Safe Delivery

Introduction to Safe Delivery and the Clean Birth Kit

Safe delivery practices drastically reduce maternal and neonatal mortality, particularly in resource-limited settings across Nigeria. The Clean Birth Kit serves as a vital intervention to prevent puerperal sepsis and neonatal tetanus during home deliveries or under-resourced clinic environments. Each standard kit contains specific items designed to maintain asepsis at the point of birth.

• Soap: Used by the birth attendant to wash hands thoroughly before conducting any examinations.
• Plastic sheet: Placed under the mother to create a clean surface and prevent contamination from the ground or bed.
• Cord tie: Used to securely ligate the umbilical cord before severance.
• New blade: Ensures a sterile, sharp instrument is used to cut the umbilical cord, preventing tetanus spores.
• Clean cloth: Used to dry and wrap the newborn immediately after birth to prevent heat loss.

Preparation of the Delivery Environment and Equipment

A well-prepared delivery room minimizes stress and ensures rapid response to emergencies. The environment must be warm, well-lit, and draft-free to protect both the laboring mother and the newborn from hypothermia. Midwives must organize all necessary instruments before the second stage begins.

Essential equipment includes sterile delivery packs, suction apparatus, oxygen supply, and emergency drugs like oxytocin. Handwashing facilities with running water and soap or alcohol-based hand rub must be accessible. Privacy and a calm atmosphere support the psychological well-being of the mother throughout her labor progression.

Monitoring and Assessment During Labour

Continuous monitoring during labour detects deviations from normal physiological progress early. The partograph remains the golden tool for tracking maternal and fetal well-being alongside cervical dilation.

• Fetal heart rate: Auscultated every 30 minutes in the first stage and every 5 minutes in the second stage using a Pinard stethoscope or Doppler.
• Contraction frequency: Counted over a 10-minute window to assess uterine activity and resting tone.
• Maternal vital signs: Blood pressure and pulse checked every four hours, or hourly if membranes have ruptured.
• Vaginal examinations: Performed periodically to evaluate cervical effacement, dilation, and fetal station.

The Clean Delivery Process and Essential Cleans

The concept of the six cleans guides safe birth attendants to eliminate infection sources during delivery. These protocols dictate actions before, during, and immediately after the baby is born.

1. Clean hands: Proper hand hygiene with soap and water.
2. Clean surface: Sanitized or protected delivery bed.
3. Clean perineum: Washing the vulva and perineal area with safe water and antiseptic.
4. Clean cord cutting instrument: Sterile blade or scissors.
5. Clean cord tie: Clean thread or plastic clamp.
6. Clean anything on the cord: Nothing applied to the cord stump post-delivery.

Applying substances like saliva, mud, or dirty oil to the umbilical stump introduces tetanus and severe sepsis. Midwives must educate family members against traditional cord practices.

Immediate Care of the Newborn and Apgar Scoring

Immediate newborn care focuses on establishing independent breathing and maintaining normal body temperature. Upon delivery, the infant is placed skin-to-skin on the mother's chest, provided breathing is established.

The Apgar score evaluates the physical condition of the newborn at 1 minute and 5 minutes after birth. It grades five criteria from 0 to 2:

Scores below 7 at 5 minutes require continued evaluation and potential resuscitation measures.

Management of the Third Stage of Labour and Prevention of PPH

The third stage spans from the birth of the baby until the complete expulsion of the placenta and membranes. Active Management of the Third Stage of Labour (AMTSL) is the single most effective intervention for preventing postpartum hemorrhage (PPH), a leading cause of maternal mortality.

AMTSL consists of three core steps:

1. Administration of a uterotonic: 10 international units of oxytocin given intramuscularly within one minute of birth.
2. Controlled cord traction: Gentle pulling of the cord with counter-pressure on the uterus once signs of placental separation appear.
3. Uterine massage: Massaging the fundus immediately after placental delivery to ensure it remains contracted.

Failing to administer oxytocin promptly significantly increases the risk of uterine atony and life-threatening blood loss.

Identification and Emergency Management of Intrapartum Complications

Intrapartum complications can escalate rapidly, threatening maternal and fetal survival. Midwives must recognize emergency signs early to institute prompt lifesaving measures.

• Postpartum Hemorrhage (PPH): Blood loss exceeding 500ml after vaginal birth, managed through bimanual compression, empty bladder, and uterotonics.
• Shoulder Dystocia: Anterior shoulder trapped behind the pubic bone, managed using the McRoberts maneuver and suprapubic pressure.
• Cord Prolapse: Umbilical cord slipping below the presenting part, requiring knee-chest position and immediate emergency cesarean section.
• Uterine Rupture: Sudden severe abdominal pain with cessation of contractions and fetal distress, requiring immediate surgical intervention.

Postnatal Maternal Care and Documentation

Postnatal care begins immediately after the delivery of the placenta. The mother requires close monitoring for at least two hours in the delivery suite because most primary postpartum hemorrhages occur during this window.

Essential assessments include checking uterine tone, lochia amount, perineal integrity, bladder distension, and vital signs every 15 minutes for the first hour, then every 30 minutes for the second hour. Accurate clinical documentation of all stages of labor, medications administered, blood loss estimates, and newborn condition is legally required and ensures seamless continuity of care.