skilled birth attendants, traditional birth attendants & intrapartum care karen hays, cnm, dnp-c...
TRANSCRIPT
Skilled Birth Attendants, Traditional Birth Attendants
&Intrapartum Care
Karen Hays, CNM, DNP-cGH 544
January 6, 2011
Clinical Activities: Maternal-Newborn Care
“A skilled attendant at childbirth is
the most effective
intervention…”
But what is skilled?
• photo of WHO Safe Motherhood book
WHO 1999.
Skilled Birth Attendant (SBA) W.H.O. Definition
An accredited health professional (e.g., a midwife, physician, or nurse) who has been educated & trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal period, & in the identification, management, and referral of complications in women & newborns.
An Accredited Health Professional…• Accredited – does that mean licensed? board
certified? registered? graduate of basic training program?
• What about upkeep of that credential?
3 photos of different types of skilled attendants:Cambodian nurse/midwife in birth centerRich-country obstetricianTrained traditional midwives in Guatemala
…educated & trained to proficiency in the skills…• ‘Educated’ & ‘Trained’ – either within
their primary MD, MW, RN program or as an extra training after graduation
• ‘Proficiency’ – to pass the tests in the context of the training; rarely any follow-up in real life work setting
• ‘The Skills’ – see next slide
SBA Skill Set• Prenatal Care• Intrapartum Care• Newborn Care• Postnatal Care
SBA skill set is standardized based on the country & the SBA’sscope of practice as defined by licensure/registration/tradition/hierarchy
Intrapartum Care• Infection prevention, patient rapport• Uncomplicated labor, birth, & postpartum• Normal newborn care (breastfeeding & the Warm
Chain)
• Complication prevention & management– obstructed labor – partograph, vacuum extraction*– pre-eclampsia / eclampsia– postpartum hemorrhage – AMTSL, bimanual
compression, manual vacuum aspiration*– neonatal resuscitation– sepsis (mom & baby)– post-abortion care – manual vacuum aspiration* *not always included
Rationale for the SBA Skill Set - Moms
Rationale for the SBA Skill Set - Babies
Reproduced from UNICEF ChildInfo website: http://www.childinfo.org/newborncare.html and based on Lawn, JE et al. ‘4 Million Neonatal Deaths: When? where? why?’ The Lancet, vol. 365, no. 9462, 2005, pp. 891–900.
Skill Set – Infection Prevention
photos of handwashing, gloving, cleaning instruments, etc
Skill Set - Patient RapportMother-Friendly Childbirth Initiative
Lonely women, delivering all over the world….
photos of women laboring alone and looking forlorn
SBA Skill Set: Uncomplicated Labor
Photos of women and their attendants during labor, in homes & facilities, from several different countries and resource-levels.
SBA Skill Set: Uncomplicated Delivery
Photos of normal births, at home & in facilities, with different types of attendants in different countries with different resource levels.
SBA Skill Set: Uncomplicated Postpartum
Photos of placental delivery and moms with their babies soon after birth.
SBA Skill Set: Normal Newborn Care
Photos of babies being cared for in many different countries
SBA Skill Set: Complication Prev & Tx
Photos of BPs being taken, women in trouble, book of PPH management, etc.
Two Trendy Prevention Strategies
1. The Partograph
• Graph to be used during Active Labor & 2nd Stage
• Charts – vital signs – contraction pattern– cervical dilation – fetal descent– medications given
• Purpose – to minimize delays in recognizing prolonged labor
2. Active Management of the Third Stage of Labor (AMTSL)
• Protocol for delivery of the placenta
• Includes – Use of a uterotonic
medication– Controlled cord traction– Abdominal uterine
massage after placenta out
• Purpose – to reduce risk of postpartum hemorrhage (PPH)
PARTOGRAPHRegistration No._____________ Name (Last, First)__________________________________ Age_____ Date_______________Gravida/Parity_____/______LMP________EDD_________Gestation (wks)_____ ROM (Time, Date)____/________ Labour Duration (Hrs)_____ Facility/Clinic Name________________
LIQUORMOULDING
180
8070
60
120
110
100
90
FETAL
HEART
RATE140130
170160150
190
180170160150
190
140130
120
110
100
908070
60
1010
(CM)
Plot X
DESCENT
Plot O
HOURS HOURS
TIME
5 54 4
CONTRACTIONS 3 3PER 10 MINS 2 2
1 1
Oxytocin U / LDrops / minute
DRUGS&IV FLUIDS
TEMPERATURE
AmountURINE Protein
Acetone
+1
+2
+3
-3
-2
-1
0
CERVIX
200190
0
4
180
10
9
8
7
6
5
3
2
1
807060
13012011010090
PRESSUREBLOOD
&
2
1
0
170160150140
80
PULSE
200190180170160150140130
11010090
120
7060
10
9
8
7
6
5
4
3
AMTSL• Oxytocin injection
is preferred, but misoprostol tablets are okay in places where injection skills & equipment management is not feasible.
• Early cord clamping is not required for AMTSL.
To the right – photo of AMTSL poster from India
SBA Skill Set: What’s Missing?Hint: 2 lifesaving medical procedures
SBA Skill Set: What’s Missing?Blood Transfusion & Cesarean Section
Photo of a C-section and of a woman getting a transfusion
Basic vs. Comprehensive Emergency Obstetric Care (EmOC)
• Basic EmOC for some health centers & all hospitals (SBA+ level care)– antibiotics, oxytocics, anti-convulsants, anti-
hypertensives, manual removal of placenta, manual vacuum aspiration
• Comprehensive EmOC for hospitals with surgical capacity (personnel, O.R., anesthesia)– basic EmOC capabilities– blood transfusions– Cesarean section
Why can’t SBAs and EmOC save more lives?
Reproductive Health Response in Conflict Consortium ©2005
The 3 Delays Model• Delay in
recognition of a problem
• Delay in transport to referral facility
• Delay in proper treatment at the facility
Photos of transportation difficulties and a crowded female hospital ward
Will the SBA reduce mortality in this setting?
Photo of a midwife in a dreadful facility
Other reasons for under-utilization of SBAs & EmOC• Women fear poor treatment due to political, socio-
economic, ethnic, religious, language, etc. problems• Facility reputation for poor quality services, long waiting
times, exclusion of family, male health care workers• Cost• Women unable to travel due to security, poor travel
conditions, no vehicle, or cultural restrictions• Concerns about privacy, social stigma• Status of Women – unable to obtain permission from
husband, mother-in-law, patriarch• Prefer local traditional healers – TBAs, shamans, etc.• Fatalism, attribute illness & death to supernatural forces
Will the SBA & EmOC reduce mortality for this woman?
Photo of an emaciated young mother with 2 small babies in a horrible refugee camp
Is a Traditional Birth Attendant (TBA) a Skilled Birth Attendant (SBA)?
TBAs are influential in their communities & need to be respected & included in MCH activities, even if non-literate
TBAs have a different, overlapping, & complementary skill sets
Photos of TBAs from 4 different countries
.
Integration of TBAs into the Slooow ‘Modernization’ of MCH Services
Recognition & Support
• Education – the 3 cleans (hands, surface for birth, cord cutting)
• Incorporate into facility services, e.g. Doula role
• Organize gatherings where TBAs can share knowledge & support
• Recognize ‘Big Picture’ issues before judging or trying to replace them
Photos of TBAs learning hand washing, being doulas in hospital, having a TBA meeting
It’s all so worth it!
Photo of happy mom with brand new baby on her chest.
Websites
• http://www.internationalmidwives.org
• http://www.who.int/reproductive-health/global_monitoring/skilled_attendant.html
• http://www.paho.org
• http://www.midwives.org
• http://www.hesperian.org/index.htm