EINC Recommended Practices in Intrapartum Care: Hand Hygiene, Partograph Use and Active Management of the Third Stage of Labor (AMTSL)



Hand Hygiene

Hand hygiene is perhaps the single most important and effective measure to prevent nosocomial infections and antimicrobial resistance in hospital settings. It is a general term that refers to either handwashing, antiseptic handwash, antiseptic handrub, or surgical hand antisepsis. Despite substantial evidence that it reduces the incidence of infections, adherence to hand hygiene by health-care workers’ remains low at an average of 40 %.  Contributing factors are dryness and irritation caused by handwashing agents, inconveniently located sinks, lack of soap and paper towels, lack of time, understaffing and overcrowding, and the patient needs taking priority.  Thus, easy, timely access to both hand hygiene and skin protection is necessary for satisfactory hand hygiene behavior. Alcohol-based hand rubs may be better than traditional handwashing as they require less time, act faster, are less irritating and contribute to sustained improvement in compliance associated with decreased infection rates.  All institutions should prioritize improving hand hygiene by providing appropriate administrative support and financial resources to this end. Strategies that are both multimodal and multidisciplinary should be utilized to improve compliance.



Sources: Pittet D. Improving Adherence to hand Hygiene Practice: A Multidisciplinary Approach. Emerging Infectious Diseases, Vol. 7 No. 2, March-April 2001, pp.240. Guideline for Hand Hygiene in Health Care Settings. MMWR 2002; vol. 51 no. RR16: 1-44.




Partograph Use

The partograph is a tool that can be used to assess the progress of labor and to identify when intervention is necessary. Studies have shown that using the partograph  can be highly effective in reducing complications from prolonged labor for the mother (postpartum hemorrhage, sepsis, uterine rupture and its sequelae) and for the newborn (asphyxia, infection, death).  As part of the safe motherhood initiative, the World Health Organization (WHO) promoted and produced a partograph with a view to improving labor management and reducing maternal and fetal morbidity and mortality.  Partograph use was recommended by Wall as one of the simple, affordable and effective approaches to reduce intrapartum-related neonatal deaths in low-resource settings. Mathai in 2009 stated that when used with defined management protocols, the partograph can effectively monitor labor and prevent obstructed labor. 



Sources: Wall SN et al. Reducing intrapartum-related neonatal deaths in low- and middle-income countries – what works? Semin Perinatol 2010 Dec: 34(6): 397-407. Review.
Mathai M. The partograph for the prevention of obstructed labor. Clin Obstet Gynecol 2009 Jun: 52 (2): 256-69.



Active Management of the Third Stage of Labor (AMTSL)


Postpartum hemorrhage is one of the leading causes of maternal mortality, and active management of the third stage of labor (AMTSL) has been promoted as an effective intervention in preventing excessive bleeding among facility-based deliveries.  The usual components of AMTSL include administration of uterotonic agents, controlled cord traction and uterine massage after delivery of the placenta. 

In a 2010 Cochrane systematic review by Begley et al, AMTSL was more effective than expectant management in preventing blood loss, severe postpartum hemorrhage (RR 0.34, 95% CI 0.14 - 0.87), low maternal hemoglobin after birth (RR 0.50, 95% CI 0.30 - 0.83) and prolonged third stage of labor. There was no identifiable difference in Apgar scores less than 7 at 5 minutes.  However, there were reported adverse effects in the mother such as increases in diastolic blood pressure, after-pains, use of analgesia and more women returning to hospital with bleeding. There was also a decrease in the baby's birthweight with active management, reflecting the lower blood volume from interference with placental transfusion. It is important to note that in this review, immediate cord clamping was practiced rather than the properly timed cord clamping after the cessation of cord pulsations that is part of the EINC protocol. It is now recommended that use of ergots be avoided and immediate cord clamping be deferred to prevent hypertension and decrease in the baby’s blood volume. The Bristol and Hinchingbrooke trials concluded that with physiologic management there is an increased risk of PPH and an increased need of blood transfusion; with active management there was no increase in the entrapment of the placenta, with oxytocin as the drug of choice.



Sources: Prendiville et al, The Bristol third stage trial: active versus physiological management of the third stage of labor. BMJ 297: 1295-1300.

Begley CM et al. Active versus expectant management for women in the third stage of labor. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD007412.

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