TECHNICAL STANDARD FOR VERTICAL
DELIVERY WITH INTERCULTURAL
ADAPTATION

HUMAN HEALTH DIVISION

NATIONAL SANITATION STRATEGY FOR SEXUAL
AND REPRODUCTIVE HEALTH


MINISTRY OF HEALTH

HUMAN HEALTH DIVISION

NATIONAL SANITATION STRATEGY FOR SEXUAL AND
REPRODUCTIVE HEALTH

NT N. 033 -MINSA/DGSP-V.01

TECHNICAL STANDARD FOR
VERTICAL DELIVERY
WITH INTERCULTURAL ADAPTATION

2005


PILAR MAZZETTI SOLER

MINISTER OF HEALTH

JOSE DEL CARMEN SARA

VICE MINISTER OF HEALTH

LUIS PODESTA GAVILANO

DIRECTOR OF THE GENERAL DIRECTORATE OF PEOPLE'S 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 (N.T. N. 033MINSA/
DGSP-V.O1) Ministry of Health, General Directorate of People's Health, National
Sanitation Strategy for Sexual and Reproductive Health-Lima: Ministry of Health, 2005
38 page.

Maternal-Perinatal Health / Regulations / Cultural Diversity / Legislation, regulations / Woman's
Health / Delivery / Peru

ISBN 9972-851-22-2
Legal Deposit made under number 2005-6714

Copyright 2006
1000 Units

Ministry of Health
Av. Salaverry N.801-Jesus Maria, Lima-Peru
Telephone: (51-1) 315-6600
http://www.minsa.gob.pe
webmaster@minsa.gob.pe

Editing, Proof reading and Translation proof reading:
Dra. Raquel Hurtado La Rosa – Technical Assistant
National Sanitation Strategy for Sexual and Reproductive Health (ESNSSR)

Translation proof reading:
Paulina Giusti Hundskopf – Advisor to the Vice Minister of Health

Translation:
Alicia Mazurec de Garaycochea
Flavia Lopez de Romana Olivares

Printing:
Editorial y Grafica EBRA E.I.R.L
Telefax: 326-4440
Ebrasa24@speedy.com.pe


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. Podesta Gavilano MD :
Director of the General Directorate of People's Health

Isabel Chaw Ortega, MD :
Director– Health Quality Care

Walter Ravelo, MD :
Executive Officer – Health Care Services

Lucy del Carpio, MD :
National Coordination Officer of the National Sanitation
Strategy for Sexual and Reproductive Health
(ESNSSR)

Raquel Hurtado, MD :
ESNSSR Technical Team

Marysol Campos, BS :
ESNSSR Technical Team

Carmen Julia Carpio, BS :
ESNSSR Technical Team

Carmen Mayuri, BS :
ESNSSR Technical Team

Jaime Moya Granda, MD : Executive Officer – Health Care Services

Ana Borja Hernani, BS : Executive Officer – Comprehensive Health Care

Luis Meza Santibanez, MD :
National Maternal and Perinatal Institute

Regional Health Division, Cajamarca:

Enrique Marroquin Osorio, MD :
Regional Health Director, Cajamarca

Julio Ponce de Leon Gavilan, MD:
Human Health Director

Rocio Portal Vasquez, BS :
Coordination Officer – Adult Female Stage

Rosa Becerra Palomino, BS :
Coordination Officer – Child Stage

Bertha Sagastegui Gil, BS :
Health Promotion – Regional Health Division (DIRES)
Cajamarca

Martin Alban, MD :
Director of the Regional Hospital of Cajamarca

Carmen Sagastegui, MD :
Regional Hospital of Cajamarca, Head of the OB/GYN
Dep.

Margarita Isla Rojas, MD : Regional Hospital of Cajamarca

Julia Arista Melendez, BS : Regional Hospital of Cajamarca

Antero Zavaleta Calderon, MD : Responsible of the ODSIS

Mariela Chavez Aldave, BS:
Coordination Officer – Adult Female Stage, San
Marcos 4th Network

Rocio Tordota Victoria,BS:
Coordination Officer – Adult Female Stage, San
Marcos Health Care Facility

Marleny Rojas Caceres, BS : Chuco Health Care Station – San Marcos Network

Glide Lozano Luna, BS:
Huayobamba Health Care Station – San Marcos 4th
Network

Miriam Rojas Zarate, BS :
Shirac Health Care Station – San Marcos 4th Network

Alicia Siguenza, BS :
Cachachi Health Care Station – Cajabamba 5th
Network

Irma Madueno Saldana, BS :
Red Hualgayoc – Bambamarca, Adult Female Coord.

Gloria Leyva, BS:
Red Hualgayoc – Bambamarca Health Care Facility
Moran Lirio

Santos Chavez Aguilar, BS :
UNICEF Health Consultant

Maria Elena Valladares, BS :
NGO Circulo Solidario

Regional Health Division, Cuzco:

Danilo Villavicencio Munoz, MD : General Director Cuzco
Juan Spelucin Runciman, MD : Regional Hospital of Cuzco
Mauro Vargas Leon, MD : Executive Officer – Human Health
Graciela Zacarias Aguirre, MD : Pediatrician of the Lorena Hospital
Javier Cuno, MD : Health Care Services Division
Hilda Robles Mena, BS : Director of Comprehensive Health Care Services
Isabel Fuentes Carayhua, BS : Director of Child Stage
Maritza Castro, BS : STI and HIV AIDS Strategy
Gina Humpire, BS : Urcos Health Care Facility
Patricia Velarde , BS : Canas Canchis Network
Katia Catacora, MD : Antonio Lorena Hospital, Cuzco
Luis Gonzales de la Vega, MD : Regional Hospital – Neonatology


Neptali Cueva Maza, MD : Manager of the Cuzco South Network
Elsa Diaz Rojas, BS : Paruro Micro Network (Cuzco South)
Ines Pari Pandia, BS : Huancarani Micro Network (Cuzco South)
Rosa Llacsa Valcarcel, BS : Paucartambo Micro Network (Cuzco South)
Marina Ochoa Linares, MD : Manager of the Cuzco North Network
William Velasco, BS: Coord. Officer – Woman's Health Area, Cuzco North

Network
Elena Neyra Velarde, BS: Quispicanchi Acomayo Network Coord. Woman's
Health Area
Simon Cruz, BS : Ocongate Micro Network (Quispicanchi Acomayo

Network).
Marta Montalico, BS : Pucyura Micro Network (La Convencion).
Patricia Medina, BS : Quimbiri Micro Network (La Convencion).
Veronica Huallpa, BS : Santa Teresa Micro Network
Nelida Vilca, BS : Yauri Micro Network
Victor del Carpio, MD : Yaurisque Micro Network
Deisy Moscoso, BS : UNICEF
Elizabeth Menendez, BS : CADEP Jose Maria Arguedas

Regional Health Division, Ayacucho:

Jose Quispe Perez, MD : Regional Health Director, Ayacucho
Jose Anicama Barrios, MD : Human Health Director
Flor de Maria 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
Diogenes Salvatierra, BS : Sucre Micro Network
Zulema Urbina, BS : San Jose de Secce Micro Network, Huanta
Graciela Alca de la Cruz, BS : San Miguel Network
Raquel Arones, BS : Sivia Micro Network
Ricardo Gutierrez, BS : Vilcashuaman Micro Network

Regional Health Division, San Martin:

Anderson Sanchez S., MD : General Health Director, San Martin
Felipe Santiago Vela O., MD : Executive Officer – Human Health Care
Militza Huivin Grandez, BS : Coord. Officer – Adult Stage – ESSSR
Maria 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 Vasquez, MD : Jepelacio Health Care Facility
Guillermo Arteaga Zaire, MD : Jepelacio Health Care Facility
Dagni Rodriguez Pinedo, BS : Jepelacio Health Care Facility
Nurse technician Edgardo Rojas S. : Jepelacio Health Care Facility
Maria Rosa Garate, Anthropologist: Policy Project
Cidanelia Salas , BS : NGORelachupan – Peru
Rosario Ruiz Santillan, MD : NGO CADES
Rosa Giove, MD : Foro Salud (Health Forum)

Regional Health Division, Apurimac II:

Angelica Penaloza, BS : Regional Coord. Officer of the SSR Strategy

Other Institutions:

Marco Martina Chavez, MD : Central Planning and Development Office – ESSalud
Miguel Gutierrez Ramos, MD : Peruvian Society of Obstetrics and Gynecology
Eduardo Maradiegue, MD : Peruvian Society of Obstetrics and Gynecology
Luis Tavara Orozco, MD : Peruvian Society of Obstetrics and Gynecology
Elena Lara Valderrama, BS : Dean of the Association of Obstetricians of Peru
Mario Tavera, MD : UNICEF


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 Martin, Huancavelica,
Huanuco, Ayacucho, Puno, Apurimac 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


9


CONTENTS


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 people's 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 people's 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 women's 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.


V. LEGAL BASIS
1.
Law 26842, Health Law.
2.
Law 27657, Ministry of Heath Law.
3.
Supreme Decree 014-2002-SA, Ministry of Health Organization and Functions
Regulations.
4.
Ministerial Order 768-2001-SA/DM Health Quality Management System.
5.
Ministerial Order 668-2004/MINSA, National Guidelines for Comprehensive
Sexual and Reproductive Health Assistance.
6.
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 women's 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 Vilcashuaman and San Jose
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%.

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 extended1 .
•
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 mother's pelvic diameters, thus not favoring the final
expulsion.
•
The mother's intrapelvic diameters reach their greatest values when the
mother's thighs are flexed upon her own abdomen (usual practice for
Shoulders Dystocia), thus the conventional horizontal position might decrease
the mother's 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 woman's uterus is not compressed, nor
are the large vessels, the aorta or the cava vein and thus, there is no
alteration in the mother's 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 dilation2 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 way6 .
1 Giraldo, 1992.
2 Arbues, 1982.
3 Gallo, 1982.
4 Garcia, C. 1987.
5 Sabatino, 1992
6 Borell, 1966.


•
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 adopted7. 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
10 11

considerably shortened in the vertical position.9 ,,.

•
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 children's 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 other's particularities and individualities. It is not a question of
imposition or subjugation but of concerting…13"

7 Mendez, B., 1976.
8 Mendez B., 1975.
9 Sabatino, 1992.
10 Paciornik, 1992.
11 Dunn, 1976.
12 Sabatino, 1992.

13 Araucaria Health Care Service – 9th Region. Ministry of Health of Chile. First National Meeting on Health and
Indigenous People. PAHO-WHO. Saavedra Chile, 1996.


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.

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.
•
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 muna, 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:

•
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).
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 Prenatal
care card (Pregnancy record).
•
Identify alarm signals.
•
Control vital signs: blood pressure, pulse, temperature.
•
Practice obstetric assessment (Leopold's 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.
•
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:

14 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.


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 family's confidence.
Be prudent and tolerant when practicing this procedure.
Pain management:

•
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.
•
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.
-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.
Squatting position: Front.
b.
Squatting position: Back.
c.
Kneeling down.
d.
Seated.
e.
Half-seated.
f.
Holding the rope.
g.
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 parturient's inferior region of the sacrum
and will later accommodate to help in the guided delivery.
•
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 companion's 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.


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 woman's 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:

•
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.
•
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.


CHILD DELIVERY SERVICES FLOWCHART15

Patient requests child delivery services

Identification of pregnant woman
Does she require
delivery proceeding?
Transferred to Delivery Room
Examination by physician
NO
Dystocic delivery
Determine the relatives that will
accompany her during delivery
Transferred to Waiting House
Inform the pregnant woman about the
positions for child delivery so that she
may decide
Can the delivery be attended to
at the Health Care Facility?
Immediate Referral
Provide an environ with adequate temperature, offer
warm solutions, indicate relative what his/her role is.
Monitor delivery process
Does Delivery present
any complication?
Take action according to
protocols and order Immediate
Referral if necessary
Assist in Vertical
Delivery
Does birth and
expulsion of placenta
present any
complication?
S
Take action according to
protocols and order Immediate
Referral if necessary
Assist in childbirth process
and provide care to
newborn
Ask what will be done with the placenta, if the mother wishes, allow her to wear support girdle and/or scarf on her head.
Assist during Puerperium
Inquire about satisfaction of User and her Relatives
NOYES
NOYES
NOYES
YES
Eutocic delivery
15 Adaptation Document PSNB 2000.

26


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Director's Resolution issued by the Alto Mayo Moyobamba Health Subregion
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Martina Chavez, M. Parto en posicion sentada (Sitting Position Child
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Allister, H. Was Man more Aquatic in the Past? The New Scientist, page
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Atwood, R. Parturition as Posture and related Birth Behavior Acta Obstet
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Barroso Nino, M.; Ruiz Clavijo, I. La posicion adoptada para la primipara
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Borell, V. Fernstrom, L. The Mechanism of Labor, Radiol Clin north am;
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Bouchtara, K., Taleb et al. Position and Delivery. Rev.Fr-Gynecol-Obstet; 82
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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.
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Dunn PM. Obstetric Delivery Today. For Better or Worse 7. Lancet; 2: 790;
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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
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Carlson, J., Diehl, J., Sachtelben-Murray, M., McRae, M., Fenwick, L.,
Friedman, E. Maternal Positioning during Parturition in Normal Labor,
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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
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Gardosi, J., Sylvester, S., Lycnch, C. Alternative Positions in the Second
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Gardosi, J. Hutson, N.,Lynch, C. Randomised Controlled Trial of Squatting
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Gold, E. Pelvic Drive in Obstetrics: An X-ray Study of 100 cases. Am J.
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Napierala, S., Water Birth; 1994.
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Johnson, J. and Odent, M. We are all Water Babies, 1995.
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Kirchhoff, H. Women's Positioning during Child Delivery "From Prehistory to
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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 319 waiting houses operating in the jurisdictions of the Health
Divisions located mainly in rural areas:


REGION OPERATING WAITING
HOUSES
AMAZONAS 16
ANCASH 8
APURIMAC 37
AREQUIPA 6
AYACUCHO 19
CAJAMARCA 8
CUZCO 108
HUANCAVELICA 20
HUANUCO 58
ICA ---
JUNIN 3
LA LIBERTAD 1
LAMBAYEQUE 2
LORETO 2
LIMA 5
PASCO 3
MADRE DE DIOS ---
MOQUEGUA ---
PIURA 5
PUNO 18
TACNA ---
TUMBES ---
SAN MARTIN ---
UCAYALI ---
TOTAL 319

Photos:
Waiting house in the rural forest area
Waiting house in the rural Andean area