Standard Labour Ward Protocol in KMCH

2. Standard Labour Ward Protocol (LWP)
Maternal Services in Khulna Medical
College Hospital
Dr. Dalia Akhter, F C P S
Assistant Professor
Department of Obstetrics and Gynaecology
Khulna Medical College

5. Introduction
The practice of obstetrics is still as art and as
such encompasses alternative approaches to
achieve the same welcome end, namely the safety
and wellbeing of both mother and child
throughout labour and after delivery
Bangladesh has made substantial progress in
reducing the maternal mortality ratio during the
last decade

6. Despite the encouraging trends MMR is
still a great concern. Main cause of these
deaths is due to Haemorrhage eclampsia,
infection, obstructed and prolonged labour
etc.
The program is established in Bangladesh
in collaboration with Government of
Bangladesh, UNFPA and OGSB.
The program is being function in 12
Medical colleges and 195 district Hospital
& Upzila Health Complex.

7. Objective
The Goals of the program: Reduction of
the leading causes of maternal death,
PPH, and eclampsia, and ensure 24
hours emergency response, Ensure
standard labour room practice through
evidence based practice

8. Contents
Evidence based prevention and treatment of PPH
Evidence based management of Eclampsia, pre-
eclampsia
Practice quality partograph
Functional and efficient OB emergency triage
system
Newborn resuscitation guided by Helping Babies
Breathe. Delayed cord clamping
Skin to Skin contact 1 hour

9. Evidence Based Care
in Normal Birth
……Name……..
……Designation …..
…….Hospital….
…….Date:..

10.  Respectful Maternity Care
 Use of Partograph
 Upright non supine and non-
lithotomy positions
 Continuous companionship
 Hydration and nutrition in labor
 Fetal Heart Rate monitoring ½
hourly
 Restricted Episiotomy
 Active management of third
stage of labour
 Delayed cord clamping
 Skin to skin for at least 1 hour
 No harmful practices
Major Recommended Evidence Based
Practices

11. Respectful Maternity Care
(RMC)
Every mother should be given respectful welcome
and greetings at labour room
Major component of RMC
Maintaining -
 Dignity & Respect
 Privacy & confidentiality
 Effective communication
 Sharing information and Informed choice
 Continuous support: emotional and comfort
measures
 No physical or verbal abuse
 Equitable care & No neglect / Discrimination
Listening to women is important to midwifery care

12. Continuous
Companionship
 Allow one companion of mother’s choice
throughout the labour
 She can help in walking and movement
 Hydration and nutrition maintained
 Position changes
 Back massage
WHO Recommendation: A companion of choice is recommended for all
women throughout labour and childbirth.

13. Hydration and nutrition in
labor
 Women need energy for childbirth
 Oral nutrition in labor is safe and facilitate
better outcomes
 Routine use of IV infusion is discouraged
 Women should be encouraged to drink and
eat soft carbohydrate during labour
WHO Recommendation: For women at low risk, oral fluid and food intake
during labour is recommended.

14. Maintaining
Partograph
 Partograph is designed for use in all settings
 Labour management should be based on
partograph

15. Pain Relief-Non
pharmacological
 Walking and mobility
 Position changes
 Breath and relax
 Back Massage
 Warm shower
 Companionship

16. Being in bed slows labor
Upright positions in first stage is
associated with:
 Shorter labor (about 1 hour 22
minutes)
 Less reported pain
 No adverse effects
• Lawrence 2009
• 2013 Cochrane systematic review
Encourage freedom of movement during labor
Walking and mobility
WHO Recommendation: Encouraging the adoption of mobility and an upright
position during labour in women at low risk is recommended

17. Supported squat:
help baby to descend
Supported kneel:
More space in the pelvis.
Good position if there is a
delay placenta delivery
Semi-sitting:
Good position for pushing
if unable to move around
much.
Birth ball kneel:
Provides more space in pelvis
All Fours:
Relieving back pain and
helping baby to rotate from
certain positions such as back-
to-back.
Hanging squat:
Provides more space
Different Labor position( 2nd
stage)

19. Judicious use of Episiotomy
 There is no evidence to support
routine episiotomy
 Routine episiotomy has no role to
prevent severe perineal trauma
 No benefit of routine episiotomy
for the baby or mother was
identified
https://www.ncbi,nlm.nih,gov/books/NBK1196
7/
Episiotomy is associated with increased-
 3rd and 4th degree lacerations
 Pain
 Healing complications
 Recto vaginal fistula
 Wound dehiscence
 Scar endometriosis
 Dyspareunia
Ref. Hartmann 2005, Carroli 2009, Frankman 2009, Jiang
et al. 2017
Restricted use of episiotomy resulted in considerable reduction in maternal morbidity:
https://pdfs.semanticscholar.org/9ef5/3a6662e822d112124848c2110345b156c884.pdf
Evidence does not support maternal benefit from routine episiotomy;
https://www.researchgate.net/publication/7868817_Outcomes_of_Routine_Episiotomy_A_Systematic_Review
WHO Recommendation: Routine use of episiotomy is not recommended for
women undergoing spontaneous birth

20. Delayed Cord Clamping
 After the cord stopped pulsing (Generally 1-3 minutes after
birth )
 DCC allows 80-100 ml blood transfer to baby (30% increase
in blood volume)
 It improves newborn hematocrit, reduce the risk of newborn
anaemia (60% increase of RBCs)
 Reduced risk of infant anemia (40-50mg iron transfer/kg body
wt.)
 The umbilical cord is very rich in stem cells that prevent
blood disorders and diseases later in life.
Hutton 2007, McDonald 2008 , Mercer 2006, Mercer 2007
WHO Recommendation: Delayed umbilical cord clamping (not earlier than 1
minute after birth) is recommended for improved maternal and infant health and
nutrition outcomes.

21. Active Management of Third Stage of
Labour
 Oxytocin Within 1 minute after birth
 Controlled Cord Traction
 Uterine Massage
WHO Recommendation :
 The use of uterotonics for the prevention of PPH during the 3rd stage of
labour is recommended for all births
 Oxytocin (10 IU, IM/IV) is the recommended uterotonic drug for the
prevention of PPH
 In settings where oxytocin is unavailable, the use of other injectable
uterotonics (if appropriate, ergometrine/ methylergometrine, or the fixed drug
combination of oxytocin and ergometrine) or oral misoprostol (600 µg) is
recommended.

22. Skin to Skin
Care
 Place healthy newborn directly onto
mother’s chest
 It keeps the infant warm; prevent
hypothermia
 Facilitates maternal-infant bonding
 Experience more stable heartbeat and
breathing
 Encourage breastfeeding within the 1st
hour after birth/ reduce PPH in mother
Moore 2007, Winberg 2005 • Skin-to-skin contact can be initiated in the Operation theatre
WHO Recommendation: Newborns without complications should be kept in
skin-to-skin contact (SSC) with their mothers during the 1st hour after birth to
prevent hypothermia and promote breast feeding

23. Triage

27. Treat patients and their families in the
way I would like to be
teated

28. Conclusion
Ultimately achieved a safe delivery without
injury to mother or baby. As far as is safely
possible
Eventually the purpose of the program is to
provide optimal service for women in labor
and the key element of this approach is to
reduce maternal and perinatal mortality and
morbidity