Nekemte Health Science Collage

Department of Health Extension

Nekemte
Oct, 2024

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 Labour and Delivery care

FOR HEALTH EXTENSION

LEVEL –IV
Prepared By G.F (BSC/MPH)

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 LO1. Promote Institutional Delivery

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 Learning Outcomes for LO-1

At the end of this session, the trainees will be able to:

• Recognize and discuss local birthing practices and cultural beliefs
with women
• Discuss roles, relationships and responsibilities to support safe
birthing
• Discuss institutional versus home delivery

• Identify and discuss signs and symptoms of onset of labour

• Arrange all possible ways of transportation to facilitate

institutional delivery
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LO1. Promote Institutional Delivery
• Definition of terms
• Cultural Beliefs: Culture is socially acquired and
transmitted or shared characteristics of a given group,
community and nation which can affect the health of the
individual in several ways
• Health promotion: is any planned combination of
educational, environmental, regulatory or organizational
mechanisms that support actions and conditions of living
conducive to the health of individuals, groups, and
communities

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 Definition ……..

• Home delivery: When a mother gave birth at her home or others’

home (neighbor, relatives, or family) or when a birth takes place
outside of health institution.
• It is Non - institutional delivery.
• Institutional delivery: Is a delivery, attended by skilled health
professional in a healthcare facility.
• Institutional deliveries or facility-based births are often promoted
for reducing maternal and neo-natal mortality.
• Skill birth attendant: is a health professional who provides basic
and emergency care to women and their newborn during
pregnancy, childbirth and the postpartum period.

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 Overview of Institutional Delivery
 Approximately 15% of all pregnant women develop a potentially life-
threatening complication that calls for skilled care and some will
require a major obstetrical intervention, which demands for
institutional delivery to survive.
 According WHO and other organization, in the year of 2017,
 295, 000 maternal deaths occurred globally from preventable
complications that occurred during pregnancy and childbirth.

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 Cont…..
 94 % of the maternal death occurred in developing
countries
 86 % of the total death occurred in South Asia and Sub-
Sahara Africa.
 Studies done by WHO in 2017 ,the proportion of
deliveries attended by skilled health providers rose from
58 % to 1990 to 80 % in 2017 worldwide.
 But remained at only about 50 % in Africa. This number
indicates that is why high number of maternal death rate.

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1.1. Identifying local birth practices and cultural beliefs
 Traditional cultural practices reflect values and beliefs held by
members of a community for periods often spanning generations
followed by different population groups such practices could be
beneficial,harmful or neutral
 Women experience certain beliefs relating to diet, behavior, use
of medicinal herbs and massaging the abdomen during their
pregnancy and childbirth

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 Cont……
• Pregnancy, childbirth and postpartum care are practiced in different
ways in different cultures.
• In many cultures, other women, mother in law, woman’s mother
and sister can attend the childbirth.
• As a HEW, be familiar with those cultural beliefs and customs in
order to promote beneficial cultures with positive outcomes for
both mother and child to discourage those cultural beliefs which
has negative effects.
• Provide positive reinforcement for women who previously
delivered at health institution
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 Cont…..

• The importance of ensuring the availability and accessibility of

skilled care during pregnancy and childbirth is highly promoted to
avoid most of the maternal deaths occurring from preventable birth
complications.
• Factors like unavailability of the service, inadequate number of
skilled personnel, geographical inaccessibility of facilities and poor
quality of care and Women do not know the importance of
institutional.
• The perception of woman that institutional delivery is unfriendly
and not in line with their belief, culture and religion is also another
factor affecting institutional delivery
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1.2. Roles, relationships and responsibilities to support safe birthing

• Respectful maternity care is a fundamental human right of pregnant

women and is a core component of the WHO intrapartum care
recommendations.
• WHO also recommends effective communication b/n health
providers and women in labour, by using of simple and culturally
appropriate language, at every stage of labour care.
• Clear explanations of procedures and their purpose should always
be provided to each woman.
• The findings of P/E should be explained
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 Cont….
• Traditional Birth Attendants‘(TBAs) assist 60% -80%
deliveries throughout the world.
• TBAs could be an important and helpful agent in advising
and referring mothers during pregnancy and delivery.
• It is also equally important for you to respect them and
their effort, acknowledge their contribution and make
them an active participant in house holds,1/5 net works,
health development army at each step of your health
promotion and communication practice.
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 1.3. Institutional versus Home delivery
• Most pregnant women in the developing world like Ethiopia receive
insufficient or no prenatal care and delivery.
• More than 7 million new born deaths are believed to result from
maternal health problems and their mismanagement.
• Stillbirths, neonatal deaths, maternal morbidity and mortality fit is
public health priorities, in Ethiopia high burden of morbidity and
mortality from poor maternal and child health outcomes
• The MMR(401/100,000- HSTP II) and only 50% of mothers deliver
with a skilled birth attendant (Min DHS 2019) as a result in high
morbidity and mortality of mothers and infants.
• 11/06/2024 LDC 14
 Cont…
• Skilled assistance during delivery Births
delivered with the assistance of doctors,
nurses/midwives, health officers, and health
extension workers.
• Most births were attended by nurses or
midwives (36%), followed by traditional birth
attendants (31%) and doctors (8%).
• In general, the percentage of births delivered
by a skilled provider increased from 11% in
2011 and 28% in 2016 to 50% in 2019
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 Advantages of Institutional delivery
 Reduced infant and maternal mortality
 Helps to recognize complication early
 Referral is immediate in case of emergency/complication
 Counseling and support are given on breastfeeding,
immunization, nutrition, personal hygiene, postnatal care ,
family planning, PMTCT and etc
 The general status of the newborn and the mother during and
after delivery is monitored
 Increased overall health status of the mother and the child
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 Giving birth at home
• When a mother gave birth at her home or when a birth
takes place outside of health institution.
• Some of the reasons for home delivery may includes
 Cultural practice, Financial problems
 Inadequate systems including a shortage of supplies and
drugs in health facilities.
 Poor quality of care , Distance of the health facilities
 Lack of transportation , All previous deliveries were at
home
 Negative attitude of staff in health facilities
 Fear about health facilities , Lack knowledge and etc

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 Promote institutional delivery

• Health extension worker could play an important role in

promoting institutional delivery by applying the principles of
health education and communication.

• You will follow the following principles and approaches in the

promotion of institutional delivery

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 Cont……
 Identify the factors/gaps for lower level of institutional delivery
in your Keble
 You should set the goal of promoting institutional delivery
 Participate all member of the community in the health promotion
activity ,make sure to involve her families, religious leaders,
respected individuals, TBA, women development army (in her 1-
5 network) and the community at large

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 Cont…..
• There are various opportunities to meet your targets like , house-
to-house visit, which will allow you to get an individual pregnant
woman, Ekube, Edir ,1-5 network of women and community
meetings could also allow you to find your targets/audience.
• Identifying your target/group will help you to adapt proper health
education method and activity that will fit your audience.

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 1.4 Signs and symptoms of onset of labour
• The same health professional will look after the pregnant woman
and her baby from the first antenatal visit until the end of the
postnatal period is known as the continuum of care
• Labour ;-is changes in anatomy and physiology in the female
reproductive tract that prepare the fetus and the placenta for delivery
• Labour announces the end of the baby’s time in the uterus and the
beginning of adaptation to life outside the mother

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 1.4.1. The indefinite nature of labour

• labour may start at any time and nobody knows exactly

• That is why even the normal onset of labour is anticipated in a

wide range of weeks.
• At Health Post level 37–40 weeks is considered the normal
‘window
• At hospital level, it can be at 37–42 weeks with close follow up
using ultrasound scanning.
• Tell her that she is probably not going to deliver on the EDD.

• Only about 2% of deliveries occur on the expected date even

among women who know their LDC
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 Causes of Normal labor

- Exact mechanism is not known.

Possible mechanisms :
A.Hormonal
1. Feto-placental theory
2. Estrogen theory
3. Prostaglandins theory
4. oxytocine theory and etc

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 Normal labour
A normal labour has the following characteristics:
• Spontaneous onset

• Rhythmic and regular uterine contractions

• Vertex presentation (the ‘crown ’ of the baby’s head is presented to the

opening cervix
• Vaginal delivery occurs without active intervention in less than 12
hours for a multigravida mother and less than 18 hours for a
primigravida (first birth)
• No maternal or fetal complications.

• Any labour that deviates from these conditions is considered abnormal

and usually requires referral for specialist
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care 24
 How do you know that true labour has begun?
True labour is characterized by ;-
 Regular
 Rhythmic and strong uterine contractions that will
increase progressively and cannot be abolished by anti-
pain medication.
• Pain symptoms may be relieved a little if the woman takes
pain killing drugs, but true labour will still progress.

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 What is adequate uterine contraction?

• If true labour is progressing, there will be adequate uterine

contraction, evaluated on the basis of three features,
frequency, the duration and the intensity of the contractions:
• The frequency of uterine contractions will be 3-5 times in every 10-
minute period.
• Each contraction lasts 40–60 seconds; this is known as the duration
of contractions.
• The woman tells you that her contractions feel strong

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 Show and leakage of amniotic fluid

During most of the pregnancy, the tiny opening in the cervix is

plugged with mucus.

• In the last few days of pregnancy, the cervix may begin to

open.

• Sometimes the mucus and a little bit of blood drip out of the
vagina. This is called show.

• It may come out all at once, like a plug, or it may leak slowly
for several days.
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 Cont….
• When you see the show, you know that the cervix is
softening, thinning and beginning to efface (open).
• Be careful not to confuse the show with the normal
discharge (wetness from the vagina) that many
women have in the two weeks before labour begins.
• That discharge is mostly clear mucus and is not
coloured a little bit red with blood.

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 Cont….
• True labour may be spontaneously established with or

without show and with or without leakage of amniotic fluid.

• When the bag of waters breaks (fetal membranes rupture),

there can be a big gush of amniotic fluid from the vagina, or

a slow leak

• If the fetal membranes rupture before labour begins, there

should only be a few hours delay before labour starts.

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 Potential complications of rupture of fetal membranes.

• If labour does not start within 6 hours after the bag of waters
breaks, there is a risk of infection entering the uterus.

• The umbilical cord may prolapse

• The cord may become trapped against the endometrial wall by

the baby which is no longer kept ‘floating’ by the amniotic
fluid.

• If the cord is compressed, the baby can develop hypoxia (low

oxygen levels) because the blood flow is restricted in the cord,
and it may die or brain damaged.
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 Helping the mother recognize a true labour

• There is no way to be sure when a woman’s labour will begin, but

there are some signs that it will start soon.
• Babies often drop lower in the mother’s belly about 2 weeks
before birth, which is known as lightening.
• Tell her that true labour is:
• Regularly and progressively increasing pushing-down pain,
which happens about 3-5 times in every 10 minutes.
• Characterized by a pushing down pain, which is usually felt first
in her lower back and moving around to the front in the lower
abdomen below her belly button.
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 Stages of labour
There are four stage of labour
• The first stage of labour (the cervical opening stage)
• The second stage of labour (the pushing stage, ending
in the birth of the baby)
• The third stage of labour (the birth of the placenta)
• The fourth stage of labour (the first 4 hours after birth).

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 First stage of labour

• Characterized by progressive opening of the cervix, which dilates

enough to let the baby out of the uterus.

• During pregnancy the cervix is long and firm, like a big toe but

the immediate effect of uterine contraction is to dilate the cervix

and shorten the lower segment of the uterus.

• The edges of the cervix gradually drawn back and are taken up.

• This process is called effacement .

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 Cont….

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effacement of the cervix. (a) before labour begins, the cervix
is not effaced. (b) cervix is 60% effaced. (c) cervix is fully
effaced

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 Cont…..
• After effacement the cervix then dilates (the diameter
gradually increases) –
this is known as cervical
dilatation.
• The first stage is divided into two phases:
• The latent and the active phase, based on how much
the cervix has dilated.

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 Latent phase
• The latent first stage is a period of time characterized by painful
uterine contractions and variable changes of the cervix, including
some degree of effacement and slower progression of dilatation up
to 4 cm for first and subsequent labours .
• During this phase, contractions may or may not be very painful
and the cervix dilates very slowly.
• The latent phase ends when the rate at which the cervix is dilating
speeds up (it dilates more quickly). This signals the start of the
active phase

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 Active phase
• The active phase is said to be when the cervix is greater
than 4 cm dilated.
• Contractions become regular, frequent and usually
painful.
• The rate of cervical dilation becomes faster and it may
increase in diameter by as much as 1.2 to 1.5 cm per
hour, but the minimum dilation rate should be at least 1
cm per hour.

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 Second stage of labour

• The second stage begins when the cervix is fully dilated (10 cm) and

is completed when the baby is completely born.

• After the cervix is fully dilated, the mother typically has the urge to

push.

• Her efforts in ‘bearing down’ with the contractions of the uterus move

the baby out through the cervix and down the vagina.

• This is known as fetal descent.

• The average duration of second stage is 1 hour and usually not longer

than 2 hours
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 Third stage of labour

• The third stage of labour is the delivery of the placenta and

membranes after the baby has been born.
• The duration is usually a maximum of 30 minutes.

Fourth stage of labour

• The first four hours immediately following placental delivery

are critical.

• This is because after the delivery of the placenta, the woman

can have torrential vaginal bleeding due to failure of uterine

contractions to close off the torn blood vessels where the

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placenta detached from the uterine wall.
 Cont…
• The placenta, membranes and umbilical cord should be examined

for completeness and for abnormalities.

• Maternal blood pressure and pulse should be recorded immediately

after delivery and every 15 minutes for the first four hours.

• Normally, after the delivery of the placenta, the uterus will become

firm due to sustained contraction, so the woman might feel strong

contractions after the birth.

• Reassure her that these contractions are healthy and help to stop the

bleeding
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 Mechanisms of normal labour

• The seven cardinal movements are the series of positional

changes made by the baby, which assist its passage through the
birth canal.

• The positional changes made by the baby are specific,

deliberate and precise.

• They allow the smallest diameter of the baby to pass through the
mother's pelvic cavity.

• The baby has the responsibility for the seven cardinal

movements.
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 1.Engagement

Engagement is when the fetal head enters into the pelvic

inlet .
• The head is said to be engaged when the biparietal
diameter (measuring ear tip to ear tip across the top of
the babys head, descends into the pelvic inlet, and the
occiput is at the level of the ischial spines in the
mother’s pelvis .

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11/06/2024 LDC 46
 2.Descent

• The term fetal descent is used to describe the

progressive downward movement of the fetal
presenting part through the pelvis.
• When there is regular and strong uterine contraction,
and the size of the babys’ head and the size of the
mother’s pelvic cavity are in proportion so the baby
can pass through, there will be continuous fetal
descent deep into the pelvic cavity.
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 Cont..
• Since the pelvic cavity is enclosed with pelvic bones,
when the uterus is strongly pushing down, occasionally
the fetal scalp bones undergo overlapping at the suture
lines in order to allow the head to pass through the
narrow space.
• This overlapping is called moulding.

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11/06/2024 LDC 49
 3.Flexion

• The movement known as flexion occurs during descent

and is brought about by the resistance felt by the baby’s
head against the soft tissues and bones of the mother’s
pelvis.
• The resistance brings about a flexion in the baby’s head
so that the chin meets the chest
• The smallest diameter of the baby’s head presents into the
pelvis.
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 4.Internal rotation

• As the head reaches the pelvic floor, it typically rotates

to accommodate the change in diameters of the pelvis
• At the pelvic inlet, the diameter of the pelvis is widest
from right to left.
• At the pelvic outlet, the diameter is widest from front to
back.
• So the baby must rotate from lying sideways to turning
its face towards the mother’s backbone
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 5.Extension

• After internal rotation is complete, the baby’s head

passes through the pelvis and a short rest occurs when
the baby’s neck is under the mother’s pubic arch.
• Then extension of the baby’s head and neck occur – the
neck extends, so the chin is no longer pressed against
the baby’s chest, and the top of the head, face and chin
are born

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 6.External rotation (restitution)

• After the head of the baby is born, there is a slight

pause in the action of labour.

• During this pause, the baby must rotate so that his/her

face moves from facing the mother’s backbone to
facing either of her inner thighs.

• This movement is called external rotation because

part of the baby is already outside the mother (it is also
called restitution).
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 7.Expulsion

Almost immediately after external rotation, the anterior

(foremost) shoulder moves out from under the pubic
bone
• The mother’s perineum becomes distended by the
posterior (second) shoulder, which is then also born
• The rest of the baby’s body is then born(expulsion),
with an upward motion of the baby’s body assisted by
the care provider.
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1.5. Arranging transportation for institutional
delivery
• Women and newborns need timely access to skilled care during

pregnancy, childbirth, and the postpartum/newborn period while

their access to care is impeded by delays, the so-called the
“Three” delays.
• These delays have many causes, including logistical and
financial concerns, unsupportive policies, gaps in services, as
well as inadequate community and family awareness, knowledge
about maternal and newborn health issues.

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 Cont..
• Delays in deciding to seek care may be caused by failure to
recognize signs of complications, failure to perceive the severity of
illness, ignorance about existing of obstetric services, cost of
transport and health care, previous negative experiences with the
healthcare system, and transportation difficulties
• Delays in reaching care may be created by the distance of health
facility or provider, distance to roads, the condition of roads, and
lack of emergency transportation.
• Delays in receiving care may result from negative attitudes of
providers, shortages of supplies and basic equipment, shortage of
healthcare personnel, and lack of knowledge and skills of
healthcare providers
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 THANK YOU!

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