Ministry of Public Health Clinical Guide

Ministry of Public Health Clinical Practice Guide

• This document is a clinical practice guide for the attention of labor, delivery, and immediate postpartum care.
• It was produced by Ecuador's Ministry of Public Health (MSP) and the United Nations Population Fund (UNFPA) in 2015.

Clinical Practice Guide Details

• The guide falls under codes 080, 080.0, and 080.9 in the CIE-10 classification system, relating to spontaneous delivery.
• It covers normal childbirth, cephalic presentation, and unspecified single spontaneous delivery.
• It addresses procedures at the first, second, and third levels of care, including both uncomplicated and complicated deliveries, and interventions for newborns.
• It targets nurses, midwives, general and family doctors, gynecologists, obstetricians, pediatricians, neonatologists, and anesthesiologists.
• The guide also aims to serve trainees and managers of obstetric centers and targets pregnant women at low risk during labor.
• It includes interventions like monitoring labor, improving labor management, attending to delivery and immediate postpartum, caring for newborns, and referring patients when required.

Methodology

• The guide uses the ADAPTE method, incorporating guidelines such as the "Guía de Práctica Clínica Atención del Parto Normal" and "ACOG Clinical Management Guidelines for Obstetrician-Gynecologists".
• The guide is based on evidence from 2000-2014, emphasizing systematic reviews and randomized controlled trials, with some older evidence considered.
• The process included peer reviews and consensus meetings for national adaptation.

Funding and Expected Impact

• Financed by the MSP and UNFPA, this guide aims to diminish maternal and perinatal morbidity and mortality.
• All contributors affirm no conflicts of interest.
• The guide is to be updated every two years or as scientific advances dictate.

Document Structure

• The document presents questions addressed, including those related to the stages of labor, newborn care, and hospital discharge.
• It covers recommendations for healthcare staff, hygiene practices, managing labor pain, delivery positions, and interventions like episiotomies and Kristeller's maneuver.
• The manual highlights the significance of ensuring a woman's emotional well-being and adaptation to motherhood during childbirth.
• It emphasizes the importance of trained, well-equipped personnel in preventing and managing complications.
• The document is structured around five key moments, encompassing the stages of labor, newborn care, and hospital discharge.

Aim of the Guide

• It aims to present healthcare professionals with the best scientific evidence for the care of labor, delivery, postpartum, and newborns across all care levels.
• The guide is tailored to the Integrated Healthcare Model (MAIS), enhancing the primary care level and offering a family-centered strategy.

Implementation instruments

• Clinical Practice Guide
• Pocket guide
• Citizen's guide
• Manual of procedures
• Available clinical research was reviewed to formulate relevant clinical inquiries and ensure recommendations are factually accurate.

Symbols used

• E = Evidence
• R = Recommendation

Parto spontaneo definitions

• Parto espontáneo/normal/eutócico: A delivery that starts on its own, does not have any risk factors and results in a child in a cephalic (head-first) position between 37 and 42 weeks.
• Parto inducido: The process of intentionally staring labor using medicine or special procedures able to dilate the cevix.
• Parto inmaduro: Delivery that occurs between 20 and 28 weeks of the pregnancy.
• Parto pretérmino o prematuro: Delivery that occurs between 28 and 36 weeks of the pregnancy.
• Part a término: Delivery that occurs between 37 and 42 weeks of the pregnancy.
• Parto postérmino: Deliver that occurs after 42 weeks of pregnancy or 294 days, calculated using the the starting date of the most recent menstrual cycle.
• Trabajo de parto: Uterine contractions of proper duration and intensity that cause the softening and expansion of the cervix.
• Primera etapa de trabajo de parto o período de dilatación: The period from when labor starts to complete dilation.
• Fase latente del trabajo de parto: From the onset of labor and presence of contractions of variable intensity. Softening the cervix, but dilation only occurs up to 4 cm.
• Fase activa de trabajo de parto: More regular contractions that dilate the cervix, starting at a dilation more than 4 cm, progressing until complete with a 10 cm dilation.
• Segunda etapa de trabajo de parto o período expulsivo: Starts with complete dilation cervix. Alternately, it is considered to have started with full maternal pushing and dilation until birth.
• Tercera etapa de trabajo de parto o alumbramiento: Starts between birth and expulsion of the placenta.
• Prueba de trabajo de parto: Evaluate cervical change in a woman with a cephalopelvic disproportion to determine if she is appropriate for a vaginal delivery.

Reccomendations for medical staff related to the healthcare of labor (dilatación y borramiento)

• Medical facilities should promote the healthcare of labor and the parto of a woman provided that she is at low risk with competently trained staffs.
• The staff assigned to labor, parto and puerperio should be alongside the patient at all times.
• This should provide adequate support and accompaniment to the woman and the hospital.

Other Notes

• In 1985 the World Health Organization established guidance on appropriate technology to use in the parto, and in 1996 a practical guide on the care of natural parto.
• In Ecuador, an average of 300000 births happen per year, of them 15% face health concerns that are dangerous during labor.
• In 2013, ~289000 women died globally during pregnancy, parto, or immediately following.