Guideline

WHO recommendations: intrapartum care for a positive childbirth experience

Year of Publication

2018

Issuing Institution

World Health Organization

Links

WHO IRIS,WHO IRIS

Recommendations

56 included recommendations

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.

Status

Maintained

Not recommended

Certainty of evidence

High

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

Status

Maintained

Recommended

Certainty of evidence

Low

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

Status

Maintained

Recommended

Certainty of evidence

Low

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)

Status

Maintained

Recommended

Certainty of evidence

Moderate

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

Status

Updated

Recommended

Certainty of evidence

Low

Effective communication between maternity care providers and women in labour, using simple and culturally acceptable methods, is recommended

Status

Updated

Recommended

Certainty of evidence

Very low

A companion of choice is recommended for all women throughout labour and childbirth

Status

Updated

Recommended

Certainty of evidence

Moderate

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 programmes

Status

Maintained

Context specific recommendation

Only in specific contexts

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.

Status

Updated

Recommended

Certainty of evidence

Low

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

Status

Updated

Recommended

Certainty of evidence

Low

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

Status

Updated

Recommended

Certainty of evidence

Low

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

Status

Updated

Not recommended

Certainty of evidence

Low

A minimum cervical dilatation rate of 1 cm/hour throughout active first stage of labour 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 an indication for obstetric intervention

Status

Updated

Not recommended

Certainty of evidence

Moderate

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

Status

Updated

Not recommended

Certainty of evidence

Moderate

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

Status

Updated

Recommendation in research context

Only in research contexts

Certainty of evidence

Very low

Routine clinical pelvimetry on admission in labour is not recommended for healthy pregnant women

Status

Updated

Not recommended

Certainty of evidence

Very low

Routine cardiotocography is not recommended for the assessment of fetal well-being on labour admission in healthy pregnant women presenting in spontaneous labour

Status

Updated

Not recommended

Certainty of evidence

Moderate

Auscultation using a Doppler ultrasound device or Pinard fetal stethoscope is recommended for the assessment of fetal well-being on labour admission

Status

Updated

Recommended

Certainty of evidence

Moderate

Routine perineal/pubic shaving prior to giving vaginal birth is not recommended

Status

Maintained

Not recommended

Certainty of evidence

Very low

Administration of an enema for reducing the use of labour augmentation is not recommended

Status

Maintained

Not recommended

Certainty of evidence

Very low

Digital vaginal examination at intervals of four hours is recommended for routine assessment of active first stage of labour in low-risk women

Status

Maintained

Recommended

Certainty of evidence

Very low

Continuous cardiotocography is not recommended for assessment of fetal well-being in healthy pregnant women undergoing spontaneous labour

Status

Updated

Not recommended

Certainty of evidence

Low

Intermittent auscultation of the fetal heart rate with either a Doppler ultrasound device or a Pinard fetal stethoscope is recommended for healthy pregnant women in labour

Status

Updated

Recommended

Certainty of evidence

Very low

Epidural analgesia is recommended for healthy pregnant women requesting pain relief during labour, depending on a woman’s preferences

Status

Updated

Recommended

Certainty of evidence

Very low

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

Status

Updated

Recommended

Certainty of evidence

Very low

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

Status

Updated

Recommended

Certainty of evidence

Very low

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

Status

Updated

Recommended

Certainty of evidence

Low

Pain relief for preventing delay and reducing the use of augmentation in labour is not recommended

Status

Maintained

Not recommended

Certainty of evidence

Very low

For women at low risk, oral fluid and food intake during labour is recommended

Status

Maintained

Recommended

Certainty of evidence

Very low

Encouraging the adoption of mobility and an upright position during labour in women at low risk is recommended

Status

Maintained

Recommended

Certainty of evidence

Very low

Routine vaginal cleansing with chlorhexidine during labour for the purpose of preventing infectious morbidities is not recommended

Status

Maintained

Not recommended

Certainty of evidence

Moderate

A package of care for active management of labour for prevention of delay in labour is not recommended.

Status

Maintained

Not recommended

Certainty of evidence

Low

The use of amniotomy alone for prevention of delay in labour is not recommended

Status

Maintained

Not recommended

Certainty of evidence

Very low

The use of early amniotomy with early oxytocin augmentation for prevention of delay in labour is not recommended

Status

Maintained

Not recommended

Certainty of evidence

Very low

The use of oxytocin for prevention of delay in labour in women receiving epidural analgesia is not recommended

Status

Maintained

Not recommended

Certainty of evidence

Low

The use of antispasmodic agents for prevention of delay in labour is not recommended.

Status

Maintained

Not recommended

Certainty of evidence

Very low

The use of intravenous fluids with the aim of shortening the duration of labour is not recommended

Status

Maintained

Not recommended

Certainty of evidence

Very low

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

Status

Updated

Recommended

Certainty of evidence

Low

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

Status

Updated

Recommended

Certainty of evidence

Low

For women without epidural analgesia, encouraging the adoption of a birth position of the individual woman’s choice, including upright positions, is recommended

Status

Updated

Recommended

Certainty of evidence

Low

For women with epidural analgesia, encouraging the adoption of a birth position of the individual woman’s choice, including upright birth positions, is recommended

Status

Updated

Recommended

Certainty of evidence

Low

Women in the expulsive phase of the second stage of labour should be encouraged and supported to follow their own urge to push.

Status

Updated

Recommended

Certainty of evidence

Low

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 can be adequately assessed and managed

Status

Updated

Context specific recommendation

Only in specific contexts

Certainty of evidence

Moderate

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

Status

Updated

Recommended

Certainty of evidence

Very low

Routine or liberal use of episiotomy is not recommended for women undergoing spontaneous vaginal birth

Status

Updated

Not recommended

Certainty of evidence

Low

Application of manual fundal pressure to facilitate childbirth during the second stage of labour is not recommended

Status

Updated

Not recommended

Certainty of evidence

Very low

The use of uterotonics for the prevention of postpartum haemorrhage (PPH) during the third stage of labour is recommended for all births

Status

Maintained

Recommended

Certainty of evidence

Moderate

Oxytocin (10 IU, IM/IV) is the recommended uterotonic drug for the prevention of postpartum haemorrhage (PPH).

Status

Maintained

Recommended

Certainty of evidence

Moderate

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 (for the prevention of postpartum haemorrhage)

Status

Maintained

Recommended

Certainty of evidence

Moderate

Delayed umbilical cord clamping (not earlier than 1 minute after birth) is recommended for improved maternal and infant health and nutrition outcomes

Status

Maintained

Recommended

Certainty of evidence

Moderate

In settings where skilled birth attendants are available, controlled cord traction (CCT) 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.

Status

Maintained

Recommended

Certainty of evidence

Moderate

Sustained uterine massage is not recommended as an intervention to prevent postpartum haemorrhage (PPH) in women who have received prophylactic oxytocin

Status

Maintained

Not recommended

Certainty of evidence

Low

Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women

Status

Maintained

Recommended

Certainty of evidence

Very low

Routine antibiotic prophylaxis is not recommended for women with uncomplicated vaginal birth.

Status

Maintained

Not recommended

Certainty of evidence

Very low

Routine antibiotic prophylaxis is not recommended for women with episiotomy

Status

Maintained

Not recommended

Certainty of evidence

Very low

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

Status

Maintained

Recommended

Certainty of evidence

Low