The World Health Organisation (“WHO”) recently issued 56 new recommendations to establish global care standards for healthy pregnant women and reduce unnecessary medical interventions. The UN agency states that every year an estimated 140 million births takes place across the globe and that most of these births occur without complications for mother and child. Nevertheless, medical providers have increased the use of interventions that were previously used to avoid risks or once complications did take place, such as oxytocin to speed up labor or caesarean sections. (1)

In our world today there is a great inconsistency in the support women get around childbirth. In some countries, they are offered too many medical interventions too soon, and in other countries women get too little support too late, or none at all. Both these scenarios result in women not having the positive childbirth experience they deserve.(2)

“A good birth goes beyond having a healthy baby”

– Dr Princess Nothemba Simelela, WHO Assistant Director-General for Family, Women, Children and Adolescents

In a recent news release the WHO Assistant-Director-General for Family, Women, Children and Adolescents, Dr. Princess Nothemba Simelela, states that WHO wants women to give birth in a safe, well-equipped environment with skilled birth attendants, but that the increased medicalisation of normal childbirth undermines a woman’s own capability to give birth and also negatively impacting her birth experience. According to WHO, women too often are subjected to potential harmful routine interventions not needed when the labor is progressing normally.

All women have a right to a positive birth experience, and WHO believes that to achieve the best possible physical, emotional, and psychological outcomes for woman and baby a model of care is required in which health systems empower all women to access care that focuses on the mother and child. And when a medical intervention is wanted or needed, the inclusion of women in making decisions about the care they receive is important to ensure that they meet their goal of a positive childbirth experience. (3)

“Individual, supportive care is key to positive childbirth experience”

–World Health Organisation

The new guidelines on essential intrapartum care brings together new and existing WHO recommendations that, when delivered as a package, the agency states will ensure good-quality and evidence-based care irrespective of the setting or level of health care. The 56 recommendations acknowledge the variations that exists globally and are thus not country or region specific. The guidelines are said to be holistic, women-centered and human-rights based. (4)

Below Bellies Abroad has created a summarised version of the 56 recommendations. To read the complete guidelines click here

 

Intrapartum care for a positive childbirth experience (2018)

Care throughout labour and birth

1. Respectful maternity care – which refers to care organized for and provided to all women in a manner that maintains their dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth – is recommended.
2. Effective communication between maternity care providers and women in labour, using simple and culturally acceptable methods, is recommended.
3. A companion of choice is recommended for all women throughout labour and childbirth.
4. Midwife-led continuity-of-care models, in which a known midwife or small group of known midwives supports a woman throughout the antenatal, intrapartum and postnatal continuum, are recommended for pregnant women in settings with well functioning midwifery programs.

First stage of labour

5. The use of the following definitions of the latent and active first stages of labour is recommended for practice.

• The latent first stage is a period of time characterized by painful uterine contractions and variable changes of the cervix, including some degree of effacement and slower progression of dilatation up to 5 cm for first and subsequent labours.
• The active first stage is a period of time characterized by regular painful uterine contractions, a substantial degree of cervical effacement and more rapid cervical dilatation from 5 cm until full dilatation for first and subsequent labours.

6. Women should be informed that a standard duration of the latent first stage has not been established and can vary widely from one woman to another. However, the duration of active first stage (from 5 cm until full cervical dilatation) usually does not extend beyond 12 hours in first labours, and usually does not extend beyond 10 hours in subsequent labours.
7. For pregnant women with spontaneous labour onset, the cervical dilatation rate threshold of 1 cm/hour during active first stage (as depicted by the partograph alert line) is inaccurate to identify women at risk of adverse birth outcomes and is therefore not recommended for this purpose.
8. A minimum cervical dilatation rate of 1 cm/hour throughout active first stage is unrealistically fast for some women and is therefore not recommended for identification of normal labour progression. A slower than 1-cm/hour cervical dilatation rate alone should not be a routine indication for obstetric intervention.
9. Labour may not naturally accelerate until a cervical dilatation threshold of 5 cm is reached. Therefore the use of medical interventions to accelerate labour and birth (such as oxytocin augmentation or caesarean section) before this threshold is not recommended, provided fetal and maternal conditions are reassuring.
10. For healthy pregnant women presenting in spontaneous labour, a policy of delaying labour ward admission until active first stage is recommended only in the context of rigorous research.
11. Routine clinical pelvimetry on admission in labour is not recommended for healthy pregnant women.
12. Routine cardiotocography is not recommended for the assessment of fetal well-being on labour admission in healthy pregnant women presenting in spontaneous labour.
13. Auscultation using a Doppler ultrasound device or Pinard fetal stethoscope is recommended for the assessment of fetal well- being on labour admission.
14. Routine perineal/pubic shaving prior to giving vaginal birth is not recommended
15. Administration of enema for reducing the use of labour augmentation is not recommended
16. Digital vaginal examination at intervals of four hours is recommended for routine assessment of active first stage of labour in low-risk women
17. Continuous cardiotocography is not recommended for assessment of fetal well-being in healthy pregnant women undergoing spontaneous labour.
18. Intermittent auscultation of the fetal heart rate with either a Doppler ultrasound device or Pinard fetal stethoscope is recommended for healthy pregnant women in labour.
19. Epidural analgesia is recommended for healthy pregnant women requesting pain relief during labour, depending on a woman’s preferences.
20. Parenteral opioids, such as fentanyl, diamorphine and pethidine, are recommended options for healthy pregnant women requesting pain relief during labour, depending on a woman’s preferences.
21. Relaxation techniques, including progressive muscle relaxation, breathing, music, mindfulness and other techniques, are recommended for healthy pregnant women requesting pain relief during labour, depending on a woman’s preferences.
22. Manual techniques, such as massage or application of warm packs, are recommended for healthy pregnant women requesting pain relief during labour, depending on a woman’s preferences.
23. Pain relief for preventing delay and reducing the use of augmentation in labour is not recommended
24. For women at low risk, oral fluid and food intake during labour is recommended
25. Encouraging the adoption of mobility and an upright position during labour in women at low risk is recommended.
26. Routine vaginal cleansing with chlorhexidine during labour for the purpose of preventing infectious morbidities is not recommended.
27. A package of care for active management of labour for prevention of delay in labour is not recommended.
28. The use of amniotomy (Artificial rupture of membranes) alone for prevention of delay in labour is not recommended.
29. The use of early amniotomy with early oxytocin augmentation for prevention of delay in labour is not recommended.
30. The use of oxytocin for prevention of delay in labour in women receiving epidural analgesia is not recommended
31. The use of antispasmodic agents for prevention of delay in labour is not recommended.
32. The use of intravenous fluids with the aim of shortening the duration of labour is not recommended.

 The second stage of labor

33. The use of the following definition and duration of the second stage of labour is recommended for practice.

• The second stage is the period of time between full cervical dilatation and birth of the baby, during which the woman has an involuntary urge to bear down, as a result of expulsive uterine contractions.
• Women should be informed that the duration of the second stage varies from one woman to another. In first labours, birth is usually completed within 3 hours whereas in subsequent labours, birth is usually completed within 2 hours.

34. For women without epidural analgesia, encouraging the adoption of a birth position of the individual woman’s choice, including upright positions, is recommended.
35. For women with epidural analgesia, encouraging the adoption of a birth position of the individual woman’s choice, including upright positions, is recommended.
36. Women in the expulsive phase of the second stage of labour should be encouraged and supported to follow their own urge to push.
37. For women with epidural analgesia in the second stage of labour, delaying pushing for one to two hours after full dilatation or until the woman regains the sensory urge to bear down is recommended in the context where resources are available for longer stay in second stage and perinatal hypoxia (deprevation of oxygen to baby) can be adequately assessed and managed.
38. For women in the second stage of labour, techniques to reduce perineal trauma and facilitate spontaneous birth (including perineal massage, warm compresses and a “hands on” guarding of the perineum) are recommended, based on a woman’s preferences and available options.
39. Routine or liberal use of episiotomy is not recommended for women undergoing spontaneous vaginal birth.
40. Application of manual fundal pressure to facilitate childbirth during the second stage of labour is not recommended.
41. The use of uterotonics for the prevention of postpartum haemorrhage (PPH) during the third stage of labour is recommended for all births.
42. Oxytocin (10 IU, IM/IV) is the recommended uterotonic drug for the prevention of postpartum haemorrhage (PPH).
43. In settings where oxytocin is unavailable, the use of other injectable uterotonics (if appropriate, ergometrine/ methylergometrine, or the fixed drug combination of oxytocin and ergometrine) or oral misoprostol (600 μg) is recommended.
44. Delayed umbilical cord clamping (not earlier than 1 minute after birth) is recommended for improved maternal and infant health and nutrition outcomes.
45. In settings where skilled birth attendants are available, controlled cord traction (pulling on umbilical cord) is recommended for vaginal births if the care provider and the parturient woman regard a small reduction in blood loss and a small reduction in the duration of the third stage of labour as important.
46. Sustained uterine massage is not recommended as an intervention to prevent postpartum haemorrhage (PPH) in women who have received prophylactic oxytocin.

 Care of newborn

47. In neonates born through clear amniotic fluid who start breathing on their own after birth, suctioning of the mouth and nose should not be performed.
48. Newborns without complications should be kept in skin-to-skin contact (SSC) with their mothers during the first hour after birth to prevent hypothermia and promote breastfeeding
49. All newborns, including low-birth-weight (LBW) babies who are able to breastfeed, should be put to the breast as soon as possible after birth when they are clinically stable, and the mother and baby are ready.
50. All newborns should be given 1 mg of vitamin K intramuscularly after birth (i.e. after the first hour by which the infant should be in skin-to-skin contact with the mother and breastfeeding should be initiated)
51. Bathing should be delayed until 24 hours after birth. If this is not possible due to cultural reasons, bathing should be delayed for at least six hours. Appropriate clothing of the baby for ambient temperature is recommended. This means one to two layers of clothes more than adults, and use of hats/caps. The mother and baby should not be separated and should stay in the same room 24 hours a day.
52. Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women.
53. Routine antibiotic prophylaxis is not recommended for women with uncomplicated vaginal birth
54. Routine antibiotic prophylaxis is not recommended for women with episiotomy
55. All postpartum women should have regular assessment of vaginal bleeding, uterine contraction, fundal height, temperature and heart rate (pulse) routinely during the first 24 hours starting from the first hour after birth. Blood pressure should be measured shortly after birth. If normal, the second blood pressure measurement should be taken within six hours. Urine void should be documented within six hours.
56. After an uncomplicated vaginal birth in a health care facility, healthy mothers and newborns should receive care in the facility for at least 24 hours after birth.

 

Resources:  

1. Individualized, supportive care key to positive childbirth experience, says WHO: https://www.who.int/mediacentre/news/releases/2018/positive-childbirth-experience/en/
2. A “good birth” goes beyond having a healthy baby: https://www.who.int/mediacentre/commentaries/2018/having-a-healthy-baby/en
3. Individualized, supportive care key to positive childbirth experience, says WHO: https://www.who.int/mediacentre/news/releases/2018/positive-childbirth-experience/en/
4. WHO recommendations: intrapartum care for a positive childbirth experience: https://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/
5. Full Report: WHO Recommendations – Intrapartum care for a positive childbirth experience: https://apps.who.int/iris/bitstream/10665/260178/1/9789241550215-eng.pdf?ua=1