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TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

TECHNICAL STANDARD FOR VERTICAL DELIVERY ASSISTANCE

Human Health Division National Program Sanitation Strategy for Sexual and Reproductive Health
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TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

Ministry of Health Library Cataloguing-in-Publication Data Technical regulation for vertical delivery care with intercultural adaptation (N.T. N 033MINSA/DGSP-V.O1) / Ministry of Health. General Directorate of Peoples Health. National Sanitation Strategy for Sexual and Reproductive Health Lima: Ministry of Health, 2005 43 p. illus. MATERNAL AND CHILD HEALTH, regulations / CULTURAL DIVERSITY / LEGISLATION, regulation / WOMANS HEALTH / LABOR, ethnol / PERU

Hecho el Depsito Legal en la Biblioteca Nacional del Per N 2006-5060

Also Published in Spanish with the title: Norma tcnica para la atencin del parto vertical con adecuacin intercultural ISBN 9972-851-22-2 Hecho el Depsito Legal N 2005-6714 Copyright 2006 1000 Units

Ministry of Health, 2006 Av. Salaverry N 801 - Jess Mara, Lima - Per Telephono: (51-1)315-6600 http://www.minsa.gob.pe webmaster@minsa.gob.pe

First Edition Edition, translation proof reading: Raquel Hurtado La Rosa, MD, MPH - Technical Assistant National Sanitation Strategy for Sexual and Reproductive Health (ESNSSR) Translation proof reading: Paulina Giusti Hundskopf, MD - Advisor to the Vice Minister of Health Translation: Alicia Mazurec de Garaycochea Flavia Lpez de Romaa Olivares

Printing: Editorial y Grfica EBRA E.I.R.L Telefax: 326-4440 ebrasa24@speedy.com.pe Lima, 30 - Per

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

PILAR MAZZETTI SOLER


MINISTER OF HEALTH

JOS DEL CARMEN SARA


VICE MINISTER OF HEALTH

LUIS PODEST GAVILANO


DIRECTOR OF THE GENERAL DIRECTORATE OF PEOPLES HEALTH

ISABEL CHAW ORTEGA


DIRECTOR HEALTH QUALITY CARE

LUCY DEL CARPIO ANCAYA


NATIONAL COORDINATION OFFICER NATIONAL SANITATION STRATEGY FOR SEXUAL AND REPRODUCTIVE HEALTH

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

This document was reviewed with the technical opinion of the following persons from the Ministry of Health, Regional Health Divisions and other Institutions: Ministry of Health: Luis E. Podest Gavilano, MD Isabel Chaw Ortega, MD Walter Ravelo, MD Lucy del Carpio, MD Raquel Hurtado, MD, MPH Marysol Campos, BS Carmen Julia Carpio, BS Carmen Mayuri, BS Jaime Moya Granda, MD Ana Borja Hernani, BS Luis Meza Santibez, MD

: : : : : : : : : : :

Director of the General Directorate of Peoples Health Director Health Quality Care Director Health Care Services National Coordination Officer of the National Sanitation Strategy for Sexual and Reproductive Health (ESNSSR) ESNSSR Technical Team ESNSSR Technical Team ESNSSR Technical Team ESNSSR Technical Team Executive Officer Health Care Services Executive Officer Comprehensive Health Care National Maternal and Perinatal Institute

Regional Health Division, Cajamarca: Enrique Marroqun Osorio, MD : Regional Health Director, Cajamarca Julio Ponce de Len Gaviln, MD : Human Health Director Roco Portal Vsquez, BS : Coordination Officer Adult Female Stage Rosa Becerra Palomino, BS : Coordination Officer Child Stage Bertha Sagstegui Gil, BS : Health Promotion Regional Health Division (DIRES) Cajamarca Martn Albn, MD : Director of the Regional Hospital of Cajamarca Carmen Sagstegui, MD : Regional Hospital of Cajamarca, Head of the OB/GYN Dep. Margarita Isla Rojas, MD : Regional Hospital of Cajamarca Julia Arista Melndez, BS : Regional Hospital of Cajamarca ntero Zavaleta Caldern, MD : Responsible of the ODSIS Mariela Chvez Aldave, BS : Coordination Officer Adult Female Stage, San Marcos 4th Network Roco Tordota Victoria,BS : Coordination Officer Adult Female Stage, San Marcos Health Care Facility Marleny Rojas Cceres, BS : Chuco Health Care Station San Marcos Network Glide Lozano Luna, BS : Huayobamba Health Care Station San Marcos 4th Network Miriam Rojas Zrate, BS : Shirac Health Care Station San Marcos 4 th Network Alicia Sigenza, BS : Cachachi Health Care Station Cajabamba 5th Network Irma Madueo Saldaa, BS : Red Hualgayoc Bambamarca, Adult Female Coord. Gloria Leyva, BS : Red Hualgayoc Bambamarca Health Care Facility Morn Lirio Santos Chvez Aguilar, BS : UNICEF Health Consultant Mara Elena Valladares, BS : NGO Crculo Solidario Regional Health Division, Cuzco: Danilo Villavicencio Muoz, MD : Juan Spelucn Runciman, MD : Mauro Vargas Len, MD : Graciela Zacaras Aguirre, MD : Javier Cuno, MD : Hilda Robles Mena, BS :

General Director Cuzco Regional Hospital of Cuzco Executive Officer Human Health Pediatrician of the Lorena Hospital Health Care Services Division Director of Comprehensive Health Care Services 5

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

Isabel Fuentes Carayhua, BS Maritza Castro, BS Gina Humpire, BS Patricia Velarde, BS Katia Catacora, MD Luis Gonzles de la Vega, MD Neptal Cueva Maza, MD Elsa Daz Rojas, BS Ins Pari Pandia, BS Rosa Llacsa Valcrcel, BS Marina Ochoa Linares, MD William Velasco, BS Elena Neyra Velarde, BS Simn Cruz, BS Marta Montalico, BS Patricia Medina, BS Vernica Huallpa, BS Nlida Vilca, BS Vctor del Carpio, MD Deisy Moscoso, BS Elizabeth Menndez, BS Patricia Velarde

: : : : : : : : : : : : : : : : : : : : : :

Director of Child Stage STI and HIV AIDS Strategy Urcos Health Care Facility Canas Canchis Network Antonio Lorena Hospital, Cuzco Regional Hospital Neonatology Manager of the Cuzco South Network Paruro Micro Network (Cuzco South) Huancarani Micro Network (Cuzco South) Paucartambo Micro Network (Cuzco South) Manager of the Cuzco North Network Coord. Officer Womans Health Area, Cuzco North Network Quispicanchi Acomayo Network Coord. Womans Health Area Ocongate Micro Network (Quispicanchi Acomayo Network). Pucyura Micro Network (La Convencin). Quimbiri Micro Network (La Convencin). Santa Teresa Micro Network Yauri Micro Network Yaurisque Micro Network UNICEF CADEP Jos Mara ArguedasLic. Red Canas Canchis

Regional Health Division, Ayacucho: Jos Quispe Prez, MD : Regional Health Director, Ayacucho Jos Anicama Barrios, MD : Human Health Director Flor de Mara Melgar, BS : Director of Comprehensive Health Care Services Rosa Pomasonco, BS : Responsible for the Sexual and Reproductive Health Strategy (SSR) of the Regional Health Division Miriam Arones Castro, BS : Center Network Digenes Salvatierra, BS : Sucre Micro Network Zulema Urbina, BS : San Jos de Secce Micro Network, Huanta Graciela Alca de la Cruz, BS : San Miguel Network Raquel Arones, BS : Sivia Micro Network Ricardo Gutirrez, BS : Vilcashuamn Micro Network Regional Health Division, San Martn: Anderson Snchez S., MD : General Health Director, San Martn Felipe Santiago Vela O., MD : Executive Officer Human Health Care Militza Huivn Grndez, BS : Coord. Officer Adult Stage ESSSR Mara Linares Sandoval, BS : Coord. Officer Adult Female Jepelacio Health Care Facility Supervisor Hilda Renee Miguel Honorio, BS : Head of the Jepelacio Health Care Facility William Bardales Vsquez, MD : Jepelacio Health Care Facility Guillermo Arteaga Zaire, MD : Jepelacio Health Care Facility Dagni Rodrguez Pinedo, BS : Jepelacio Health Care Facility Nurse technician Edgardo Rojas S. : Jepelacio Health Care Facility Mara Rosa Grate, Anthropologist : Policy Project Cidanelia Salas, BS : NGO Relachupan Peru Rosario Ruiz Santilln, MD : NGO CADES Rosa Giove, MD : Foro Salud (Health Forum) 6

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

Regional Health Division, Apurmac II: Anglica Pealoza, BS Other Institutions: Marco Martina Chvez, MD Miguel Gutirrez Ramos, MD Eduardo Maradiegue, MD Luis Tvara Orozco, MD Elena Lara Valderrama, BS Mario Tavera, MD : Regional Coord. Officer of the SSR Strategy

: Central Planning and Development Office ESSalud : Peruvian Society of Obstetrics and Gynecology : Peruvian Society of Obstetrics and Gynecology : Peruvian Society of Obstetrics and Gynecology : Dean of the Association of Obstetricians of Peru : UNICEF

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

PRESENTATION
One of the cultural practices related to child delivery is the position that the woman adopts at the moment of labor. Most Andean and Amazon women prefer the vertical position either by squatting, sitting or kneeling, among others (traditional child delivery). Health professionals have been trained to treat patients in labor in a horizontal position (lying down). These two different practices produce a cultural disagreement between the health care professionals and the rural women, who often prefer to avoid going to the health institutions, risking their wellbeing and their life, as well as their unborn babies, if any difficulties may arise. There is an important experience in vertical delivery in our country. The different cultural approach has created an important increase in the percentage of deliveries handled by the health care personnel in the last years. The last National Survey of Health and Demography, reports an increase of 24% (2000) to 44% (2004) in delivery assistance in the health care services for rural population. Within the framework of sexual and reproductive rights, where giving birth and be born are decisive moments for our future life, the Health Ministry faces the challenge to find an equilibrium between the modern hospital care and the sensitivity and significance that these events represent in the life of a large part of our population. Also, scientific evidence shows that vertical delivery is more physiological and helps the parturient in the expulsion of the infant. Consequently, the Health Ministry, through the National Sanitation Strategy for Sexual and Reproductive Health of the Human Health Division, has decided to support the initiative of the departments of Cuzco, Cajamarca, San Martn, Huancavelica, Hunuco, Ayacucho, Puno, Apurmac and Amazonas in the preparation of the Technical Standard for Vertical Delivery with Intercultural Adaptation. The purpose of this regulation is to standardize the medical assistance on vertical delivery according to international criteria and national experience, responding to the need of adjusting the health care services offered to women in order to increase institutional delivery and thus, reduce obstetric complications that cause maternal death. Therefore, when this regulation becomes official, health care professionals will be able to offer vertical delivery assistance in all health care facilities, guaranteeing quality assistance in response to the needs of all Peruvian women.

Dra. Lucy del Carpio Ancaya National Coordinator National Sanitation Strategy for Sexual and Reproductive Health

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

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TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

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TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

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TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

CONTENTS
I.II.III.IV.V.VI.INTRODUCTION ............................................ 1 5 PURPOSE ..................................................... 15 OBJETIVE .................................................... 15 SCOPE OF APPLICATION ....................................... 15 LEGAL BASIS ....................................................... 16 HISTORICAL AND EPIDEMIOLOGICAL ASPECTS ...................... 16

VII.- PHYSICOLOGICAL ASPECTS .................................. 17 COMPARED PHYSIOLOGY .................................... 17 Horizontal Delivery .......................................... 17 Vertical Delivery ................................................ 17 VIII.- DEFINITIONS ................................................ 18 Vertical delivery ...................................................... 18 Interculturality ................................................. 18 Delivery Plan ................................................. 18 IX.- VERTICAL DELIVERY ASSISTANCE ...................................................... 19 ORGANIZATION COMPONENT ..................................................... 19 Human Resources ............................................. 19 Infrastructure .................................................. 19 Equipment, medication and materials ......................................... 19 PROVISION COMPONENT ................................................ 20 Indications ..................................................... 21 Counter-indications ................................................... 21 RECEPTION OF THE EXPECTANT PREGNANT WOMAN ....................... 21 Supporting company ...................................................... 21 Meals ........................................................... 22 ASSISTANCE IN THE DILATION PHASE ....................................... 22 Procedures ....................................................... 22 Vaginal Examination ................................................. 22 Pain management .................................................... 22 Monitoring of labor progress .................................................. 23 Positions during the dilation phase ........................... 23 Relaxation and Massages ....................................................... 23 ASSISTANCE IN THE EXPULSION PHASE ...................................... 23 Asepsia and hygiene ..................................................... 24 Positions in the Expelling Period ..................................................... 24 IMMEDIATE ASSISTANCE TO THE NEWBORN ...................................... 26 CHILDBIRTH PERIOD ASSISTANCE ................................................ 26 Final Disposal of the Placenta ................................................... 26 IMMEDIATE PUERPERIAL ATTENTION ........................................ 26 Diet and Hydration ........................................... 27 13

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

COMPLICATIONS DURING VERTICAL DELIVERY ......................... GUIDANCE/POST-DELIVERY ADVISORY ............................. CRITERIA FOR DISCHARGE ............................................. REFERRAL AND COUNTER-REFERRAL ............................ CHILD DELIVERY SERVICES FLOWCHART ......................... X.-

27 27 28 28 29

BIBLIOGRAPHY ............................................................. 30 32 32 33 34 37

XI.- ANNEXES ...................................................................... Annexe 1A Delivery Plan Format ........................................ Annexe 1B Waiting my Delivery ......................................... Annexe 2 List of herbs and other products used during Labor and after Delivery .............. Annexe 3 Waiting House or Maternity Home ...........................

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TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

I.

INTRODUCTION

Within the framework of the Guidelines on Health Policy and in fulfillment of its duty to conduct, regulate and promote quality assistance proceedings, aimed at satisfying the peoples health needs, the Ministry of Health provides technical regulating instruments for compliance by health institutes country-wide. Thus, the Human Health Division has considered it necessary to develop a technical standard to facilitate adapting services in assisting vertical delivery, with an intercultural, gender, equity and respect-oriented approach with respect to the High Andean and Amazon peoples rights, seeking to improve the quality, accessibility and satisfaction of users and health care providers. The intention of addressing health assistance through these approaches is to empower people, from the rural area, in particular, by recognizing their culture within a frame of equality and respect, generating, as a result, the lifting of their self-esteem and access to health care services. The Technical Standard for Vertical Delivery with Intercultural Adaptation proposes the building of mutual enrichment bridges between occidental and traditional models which, while different in their conceptual frameworks, need not to oppose but complement one another. This implies rescuing their traditions and positioning the womens right to actively participate in the way they wish to be assisted, strengthening the affective link between the mother, the baby and the family environment. This regulation defines concepts and describes, in an organized way, the vertical delivery processes and the cultural adaptation of the health care facilities of different complexity level.

II.

PURPOSE

To improve the access of High Andean and Amazon people to health care services for quality assistance in vertical delivery with intercultural adaptation.

III.

OBJECTIVE

To establish the regulation framework for vertical delivery assistance with intercultural adaptation in the different assistance levels of the health care service network.

IV.

SCOPE OF APPLICATION

This technical standard shall be applied in Level I-4, Level II and Level III health care facilities, for vertical delivery assistance with intercultural adaptation.

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TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

V.
1. 2. 3. 4. 5. 6.

LEGAL BASIS
Law 26842, Health Law. Law 27657, Ministry of Heath Law. Supreme Decree 014-2002-SA, Ministry of Health Organization and Functions Regulations. Ministerial Order 768-2001-SA/DM Health Quality Management System. Ministerial Order 668-2004/MINSA, National Guidelines for Comprehensive Sexual and Reproductive Health Assistance. Ministerial Order 195-2005/MINSA, 2004-2006 National Sanitation Strategy for Sexual and Reproductive Health.

VI. HISTORICAL AND EPIDEMIOLOGICAL ASPECTS


Since the onset of humanity, delivery has been practiced in different vertical positions, as evidenced by engravings or sculptures of almost every culture. There are pictures illustrating chair designs used for childbirth in sitting position throughout Ancient Times, Middle Ages and the Renaissance. It was in the 17th Century that the famous Obstetrician Mauriceau made women lie down for delivery, apparently, to be able to apply the forceps, the fashionable instrument at that time. With the use of Epidural Anesthesia in the decade of the 70s, in an attempt to reduce delivery pain, the horizontal position was even more favored, since what position other than horizontal could be asked from a woman under anesthetic effect. The history of the delivery process dating back to the onset of humanity, illustrates its route with women who, for centuries, have chosen the sitting or squatting position to push; thus, refusing to recognize this evidence does not form part of mature reflection and decision taking in this respect, that is, favoring this physiological position. Biomedical approach to health care provision and the influence of urban culture consolidate womens conviction in respect of the convenience of horizontal position at the time of delivery, recognizing it as a more advanced technology. However, the influence of occidental and urban culture science is also unaware of the priorities and needs of women in general and rural women in particular, at delivery time, which they consider a natural event that does not require any intervention modifying the traditional way of delivery assistance. The vertical position traditionally used by different cultures and by a great number of ethnic groups, has finally started to spread in occidental countries: U.S.A. (Howard 1958); as well an in the Latin American region: Uruguay (Caldeyro Barcia, 1974); Brasil (Paciornik, 1979) etc. and more recently, having considered its advantages, by the World Health Organization (WHO, 1996). In Peru, assistance in vertical delivery is being implemented by regional health care facilities serving rural people, as a strategy to simplify access to maternity assistance services. The Regional Health Office (DIRESA) of Ayacucho reports that the 2,300 home deliveries that took place in 2004, which accounted for 28% of total deliveries in the Region of Ayacucho in that period, were assisted in this upright position; there have been labor experiences in the Health Care Facilities of Vilcashuamn and San Jos de Secce. The records in DIRESA Cajamarca show that 9.3% of total deliveries assisted by the health care personnel at home and at the health care facilities in 2003, were vertical deliveries. In 2004 the rate increased to 14.8%. 16

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

VII. PHYSICOLOGICAL ASPECTS


COMPARED PHYSIOLOGY Horizontal Delivery The uterus of the pregnant woman might compress the large vessels, aorta and cava vein, originating decrease of the cardiac output, hypotension and bradycardia; it may also cause alteration of the placenta irrigation, and thus, decrease of the oxygen amount the fetus receives (Aorta-Cava Compression). These translates in significant changes on the fetus beats, which may be verified by monitoring and which may lead to fetus stress if the expulsion period is extended 1. The immobilized lower limbs act as dead weight, and do not allow the pushing effort or the pelvis movements to accommodate the fetus cephalic pole diameter with the mothers pelvic diameters, thus not favoring the final expulsion. The mothers intrapelvic diameters reach their greatest values when the mothers thighs are flexed upon her own abdomen (usual practice for Shoulders Dystocia), thus the conventional horizontal position might decrease the mothers transverse and anteroposterior pelvis diameters. The uterine contractile activity tends to be weaker in horizontal position than it is in vertical position. The need to push becomes more problematic due to the requirement of a greater effort, not being favored by gravity force. Nervous compression exercised by the pressure on the legs hanging on the stirrups, besides uncomfortableness of the position, increases the adrenergic charge. Horizontal position does not allow fetal head exercise a sustained pressure on the perineum, making difficult an effective and slow distension. A lithotomy position with legs hanging, overstretches the perineum, making tearing possible.

Vertical Delivery In the vertical position, the pregnant womans uterus is not compressed, nor are the large vessels, the aorta or the cava vein and thus, there is no alteration in the mothers circulation or in the placenta irrigation; therefore the amount of oxygen received by the fetus is not affected. There is a better acid balance in the fetal basis during dilation 2 period, as well as during the expulsion period3,4, facilitating the fetus-neonatal transition5. As the lower limbs are leaning, they constitute a point of support and indirectly help with birth. There is an increase in the delivery channel diameters: 2 cm in the anteroposterior way and 1 cm in the transverse way 6 . The vertical position determines that the dive angle be less acute (more open) favoring dive and fetus progression. The positive action of gravity forces also favors dive and descent of fetus. It is estimated that the mother gains between 30-40 mm Hg in intrauterine pressure values when vertical position is

(Footnotes)
1 2

Giraldo, 1992 Arbues, 1982 3 Gallo, 1992 4 Garcia C. 1987 5 Sabatino,1992 6 Boreli, 1966

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TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

adopted 7. Likewise, the contractile action of the abdominal press and the uterine contractions favored with this position helps fetus push out towards the vulva opening as unique exit. Increased efficiency of the uterine contractions during delivery labor and expulsion period which succeed one another with less frequency but more intensity, demanding less obstetric interventions, less oxytocin use and less alteration risk of the fetus cardiac beats8. As a result of the foregoing reasons, labor and delivery process is considerably shortened in the vertical position.9 ,10, 11. Vertical delivery provides psycho-affective benefits such as less pain (or absence of same) feeling of freedom and greater satisfaction after delivery12. Women are allowed greater participation in their childrens birth, encouraging them to push in a more effective way, besides allowing a better control of the situation.

VIII. DEFINITIONS
VERTICAL DELIVERY Vertical Delivery is that in which the pregnant woman places herself in a vertical position (standing on her feet, sitting position leaning one or both knees or squatting position) while the health personnel assisting her is in front or behind the pregnant woman, waiting to assist delivery. This position allows the product, which acts as final vector resulting from the expulsion forces, to orient itself towards the delivery channel, favoring its birth, decreasing trauma effects of the newborn. INTERCULTURALITY The Pan-American Health Organization states: Interculturality is a relationship between several different cultures that takes place with respect and horizontality, where none of them, is above or below the other. The intercultural relationship aims at favoring mutual understanding between persons from different cultures, becoming aware of the way the others perceive the reality and the world of the other, thus enabling openness and mutual enrichment () Interculturality is based on dialogue, where both parts listen to each other, where both parts talk to each other and where each part takes what may be taken from the other part, or simply respects the others particularities and individualities. It is not a question of imposition or subjugation but of concerting13" DELIVERY PLAN The Delivery Plan is an effective tool that seeks to organize and mobilize family and community resources for the timely assistance of the pregnant woman, the mother who has just given birth and the newborn. The plan must set forth specific information to allow organizing the assistance process for the pregnant woman, indicating the aspects of delivery and referral if necessary. The plan provides the necessary information so that the pregnant woman and her family know where to go upon evidence of imminent delivery or alarm signals.

7 8 9 10 11 12 13

Mendez, B., 1976 Mendez B., 1975 Sabatino.1992 Paciornik, 1992 Dunn,1976 Sabatino. 1992 Araucaria Health Care Service 9th Region. Ministry of Health of Chile. First National Meeting on Health and Indigenous People. PAHO-WHO. Saavedra Chile, 1996.

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TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

IX. VERTICAL DELIVERY ASSISTANCE


ORGANIZATION COMPONENT The organization component for vertical delivery assistance with intercultural adaptation covers a set of processes and actions that allow adapting the offer of maternity services to provide health care services to cover delivery assistance requirements of women of the Andean and Amazon populations. Health care facilities must adapt and design organization proceedings that are essential to provide quality assistance in vertical delivery. Health care facilities shall consider the available resources within the area and, according to its complexity level, within the health care provider network they belong to. Human Resources The health personnel must be technically competent and have the skills required to allow them establish an empathic relationship with the parturient and their relatives since the beginning, providing a climate of safety and confidence. Human resource availability will respond to complexity level of the health care facilities and existing resources. The health care service shall have the following staff: Gynecologist-Obstetrician Physician or a General Practitioner with Competence in Obstetrics for obstetric attention. Pediatrician or a General Practitioner with Competence in Newborn care. Midwife. Nurse with Competence in Newborn care. Nurse technician with Competence to assist in Obstetrics and Newborn care. Infrastructure Room conditioning with faint light and comfortable temperature (approximately 24 degrees centigrade) providing warmth with heaters or any other heating means. Protection of windows with color curtains made of adequate local material. Painted walls in not too light colors.

Equipment, medication and materials Health care facilities must have equipment, material and medication for vertical delivery assistance. The health care service shall be equipped with the following: Full equipment for delivery assistance. Tensiometer. Stethoscope. Newborn reanimation equipment. A pediatric scale. A flexible light shield. A stretcher for vertical delivery. A wooden circular stool 30 x 45 cm tall. Two chairs. 19

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

Glass cabinet to keep medication. Heating source: heater or other heating means. Two cushions 30 cm diameter each. A small stool 50 cm tall. Metal or wooden ring installed in the ceiling. A thick, 5-meter rope. A mat on the floor covered with linen, where the child will be born. A bucket for blood reception. Hot-water bottles. A roll of cloth or wool ball, 10 x 5 wide. Cloth boots for the parturient to avoid contaminating the newborn child. Sheets for child reception. Wide robes to cover the parturient adequately. Medication set for delivery. Traditional medicines (thymolin, flower water, pink oil, Del Carmen water, orange, seven spirits water, hot infusions such as mua, lemon verbena, rue, matico leaves, oregano, celery); all these elements are considered necessary by the Andean and Amazon people to prevent complications.

The health care facility must organize the referral and counter-referral for continuity and timely assistance in case of complications during vertical delivery, pursuant to regulations in force and to provisions at local level for the service network. The reason for referral responds to the resolving capacity of each health care facility. PROVISION COMPONENT The provision component covers the set of assistance and care services that the health team offers the parturient, together with the person, family and community. For vertical delivery assistance, the pregnant woman must previously have prenatal care service, according to the national guidelines for comprehensive sexual and reproductive health assistance. In case no prenatal attention has been received, the respective routine analysis shall be requested. The health care facility providers must encourage Andean and Amazonian women to express their will with respect to the position they wish to be assisted for delivery, through the design of a Delivery Plan (Annex 1A, 1B). The delivery plan shall be designed with the participation of the pregnant woman so that she and her family will interest themselves in solving critical aspects that she may face during pregnancy and delivery, counting with family and community resources available. The delivery plan data sheet must include the following information: 20 Personal details of the pregnant woman. Probable delivery date. Health care facility visited for prenatal care. Analysis results. Location where delivery will take place. Preferred position to give birth. Transportation means available in her community. Persons who will help her in the transfer. In case blood is required, who will be the donor? If she will make use of the waiting house (Annex 3).

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

The health care professionals shall observe the clinical indications and counter-indications in order to proceed with vertical delivery assistance. Indications: Pregnant woman without obstetric complication. Cephalic presentation of fetus. Fetus-pelvic compatibility.

Counter-indications: Counter-indications for vertical delivery are all those complications that may have C-section as indication, the most frequent being: Previous C-section, one if it is of body type. Iterative C-section. Fetus-pelvic incompatibility. Fetus stress. Fetus in podalic position. Twins pregnancy. Presentation Dystocia. Cord Dystocia. Dystocia due to contraction. Fetal macrosomy. Prematurity. Bleeding in the third quarter (previous placenta or premature detachment of placenta). Premature rupture of membranes with head still high. Post-term pregnancy. Severe pre-edampsia, eclampsia. Record of complicated delivery.

RECEPTION OF THE PREGNANT WOMAN The health care personnel must offer the pregnant woman a warm welcome, explain her the procedures in a simple way, respecting her beliefs and traditions and evaluating the possibility to consider them so as to improve the health care professional relationship with the pregnant woman. Thereafter they will proceed to: Verify the information related to her pregnancy in the clinical record and Pre-natal care card (Pregnancy record). Identify alarm signals. Control vital signs: blood pressure, pulse, temperature. Practice obstetric assessment (Leopolds maneuver, uterine height, fetus beats, uterine contractions) and pelvic exam. Determine delivery labor initiation.

Supporting company: The parturient must be allowed to bring with her a companion of her choice, who may be her spouse, mother, mother-in-law, midwife or any other relative. If she is not accompanied by a relative, members of the social network of support to pregnant woman may be involved, prior consent of the parturient. 21

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

The health care personnel shall inform the relative or companion about his/her role and responsibilities during the parturient stay, in particular during delivery.

Meals: The staff shall allow for the parturient to take some light meals during labor and immediately after delivery. Meals shall be preferably warm and energetic: soups, infusions, jelly, etc. These will give her a sensation of warmth that will favor labor progress. (Annex 2).

The following are recommended14: Tea or milk with cinnamon and cloves. Hot chocolate. Basil tea. Three or four rue leaves per cup of water. On teaspoon of melissa.

The staff should be acquainted with the effect of some herbs and prevent the use of those that stress uterine contractions.

ASSISTANCE IN THE DILATION PHASE The health care personnel, according to their designated duties and competences will perform the following: Procedures: Control vital functions on an hourly basis. Evaluate cardiac fetal frequency every 30 to 45 minutes (at the beginning and immediately after each contraction). Keep a detailed record of the partogram, which will enable the health care personnel to carry out the necessary actions if complications should arise (Take into consideration that the CLAP WHO partogram record allows monitoring child delivery in vertical position).

Vaginal Examination: Will only be carried out by qualified health care personnel, with clean hands, covered by sterile gloves. The number of vaginal examinations must be limited to the strictly necessary during the dilation phase. Once every four hours is enough except in the following cases: When there is a decrease of the frequency and strength of the contractions. When there are signs that the woman wants to push. Try, when possible, to practice the vaginal tact explaining why it is necessary, and, at the same time, try to win the parturient and her familys confidence. Be prudent and tolerant when practicing this procedure.

Pain management:
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The health personnel must provide emotional support together with the companion that the parturient has chosen. Offer freedom of speech and action to the woman according to her habits.
There are diverse preparations and infusions that midwives recommend to pregnant women. As there is the possibility that we may not be aware of their collateral effects, we prefer to provide only the most commonly used, known and innocuous.

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TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

Evaluate relaxation techniques and massages. Consumption of herb infusions according to local habits. (Annex 2).

Monitoring of labor progress: The evaluation of the progress of labor is performed by observing the pregnant woman: appearance, conduct, contractions and the descent of the fetal head. The most accurate measurement is the cervix dilation. A deviation of the normal dilation rate 1 cm per hour should be a warning to review the plans for delivery and refer the parturient to a better equipped hospital facility.

Positions during the dilation phase: The woman must choose the position she prefers. The supine position is not recommended during the dilation process because it presents a number of problems from the physiological point of view. The compression of the large dorsal blood vessels interferes with circulation and diminishes the blood pressure causing a decrease of oxygen to the fetus. The contractile uterine activity becomes weaker, less frequent and the need to push becomes more difficult because it demands more effort when the force of gravity is not present. The slow descent increases speed up techniques which accelerate the process and at the same time, cause fetal stress. The coccyx is compressed against the bed and forced forward which narrows the pelvic exit making the delivery long and difficult. The woman in labor must be able to move and change positions whenever she considers necessary. The vertical position is more physiological and shortens the time for the delivery process in 25%. Walking or standing stimulates contractions, helps the descent of the fetus and the dilation of the cervix making contractions more efficient and less painful. This is why many women feel the need to walk helped by their companions. The only exception that supports the supine position during the dilation process is when the membranes have broken when the head is still high.

Relaxation and Massages : To give a massage, the personnel or the relatives, must have their hands warm. These will be done slowly, with the palm of the hand and the fingertips. The use of oil or talcum powder will help the hands slide and press the lumbar zone softly and evenly. This will reduce the stress and anxiety levels, control the physical and emotional stress that labor causes, recover energy for the next contractions, reduce muscular tension and thus, reduce fatigue.

ASSISTANCE IN THE EXPULSION PHASE The staff, according to their functions and roles, will do the following: Verify the material and necessary medicine for assistance to the parturient and the newborn. Equip or verify that the labor room has the following: - Heat produced by heaters. - Stretcher or adequate chair for vertical delivery. - Rope hanging from a beam. 23

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

- A mat on the floor covered with linens where the baby will be placed. - An auxiliary small table will be provided to put all sterile equipment. Asepsia and hygiene: Verify the hygiene and cleanliness of the environment. Check if the set of instruments is decontaminated, washed and sterilized. Wash the hands carefully with soap and water before wearing the sterile gloves. Pay attention to the personal hygiene of the parturient. Carry out perineal washing using warm water and additional herbs if customary, at the beginning and repeat when necessary. If necessary, cloth boots will be placed on the parturient in order to keep the zone clean.

Positions in the Expelling Period In vertical position, the roles of health care personnel in the expelling period is limited to the reception of the baby, to the maneuvers required when the umbilical cord is trapped, to detect and help if any complications arise. The woman must be allowed to move so that she may find the position where she can have more strength to expel the fetus. The health care personnel assisting the delivery will have to adjust to the chosen position. These are the positions that a parturient may adopt: a. b. c. d. e. f. g. Squatting position: Front. Squatting position: Back. Kneeling down. Seated. Half-seated. Holding the rope. Hand and foot position (four support points).

Squatting Position: Front Is one of the positions preferred by rural women because it eases the separation of the joints between the pelvic bones increasing the pelvic diameters and thus helping the descent of the fetus through the delivery channel. The health care personnel will perform the obstetric procedures of the expelling period in a comfortable position (kneeling down, squatting or sitting in a low stool) and will help the parturient in the guided delivery. The parturient must have her legs bent and separated to improve the width of the transversal diameter of the pelvis. The midwife or relative acts as a support to the parturient, sitting on a low stool, placing the knee on the lower part of the sacrum region, holding and embracing her by the hypochondrias and epigastric region. This procedure helps adapt the position of the fetus and guides it to the vertical axe and favors the action of abdominal press.

Squatting Position: Back The health care personnel will perform the obstetric procedures of the expelling period in a comfortable position which will enable them to protect the perineum, placing their knee in the parturients inferior region of the sacrum and will later accommodate to help in the guided delivery. 24

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

The companion must sit on a chair or on the edge of the bed and hold the parturient from below the underarm region, placing his knee at the level of the diaphragm, acting as a support spot, letting the pregnant woman hold herself placing her arms around the neck of the companion.

Kneeling Down The health care personnel will practice the obstetric procedures of the expelling period, face to face with the parturient and will later accommodate to help in the guided delivery. The companion will sit on a chair or at the edge of the bed, with the legs open, separated and will embrace the parturient by the thorax letting the pregnant woman lean on her companions thighs. In this position, the parturient assumes a more rested and comfortable position while birth gets closer and helps with the obstetric procedures.

Seated and half-seated position Health care personnel will perform the obstetric procedures of the expulsion period and then will be prepared to guide delivery. The companion must sit on a chair with legs opened or kneel on the bunk-bed, holding the parturient at chest level letting her lean on his thighs or hold the neck of her companion. While in this position, the parturient must be sitting on a low chair (on a lower level than her companion) or on the edge of the bunk-bed, taking care that the mat is under her. In the half-seated position the parturient will lean on pillows or on her companion. She may sit straight or bend herself to the front on the floor or on the edge of the bed. This position will relax her and allows pelvis to open.

Holding-the-rope position This position makes maneuvering difficult when there is a circular cord or to detect any sudden complication. The health care personnel will perform the obstetric procedures of the expulsion period and then will be prepared to guide delivery. The parturient holds a rope that is suspended from a beam in the ceiling. The fetus is the favored one, as helped by the force of gravity, slides down through the birth canal smoothly and calmly.

Feet and hands position It is the preferred position for some women, particularly for the ones who experience pain in the lower part of their back. The health care personnel will perform the obstetric procedures of the expulsion period and then will be prepared to guide delivery. Some women prefer to kneel on a mat, leaning forward on their companion or on the bed. Probably when delivery is imminent the parturient must adopt a more reclined position to help control delivery. Reception of the baby shall be made from the back of the woman.

The health care personnel assisting a vertical delivery in any of the vertical positions shall instruct the parturient to practice shallow breathing (panting) to relax her body and breathe through the mouth; and to do it with the mouth closed when pushing, to increase her strength with the abdomen muscles.

25

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

IMMEDIATE ASSISTANCE TO THE NEWBORN The health care personnel shall verify the material is prepared with anticipation, as well the place where the newborn will be assisted exclusively. The newborn care shall apply the techniques and procedures established in the National Guidelines for Comprehensive Sexual and Reproductive Health Assistance. CHILDBIRTH PERIOD ASSISTANCE The health care personnel shall assist childbirth in the dorsal position (horizontal), due to the fact that the vertical position produces regular bleeding. Personnel shall: Conduct guided delivery, seeking to shorten the third period of delivery and decreasing the amount of bleeding. Apply an ampoule of intramuscular oxytocin (10 UI) immediately after childbirth. Use techniques that are customary in the rural area to help expel the placenta: Induce nausea stimulating the uvula in order to cause an effort. Blow into a bottle. Place a clip on the cord or tie it to the womans foot or leg to avoid it goes in again. Assess the vaginal bleeding volume, the uterine contraction rate, the consciousness condition of the mother and her vital signs (blood pressure, pulse). Perform a thorough evaluation to verify placenta detachment, assist in its expulsion and examine it very carefully, verifying that membranes are complete. Examine for lacerations in the vulva, vagina and/or cervix. Assess bleeding volume after childbirth. In case any complication arises during the childbirth period, parturient must be tubed using a cannula No. 18 immediately to pass sodium chloride at 9/00 and she must be transferred to a more complex health care facility (Use some other solution only in case no sodium chloride is available).

Final Disposal of the Placenta: Health care personnel must allow the family to decide about the final disposal of the placenta according to their traditions, except if the health personnel should consider that the placenta may be a contaminating factor. (VHS-AIDS and sexually transmitted infections). The personnel must understand that the burial of the placenta is an important tradition in the life of the family because they have the belief that their child did not come alone into this world, but accompanied by the placenta which they consider an organ with a life of its own. In all cases, the placenta must be handed in a sealed bag following security procedures.

IMMEDIATE PUERPERIAL ATTENTION The personnel must respect some harmless practices that the parturient and her family perform on her and on the newborn, taking into consideration the importance of the family ties that strengthen the members of the family when they get accommodations together, the mother, new-born and their family. The following procedure must be followed regardless of the place where the parturient is staying and depending on infrastructure, equipment and the amount of patients in the health care facility:

26

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

Vital functions control, tone of uterine contractions and vaginal bleeding every half hour for the first two hours. Before the woman is allowed to rest, the personnel must check the following: - Tone of uterine contraction. - Control of vital functions, blood pressure, pulse. These controls must be taken every half hour at least during the first four hours. Massages to stimulate the release of lochia (clots) and the contraction of the uterus, which provides a sense of wellbeing to the mother. Some mothers prefer to bandage their abdomens with previously prepared bandages. Make the recent mother comfortable and place her in a warm room with low light. You can provide the mother with a bed (bunk bed) of about 60 cm. high so that she can rest with her spouse or relatives. It is better to use sheets and blankets of bright or dark colors but not white because the rural women feel embarrassed when the sheets get stained. Allow the parturient to use the chumpi (sort of belt-bandage).

Diet and Hydration: Feeding will be allowed according to the needs, possibilities and traditions of the woman, encouraging them to eat healthy food using the resources in the area. The first food after delivery is a bird broth. A hyper protein diet with few spices should be observed the first days after delivery. A large amount of liquid is also recommended for breast-milk production. Take into consideration that some Andean and Amazon communities do not allow the consumption of pork, avocado, or fish at this time. Do not allow the use of alcoholic beverages.

COMPLICATIONS DURING VERTICAL DELIVERY The following complications may appear during vertical delivery: Increase of bleeding when oxytocin is not used during delivery. Tearing in the perineal area. Sudden expulsion of the fetus. Umbilical cord prolapse. Upper limbs protrusion. Shoulders dystocia.

In the event any of the above complications should occur, adequate action shall be taken according to the degree of complexity GUIDANCE/POST-DELIVERY COUNSELING Health personnel must provide information, guidance and counseling to the mother and to the family on topics related to newborn care and sexual and reproductive health care. Exclusive breastfeeding, emphasizing benefits and teaching the technique. Nutrition for the mother. Reproductive health and family planning.

27

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

Hygiene of mother and child. Newborn vaccination. Identifying alarm signs in the puerperial period. Identifying alarm signs in the newborn. Newborn care.

CRITERIA FOR DISCHARGE The general, therapeutical measures, adverse collateral effects of treatment, alarm signs to be considered, as well as criteria for discharge and prognosis, are the same as those taken into account for assistance in a horizontal eutocic delivery. REFERRAL AND COUNTER-REFERRAL If the referral of the parturient or puerperal mother should be necessary due to any complication arisen, actions shall follow the procedures and protocols pursuant to the provisions under the Ministry of Health, according to the resolving capacity of the health care facility level. Counter-referral must include the recommendations for the return of the mother to her home.

28

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

CHILD DELIVERY SERVICES FLOWCHART 158

E u to c ic d e liv e ry
Identification of pregna nt wom a n E xam ina tio n b y ph ysician

D y s to cic d e liv e ry

Doe s she requ ire delivery proceed ing?


YES

NO

Transferred to Lab or W aiting House

YES

C a n th e d e liv e ry b e a tten d e d to at th e H ea lth C a re F a cility ?

NO

Transferred to Delivery Room

Determ ine the rela tive s that w ill accom pa ny he r du ring delivery

Imm ediate Referral

Info rm the preg nant w om an abou t th e positions for child d elivery so that she m ay decide

P rovid e an enviro n with a dequ ate tem perature, offer warm solution s, ind icate re lative what his/her ro le is. M onitor delivery p rocess

YES

Doe s De livery present any com plication?

NO

Take action according to protocols an d o rder Im m edia te Referral if necessary Doe s birth and expu lsion of placen ta present any com plication?

A ssist in Vertical

D e liv e ry

YES

NO

Take action according to protocols an d order Imm ed iate Referral if necessary

A ssist in childbirth process and p rovide care to new born

A sk what will be done with the placenta, if the m other wishes, allow her to wea r support gird le and/or scarf on he r he ad.

A ss is t d urin g P u e rpe riu m

Inquire a bout sa tisfa ction of User and he r Re latives am iliares

15

Adaptation Document PSNB 2000.

29

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

BIBLIOGRAPHY
PERUVIAN Resolution 002-REG-CAJ/DRSC-DESP/AIS-MNA Rules for Implementing the Cultural Adaptation Process in the Health Care Facilities of the Cajamarca Health Division for Maternal Health Care Services, dated December 19, 2003. Directors Resolution issued by the Alto Mayo Moyobamba Health Sub-region 0100-2004/D-SRS-AMM-SGMC-UGRDHH. Pilot Program Cultural Adaptation of Maternal Health Care Services in the District of Jepelacio, dated July 19, 2004. Martina Chvez, M. Parto en posicin sentada (Sitting Position Child Delivery). Mad Medicina al da (Medicine updated) Vol.3 N 3, May 1995. Ministry of Health. National Guidelines for Comprehensive Sexual and Reproductive Health Care Lima Peru, 2004. Kruger, H., Arias Stella, J. Offprint from the Gynecology and Obstetrics Journal Vol. XIII N 3; Page 139. The Newborn and Placental Quotient in High Altitude, Dec. 1967. Vargas L., Nacarato P. De salvia y toronjil (About Sage and Melissa). CMP. Flora Tristn, 1995.

INTERNATIONAL Allister, H. Was Man more Aquatic in the Past? The New Scientist, page 642-645; March 1960. Andrews CM. Changing Fetal Position through Maternal Posturing in Raff BS ed Perinatal Parental Behavior: Nursing Research and Implications for Newborn Health. White Plains. NY: March of Dimes Foundations, 1981. Atwood, R. Parturition as Posture and related Birth Behavior Acta Obstet Gynecol Scand (supl 57): 5; 1975. Barroso Nino, M.; Ruiz Clavijo, I. La posicin adoptada para la primpara durante el trabajo de parto, sus efectos en la evolucin del parto y condiciones del recin nacido (Position adopted by a Primiparous Woman during Labor and Delivery, its Effects in the Delivery Evolution and Conditions of the Newborn). Bogota, Colombia, National University, Nursing School, 144p; Jun. 1986. Borell, V. Fernstrom, L. The Mechanism of Labor, Radiol Clin north am; 5:73; 1966. Bouchtara, K., Taleb et al. Position and Delivery. Rev.Fr-Gynecol-Obstet; 82 (3); p. 205-7; Mar. 1987. Buchmann,E., Kritzinger,M; Tembe,R; Berry,D. Home Births in the Mosvold Health Ward of Kwazulu.S.Afr-Med-J ;1.76(1) p 29-31; Jul. 1989. Dunn PM. Obstetric Delivery Today. For Better or Worse 7. Lancet; 2: 790; 1976. Caldeyro-Barcia, R. The Influence of Maternal Position on Time of Spontaneous Rupture of the Membranes, Progress of Labor and Fetahead Compression Birth Fam J. , 6:7; 1979 Carlson, J., Diehl, J., Sachtelben-Murray, M., McRae, M., Fenwick, L., Friedman, E. Maternal Positioning during Parturition in Normal Labor, Obstet, Gynecol; 68:443; 1986. Chen, S.; Aisaka, K; Mori, H; Kigawa, T. Effects of Sitting Position on Uterine Activity during Labor. Obstet-Gynecol; 69(1) p. 67-73; Jan. 1987. Engelmann, G. Labor among Primitive Peoples. Reprint of 1882, edition New York: AMS Pres 1977. Gardosi, J., Sylvester, S., Lycnch, C. Alternative Positions in the Second Stage of Labour: A Randomized Controlled Trial. Br-J-Obstet-Gynecol; 96(11): 1290 6; nov. 1989. Gardosi, J. Hutson, N.,Lynch, C. Randomised Controlled Trial of Squatting in the Second Stage of Labour see comments. Lancet. 8. 2 (8654) p. 74-7; July1989. Gold, E. Pelvic Drive in Obstetrics: An X-ray Study of 100 cases. Am J. Obstet Gynecol; 59:890; 1950. Gowri, M. How to Prepare for a Safe and Easy Waterbirth; Video Napierala, S., Water Birth; 1994.

30

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

International Medical New Service. Standing, Sitting, during Delivery not Dangerous. Report of a Presentation by H. Nagai at the 11th World Compress of Ginecology and Obstetrics in Berlin. Obstet. Gynecol New; 20:10; 1985. Johnson, J. and Odent, M. We are all Water Babies, 1995. Kirchhoff, H. Womens Positioning during Child Delivery From Prehistory to Date. Gottingen, Al. occidental. Organorama; May 1976. Koga, S. Effects of Delivery Positions on the Onset of first Cry and Umbilical Blood Gas Parameters. Nippon-Sanka-Fujinka-Gakkaizasshi; 37 (1); 107-14; Jan 1985. Lakshmi, B. y Odent, M. Choosing Waterbirth Global Maternal/Child Health Assoc. Inc, 2001. Lupe, PJ. Gross, T.L. Maternal Upright Posture and Mobility in Labor a Review. Obstet. Gynecol : 67:727; 1986. Mehl, L. Home Delivery Researches Today a Review, Women Health. 1976. Mitzuta, M. Studies on the influence of maternal delivery position on fetal status. Nippon-sankaFujinka-Gakkai-Zasshi. 39 (6) p 965-71; Jun 1987. Morgan, E. The Aquatic Ape Hypothesis; Souvenir Press, 1997. Morgan, E. The Descent of the Child; Penguin Books, 1994. Morgan, E. Scars of Evolution; Oxford University Press, 1990. Morgan, E. The Aquatic Ape, 1982. Morgan, E. The Descent of Woman; Souvenir Press, 1972. Obsterical and Gynecological Survey. Vol 46, N 9, Pulse Oximetry and Fetal Monitoring; 1991. Olson,R; Olson,C; Cox,NS. Maternal Birthing Positions and Perineal Injury J-Fam Pract; 30 (5): 553-7; May 1990. Paciornik, M. et. al. Quality of Health Care Services in Pregnancy, Labor and Delivery within a Framework of Rights. Montevideo, Uruguay; 2003. Read, J.A, Miller, FC, Paul, R.H. Randomized trial of ambulation, versus oxytocin for labor enhancement: a preliminary report. Am J. Obstet Gynecol; 139:669; 1981. Sabatini, H. Parto fisiolgico: la posicin vertical es la fisiolgica para el parto (Physiological Delivery: Vertical Position is the Physiological Posture for Delivery). Campina University, Sao Pablo Brasil; 1992. Araucaria Health Care Services, 9th Region. Ministry of Health of Chile. First National Meeting on Health and Indigenous People. PAHO-WHO. Saavedra, Chile; 1996. Stewart, P. Spiby, H. Randomized Study of the Sitting Position for Delivery using a Newly Designed Obstetric Chair. Br-J-Obstet-Gynecol; 96(3): 327-33; Mar. 1989. Simkin P., Stress, Pain and Catecholamines in Labor: Part 1: a review. Birth; 13: 8; 1986. Westenhofer, M. On the Preservation of Ancestors Characteristics in Human Beings, 1927.

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TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

ANNEXES ANNEX 1A

32

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

ANNEX 1B

33

ANNEXES 2
34
Piper (soldiers tree) Chamomile Malva Oregano Parsley Dogs paw (Manuy tus) Mullaca (winter cherry, gooseberry, wild tomato)

LIST OF HERBS AND OTHER PRODUCTS USED DURING LABOR AND AFTER DELIVERY
Common Name Basil Absinth wormwood Horsetail Canchalagua (Cintaura) Chancuas (Chauncas) Black Maidenhair Fern Scientific Name Ocimum basilicum Artemisia absinthium Equisetum telmateia Properties Accelerates labor process Accelerates labor process Strengthens the bones Increases the body temperature and accelerates labor process Increases body temperature and accelerates labor process To clean and purify blood and helps to stop lochia (postpartum bleeding) Accelerates labor process Accelerates labor process Strengthens the bones Good for delivery Helps in delivery and keeps the belly warm Used to clean the womans genitals Antiseptic, wound healing, use to clean the womans genitals Antiseptic, wound healing, use to clean the womans genitals Antiseptic, wound healing, use to clean the womans genitals Accelerates labor process To increase body temperature Strengthens the bones Strengthens the bones Method of Preparation Infusion - must be taken hot Infusin - must be taken hot Infusion must be taken hot Infusion Boil the herbs twigs and fruit peelings. Must be taken hot. When to Use Dilation Dilation Dilation and labor Dilation Dilation and labor Dilation and puerperium Hot infusion Dilation Dilation, labor and puerperium
TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

Minthostachyssatureja Adiantum capillus- veneris

Mint Marigold/Black Marigold Golden berry

Tageter minuta Prunus

Castor Bean (castor oil plant) Mint Plantain (ixtle, cancer herb)

Ricinus communis Mentha

Taurnefortia polystachys Matricaria chamomilla Wild Malvas

Petrocilinum

To be taken cooked and sweetened with honey To be boiled and used while warm To be boiled and used while warm To be boiled and used while warm To be boiled and used while warm Hot infusion Boiled and combined with algarrobina (algarobo syrup) Boil and drink as fresh water Boil and drink as fresh water

Puerperium Dilation and puerperium Dilation and puerperium Puerperium Puerperium Dilation Dilation Puerperium Puerperium

Common Name Quinoa (Field quinoa, wild quinoa) Rue Rosemary (Romeromacha, callaaquero) Staggerweed (Supiquehua farm basil, quehaua, quhua, rosario quehua deadmans cord Cactus fruit Melissa

Scientific Name Ruta graveumens Rosmarinus officinaris Stachys arvensis

Properties Strengthens the bones Accelerates labor process Increases body temperature and accelerates labor process Accelerates labor process

Method of Preparation When to Use Boil and drink as fresh water Puerperium Dilation Dilation Infusion Dilation

Melissa offcionalis Valeriana officinales

Trinidad (three-leaf, quiso, tritaria nichillo) Valerian COMBINATIONS Grated horn, Rosemary, Chancua, jorajora, peach flower, cactus flower, poroporo flower (Kangaroo apple) golden berry flower, parturients flower, ground olluco fruit Melissa and colcas Melissa offcionalis

Increases body temperature and accelerates labor process Increases body temperature and accelerates labor process (flexibilizes bones) Strengthens the bones

Boil one twig and take while still very hot Boil one twig and take while still very hot

Dilation and labor


TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

Dilation and labor

Accelerates labor process

Boil a small amount of each of the Puerperium herbs mentioned and let cool, take as fresh water Hot infusion Dilation

Increases body temperature and accelerates labor process

Boil one twig of all the herbs and Dilation and labor fruit grates. Take hot.

Lanche tree bark (Myrcianthes) Tritaria rumilanche tree bark, canchaquero tree bark, bark from the Trinidad (three-leaf) guiso, wild quinoa bark, muuo tree bark, taranco tree bark, huanga tree bark, Piper (matico) bark, canistel bark, guava tree bark, golden berry bark, mullaca bark canchalagua, deer tongue, horse tail, dogs paw

Increases body temperature and accelerates labor process (flexibilizes bones) Strengthens the bones

Prepare infusion with the melissa Dilation and labor twig Boil a small amount of each of the Puerperium herbs mentioned and let cool, take as fresh water

35

Common Name Canchalagua, snake herb, black maidenhair fern, coca and basil leaves Canchaquero, humburo, rumilanche, wild quinoa, huanga, three-leaf, three-rose, rosemary, dogs paw, horse tail Walnut tree leaves, coca, whitesnake root / chilca (three shoots) Fox arracacha, basil, panisara, melissa, black mint

Scientific Name

Properties To clean and purify blood and helps to stop lochia (postpartum bleeding) To clean genitals

Method of Preparation When to Use Boil all the products and sweeten Puerperium with honey. Drink during 8 days. Boil all the products and use them for warm vaginal cleaning Puerperium

36

To clean genitals Helps in delivery and keeps the belly warm

Boil all the products and use them for warm vaginal cleaning Take cooked and sweetened with honey.

Puerperium Puerperium
TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

ANNEX 3
WAITING HOUSE OR MATERNITY HOME

During the past years, important strategies and initiatives have been developed in Peru, aimed at reducing the economic barriers (Mother-Infant Insurance and Comprehensive Health Insurance) geographical barriers (waiting house) and cultural barriers (cultural adaptation, vertical delivery with intercultural adaptation) in order to increase the incidence of institutional delivery and respond with effective and timely assistance in obstetric complications. Furthermore, investments have been made in infrastructure, equipment and training of health care personnel from the Ministry of Health, to enhance resolving capacity in the attention of obstetric complications. The 2004 Demographic and Family Health Survey reveals a significant increase of institutional delivery assistance in the rural areas, from 24% in 2000 to 42.9% in 2004. These figures show there may be an improvement in the accessibility to services (geographical and cultural) as well as greater resolving capacity in the response to obstetric emergencies presented by rural, indigenous and Amazonian women in poverty condition, who are the most vulnerable. The waiting house or maternity home is a house that has been conditioned for the specific use, either built, rented or donated through community efforts, jointly managed by local authorities, the community and the health sector. Its main purpose is to shelter pregnant women and their families coming from remote areas and keep them close to a health care facility with Basic or Essential Obstetric and Newborn Care facilities. Identification of pregnant women qualifying as users shall be the responsibility of the primary health care level staff; local authorities; municipal agents; neighbor boards, relatives, friends and neighbors of pregnant women. The criteria for a pregnant women to qualify for access to the waiting house services are: To live in a rural area with difficult access. To be exposed to child delivery without social or family support, being a widow, single or abandoned mother, etc. To be a victim of domestic violence because of spouse or any other family member. To be exposed to being assisted by personnel not qualified for child delivery or new born care. To be a pregnant woman with some kind of obstetric complication requiring treatment by specialized personnel.

There are currently 337 waiting houses operating in the jurisdictions of the Health Divisions located mainly in rural areas:

37

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

WAITING HOUSES

38

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

WAITING HOUSE IN THE RURAL FOREST AREA

WAITING HOUSE IN THE RURAL ANDEAN AREA

39

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

HUACO CULTURA MOCHE POSICIN PARA EL PARTO VERTICAL VARIEDAD SENTADA

CERAMICA DE CHULUCANAS POSICIN PARA EL PARTO VERTICAL

40

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

RETABLO AYACUCHANO PARTO VERTICAL

41

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

KNEELING DOWN

SQUATTING POSITION

VERTICAL DELIVERY

HOLDING THE ROPE POSITION

42

TECHNICAL STANDARD FOR VERTICAL DELIVERY WITH INTERCULTURAL ADAPTATION

VERTICAL DELIVERY

KNEELING DOWN

FINAL DISPOSAL OF THE PLACENTA

43

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