute Apgar has some correlation with long-term outcome and should be repeated at ten minutes if less than
six at five minutes.
Prolonged early contact is also a positive predictor
for success with breastfeeding. Separation from mothers
immediately after delivery jeopardizes successful establishment of lactation. It appears the initial prolonged
contact of mother and baby is the critical factor. Correct
positioning of the baby at its first feed (cuddle at the
breast) is very important. The issue of the duration and
frequency of feeding and the cues to the baby’s hunger
are important education issues for the mother. According to the WHO Guidelines for Baby-Friendly Hospitals, healthy breastfed newborns do not require
supplementation and the practice of distributing free
samples of formula to breastfeeding mothers should be
discouraged.
Thirst should guide healthy lactating women to
maintain their hydration. There is no evidence to suggest “pushing fluids” will increase milk supply.
This is not to say that issues of physical health should
be discounted, but all areas of care and concern could be
carried out with healthy newborns and mothers in a
combined care setting. A decrease in the number of caregivers interacting with mother and baby will increase
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Obstetrical and nursing staff working in Labour and
Delivery ideally should be trained in neonatal resuscitation programmes, and updated regularly. Each centre
should endeavour to have staff trained for support at the
time of delivery. There are various protocols established
for monitoring neonatal well-being in the first few hours
of life. These routines should NOT necessitate the separation of the mother and baby.
SUGGESTED READING
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–
–
–
–
–
–
–
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–
–
–
–
Anisfeld E et al. Early contact, social support and motherinfant bonding. Pediatrics 1983;72:79-83.
Bent RC et al. Removing meconium from the infant
trachea. Am J of Dis of Children 1992;146:1085-89.
Carlsson J et al. Early mother-child contact and nursing.
Reproduction, Nutrition and Development 1980;20:881-89.
Inch S, Garforth S. Establishing and maintaining
breastfeeding. In: Chalmers I, Enkin M, Kierse M, eds.
Effective Care in Pregnancy and Childbirth. Oxford University Press, 1989(1991):1359-73.
Chess S et al. Infant bonding—mystic or reality? J of
Orthopsychiatry 1982;52(2):213-21.
Curry MA. Maternal attachment behaviour and the mother’s self concept. Nursing Research 1982;31:73-78.
Dunlop M. Few hospitals qualify as baby friendly by promoting breast feeding—Survey. Can Med Assoc J
1995;152(1):87-90.
Ishmael A. And baby came too. Nursing 1991;4(35):12-4.
Hall V. Breast feeding in the modern health sector. Soc Sc
and Med 1990.
Tanton-Mardi W. Is routine endotracheal suction indicated? Arch of Dis in Childhood 1991;66:374-75.
Dimich I et al. Evaluation of oxygen saturation monitoring
by pulse oximetry in neonates in the delivery suite. Can J
of Anesth 1990;38:985-88.
Kerem E et al. Effect of E-T suctioning on arterial blood
gases in children. Intensive Care Medicine 1990;16(2):
95-99.
Estal P. Oro-nasal-pharyngeal suctions at birth. Journal of
Perinatal Medicine 1992;45:678-79.
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Chapter 8
THE THIRD STAGE OF LABOUR
PASSIVE MANAGEMENT
ACTIVE MANAGEMENT OF THE THIRD
STAGE OF LABOUR
Immediately after delivery of the infant, as long as
the uterus remains firm and there is no unusual bleeding, watchful waiting until the placenta is separated is
the usual practice. The height of the uterine fundus and
its consistency are ascertained, and the hand is rested on
the fundus frequently to make certain that the uterus
does not become atonic or fill up with blood behind the
separated placenta.
Some people will rub the fundus of the uterus gently, which is acceptable. The usual signs of placental separation should be recognized. If the placenta is felt
digitally to be in the lower uterine segment, gentle traction on the umbilical cord is permitted to pull the placenta from the uterus after separation, or the mother may
be asked to bear down. Aristotle appears to have been
the first person to have advocated cord traction as a
means of expediting delivery of the placenta.1
Because of the spectre of postpartum haemorrhage,
which continues to dominate the management of the
third stage, it is widely acceptable to be involved in a certain amount of active management to reduce the rates
of postpartum haemorrhage and retained placenta. The
essential components of active management are the use
of oxytocic drugs, early clamping and division of the
umbilical cord, as well as controlled cord traction for
delivery of the placenta. If there is any excessive bleeding in the postpartum period, the source must be rapidly
determined and corrected. If it is traumatic, this will
require surgical repair. If it is due to uterine atony, the
uterus must be stimulated either by rubbing up a contraction or by the use of oxytocics. Oxytocin and
ergometrine have been the traditional means to achieve
uterine contractions. Prostaglandins have been shown
to have a dramatic effect in arresting uterine haemorrhage when all other measures have failed and it is
worthwhile for labour and delivery units to keep
prostaglandins on hand in case all else fails.2
In the United Kingdom and in other countries, it has
now become standard teaching to advocate routine oxytocin administration before delivery of the placenta for
managing the third stage of labour. Nine trials have been
published comparing women who did not and who did
receive oxytocic preparations and the data suggest that
routine administration of oxytocics decreases the frequency of postpartum haemorrhage by 40 percent. 3
There is also some suggestion from these limited data
that routine administration of oxytocics reduces the risk
of retained placenta.3 There is an increase in the risk of
PLACENTAL EXPRESSION
Placental expression or excessive uterine massage
should never be used before placental separation lest
uterine inversion occur. Draining of the umbilical cord
will diminish the amount of blood left in the placenta
and decrease fetal/maternal transfusion, and this is especially important in Rh-negative mothers. Routine manual removal of the placenta, routine manual exploration
of the uterus, and routine examination of the cervix is
extremely discomforting to the patient and should be discouraged unless there is active uterine bleeding. In this
case, a general anaesthetic or some strong anaesthesia
will be required to do this examination correctly.
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hypertension if ergometrine is used. Maternal deaths
from cardiovascular complications have been reported,
but they are so rare and the available randomized trials
cannot provide useful estimates of the extent to which
they may be attributed to the use of the oxytocin agent.
haemorrhage rate.8 Three other trials showed that free placental drainage after early cord clamping is associated with
a reduced risk of feto-maternal transfusion.9 Fifteen controlled trials compared the effects of different cord management practices on the neonate.10 Haematological indices
confirm that early cord clamping reduces the extent of placental transfusion to the baby. Babies born after early cord
clamping have lower haemoglobin values, however, the difference in haemoglobin levels virtually disappears by six
weeks of age and is undetectable six months after birth.
Two trials had suggested that late cord clamping resulted
in less neonatal respiratory distress, but the effects were not
statistically significant.11 In four out of five trials in which
neonatal bilirubin levels were measured, they were lower
in the babies born after early cord clamping.12 Two trials of
the effect of early cord clamping on neonatal jaundice were
flawed and did not provide conclusive evidence.
On balance, the evidence supports the routine of oxytocin
administration with delivery of the anterior shoulder.
RETAINED PLACENTA
Retained placenta is the failure of the placenta to
deliver before a certain time limit. The limit leading to
diagnosis is not consistently defined, but Beischer &
Mackay allowed 20 minutes.4 Few would dispute the diagnosis after an hour has elapsed. The conventional treatment of retained placenta is manual removal following
digital separation of the placenta from the uterine wall,
usually under either general anaesthesia or epidural block.
Selinger et al noted that waiting 60 minutes before resorting to manual removal will decrease by almost half the
number of women who will require this procedure.5
CONCLUSION
Early cord clamping reduces the length of the third
stage of labour. The available evidence does not reveal
any effect on blood loss or postpartum haemorrhage.
In Rh-negative women, it should be avoided due to the
increased risk of feto-maternal transfusion.
INVERSION OF THE UTERUS
This will occur as a result of excessive cord traction
in the presence of a relaxed uterus or with vigorous fundal pressure. Treatment involves replacement of the
inversion manually with the patient under some form of
anaesthesia.
REPAIR OF PERINEAL TRAUMA AFTER
CHILDBIRTH
Seventy percent of women are likely to require repair
of perineal trauma following childbirth, and even three
months later as many as 20 percent may still have problems such as dyspareunia, likely to be related to perineal
trauma and its repair. Suture materials used for perineal
repair in a random sample of fifty English maternity units
studied included plain catgut, chromic catgut, polyglycolic acid (Dexon), polyglycolic acid plus lactic acid
(Vicryl), glycerol-impregnated catgut (Softgut) silk and
nylon.13 Chromic catgut for all layers was the most popular, being the choice in 50 per cent of the units surveyed.
No controlled studies have comprehensively compared the various techniques for perineal repair. Four controlled studies showed that continuous, subcuticular
sutures are associated with less pain than interrupted transcutaneous sutures in the immediate postpartum period.14
There was no substantial difference in respect of long term
pain and dyspareunia. In one trial, 18 percent of the
women who had continuous sutures and 29 percent of the
women who had interrupted sutures had to have them
EARLY CLAMPING AND DIVISION OF
THE UMBILICAL CORD
Precisely when the umbilical cord should be ligated
and divided has been a controversial matter for many years.
Active management of the third stage of labour usually
entails clamping and dividing the umbilical cord relatively early, prior to beginning controlled cord traction. There
appears to be general agreement that delayed cord clamping is associated with placental transfusion to the baby
varying between 20 and 50 percent of neonatal blood volume, depending on when the cord is clamped and at what
level the baby is held prior to the clamping. The results of
two trials confirm that early cord clamping leads to heavier placentae and a higher mean residual placental blood
volume. However, both trials concluded that early cord
clamping reduces the length of the third stage.6-7
Three trial reports showed no statistically significant
effect of the timing of cord clamping on the postpartum
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removed in the first 10 days postpartum, and a further 26
percent and 37 percent respectively had to have the
sutures removed during the first three months after delivery.15 However, 30 percent of the repairs in this trial were
performed by midwives.
In choosing which absorbable suture to use for perineal repair, seven studies showed that perineal pain and
dyspareunia were equally common in the groups three
months after delivery. Comparisons of catgut and polyglycolic acid when used to repair all layers have shown
lower use of analgesia and less pain in the immediate
postpartum period, as well as less requirement for resuturing, in the polyglycolic acid group.16
Polyglycolic acid sutures cause minimal tissue reaction
and this contrasts with chromic catgut and silk, both of
which elicit a polymorphonuclear reaction. Dexon and
Vicryl have been compared in various studies and different knotting techniques are required for the two materials. The two materials have comparable losses of tensile
strength, with 50 percent loss in 20 days and 100 percent
in 30 days. Other studies have compared absorbable with
non-absorbable sutures such as silk, and they showed less
pain and analgesia in the polyglycolic acid group in the
short term but no clear difference in the longer term.
The skills of the operator are as important, if not
more important, than the materials and techniques used,
and the British Royal College of Midwives’ Representatives meeting in 1985 “deplored the fact that repair of
episiotomy is still undertaken by medical students and
junior obstetricians.” However, they obviously ignored
the fact that the Southmead trial, where midwives had
performed 30 percent of the repairs, required the patients
having half their sutures removed in 20 to 30 percent of
cases within the first three months after delivery.15 This
reinforces the notion that the skill of the person performing episiotomy is important.
SUMMARY OF RECOMMENDATIONS
1. The implications for current practice show that evidence from controlled trials supports the routine use
of oxytocic drugs in the third stage of labour, because
they give a reduced risk of postpartum haemorrhage,
which risk is in the order of 30 to 40 percent. This
advantage must be weighed against the relatively
small risk of hypertension and the disadvantages
attending the routine use of injections.
2. The evidence available provides no support for the
continued prophylactic use of ergometrine. This drug
offers no advantage over oxytocin in reducing blood
loss and it is associated with a greater risk of hypertension and vomiting.
3. Early cord clamping reduces the length of the third
stage of labour. The available evidence does not
reveal any effect on blood loss or postpartum haemorrhage. In Rh- negative women it should be avoided
due to the increased risk of feto-maternal transfusion.
4. Active management of the third stage of labour is superior to expectant management by virtue of its significant
protective effect against postpartum haemorrhage.
5. On the basis of current available research evidence,
polyglycolic acid sutures (Dexon, Vicryl or Monocryl)
should be chosen for both deep layers and skin and a
continuous subcuticulous stitch appears to be preferable to interrupted transcutaneous sutures.
5.
6.
7.
8.
9.
10.
11.
12.
13.
REFERENCES
1.
2.
3.
4.
Aristotle. The complete works. London: E. Wilson, 1786.
Thiery M. Prostaglandins for the treatment of hypotonic
postpartum haemorrhage. In: Prostaglandin perspectives,
1986;2:10.
Prendeville W, Elbourne D. Care during the third stage of
labour. In: Chalmers I, Enkin M, Kierse M, eds. Effective
care in pregnancy and childbirth. Oxford University Press,
1989(1991); 1145-69. Table 67.2.
Beischer NA, Mackay EV. Obstetrics and the Newborn.
Eastbourne: Balliere Tindall. 1986; 360 & 375.
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14.
15.
16.
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Selinger M, MacKenzie I, Dunlop P, James D. Intra-umbilical vein oxytocin in the management of retained placenta. A double-blind controlled study. J Obstet Gynaecol
1986;7:115-17.
Newton M, Mosey LM, Egli GE, Gifford WB, Hull CT.
Blood loss during and immediately after delivery. Obstet
Gynecol 1961;17:9-18.
Phillip AGS. Further observations on placental
transfusion. Obstet Gynecol 1973;47:334-43.
Prendeville W and Elbourne D. Care during the third
stage of labour. In: Chalmers I, Enkin M, Kierse M, eds.
Effective care in pregnancy and childbirth. Oxford University Press, 1989(1991); 1145-69. Table 67.14.
Ibid., Table 67.15.
Ibid., Table 67.16.
Ibid., Table 67.18.
Ibid., Table 67.19.
Grant A. Repair of perineal trauma after childbirth. In:
Chalmers I, Enkin M, Kierse M, eds. Effective care in
pregnancy and childbirth. Oxford University Press,
1989(1991); 1170-81. Table 68.1.
Ibid., Table 68.2.
Mahomed K, Grant A. Southmead perineal suture trial. Br
J Obstet Gynaecol 1989;96(11): 127-80.
Grant A. Repair of perineal trauma after childbirth. In:
Chalmers I, Enkin M, Kierse M, eds. Effective care in
pregnancy and childbirth. Oxford University Press,
1989(1991); 1170-81. Table 68.7.
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Chapter 9
POSTPARTUM CARE
By providing the proper care and support, the health
care team will be able to meet the individualized educational and psychosocial needs of the families and provide
safe and effective care.
MANAGEMENT OF POSTPARTUM CARE
After the birth of the baby and completion of the
third stage of labour, most caregivers recognize a “fourth”
stage, usually lasting one to two hours, when there is a
need for closer supervision of mother and baby while
both re-adapt to their changed physiologic state. Concurrent with this, there is a time when there is a heightened responsiveness of both mother and baby to each
other, which represents an important window of opportunity for bonding and initiation of breastfeeding. The
necessary observations of vital signs, monitoring of uterine flow, and of the baby’s physiological status should
therefore be done with mother and baby together, while
simultaneously facilitating the natural process of maternal-infant interaction.
Following this, the aim of care for the mother and
newborn infant should follow along the continuum of
family-centred care, addressing the individual needs of
families while providing safe care. This includes prompt
treatment for any complications, such as haemorrhage
or infection. These complications will occur in a minority of patients and are usually apparent within the first
twenty-four hours. In the absence of such complications,
the specific and most important needs of the mother in
the postpartum period are rest, education about care of
the new baby, professional support and advice regarding
breastfeeding, and observation and advice about her own
physical status.
The baby’s specific needs are establishment of a good
feeding pattern and observation to assure normal newborn physiologic transition and absence of signs of infection or congenital problems.
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LENGTH OF HOSPITAL STAY
Length of stay (LOS) has changed remarkably over
the past two decades, reflecting the low risk of serious
postpartum complications and changing medical and
societal attitudes toward birth. There continues to be
debate about the appropriate length of stay. There have
been numerous reports, including three randomized controlled studies which have shown that early discharge
(12-48 hours post-delivery), with appropriate follow-up
in the home, results in a low and acceptable rate of readmission of mothers and babies.1,2,3 Some studies have
shown positive effects on such factors as maternal postpartum adjustment, time spent by fathers with their
infants in the immediate postnatal period, and breastfeeding success.2,4,5
Experience in some centres regarding short length of
stay (LOS) with home care for the majority of a large
group of patients have similarly shown reassuring outcomes.6
Experience in the United States with very short LOS
with no home care follow-up has shown poorer outcomes
with unacceptable rates of readmission (15 percent) for
mothers and babies.
It is appropriate to have the length of stay reflect
individualized and family needs, as previously indicated.
The vast majority of mothers and babies will have effective care with a short LOS (24 to 48 hours) if there is
early post-discharge home follow-up to address physical
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and psychological needs and ongoing teaching. This presumes that there is adequate support in the home and
the mother and baby are healthy. For those who do not
meet these requirements, a longer hospital stay may be
more appropriate. Those individuals who have greater
needs may need more prolonged or additional support at
home.
REFERENCES
1.
2.
3.
4.
5.
6.
Waldenström U, Sundelin C, Lindmark, G. Early and late
discharge after hospital birth. Uppsala Journal of Medical
Sciences 1987;92:301-14.
Carty EM, Bradley CF. A randomized controlled evaluation of early postpartum hospital discharge. Birth
1990;17:199-204.
Yanover MJ, Jones DJ, Miller MD. Perinatal care of lowrisk mothers and infants: Early discharge with home care.
N Engl J of Med 1976;294:702-5.
Waldenström U. Early and late discharge after hospital
birth: Father’s involvement in infant care. Elsevier Scientific Publishers Ireland Ltd., Early Human Development,
1988;17:19-28.
Waldenström U, Sundelin C, Lindmark G. Early and late
discharge after hospital birth: Breastfeeding. Acta Paediatrica Scandinavica, 1987;76:727-32.
Schuurmans SN, Stewart M. Healthy beginnings — The
development and implementation of an integrated community-based maternity programme in the Edmonton
capital health region. Journal SOGC 1996;18:794-99.
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