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