Intrapartum care
Intrapartum care
The majority of approximately 140 million births that occur globally every year are among women without risk factors for complications for themselves or their babies at the beginning and throughout labour. Nevertheless, the time of birth is critical to the survival of women and their babies, as the risk of morbidity and mortality could increase considerably if complications arise. In line with the targets of Sustainable Development Goal 3 – ensure healthy lives and promote well-being for all at all ages - and the new Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030), global agendas are expanding their focus to ensure that women and their babies not only survive labour complications if they occur but also that they thrive and reach their full potential for health and life.
In spite of the considerable debates and research that have been ongoing for several years, the concept of “normality” in labour and childbirth is not universal or standardized. There has been a substantial increase over the last two decades in the application of a range of labour practices to initiate, accelerate, terminate, regulate or monitor the physiological process of labour, with the aim of improving outcomes for women and babies. This increasing medicalization of childbirth processes tends to undermine the woman’s own capability to give birth and negatively impacts her childbirth experience. In addition, the increasing use of labour interventions in the absence of clear indications continues to widen the health equity gap between high- and low-resource settings.
About WHO guidelines on Intrapartum care
The World Health Organization (WHO) recommendations on Intrapartum care for a positive childbirth experience is an up-to-date, comprehensive and consolidated guideline on essential intrapartum care. These when delivered as a package, will ensure good-quality and evidence-based care irrespective of the setting or level of health care.
The guideline recognizes a “positive childbirth experience” as a significant end point for all women undergoing labour. It defines a positive childbirth experience as one that fulfils or exceeds a woman’s prior personal and sociocultural beliefs and expectations, including giving birth to a healthy baby in a clinically and psychologically safe environment with continuity of practical and emotional support from a birth companion(s) and kind, technically competent clinical staff. It is based on the premise that most women want a physiological labour and birth, and to have a sense of personal achievement and control through involvement in decision-making, even when medical interventions are needed or wanted.
The guideline highlights the importance of woman-centred care to optimize the experience of labour and childbirth for women and their babies through a holistic, human rights-based approach. It introduces a global model of intrapartum care, which takes into account the complexity and diverse nature of prevailing models of care and contemporary practice.
Summary list of recommendations on intrapartum care for a positive childbirth experience
Care throughout labour and birth
| Care option | Recommendation | Category of recommendation |
|---|---|---|
| Respectful maternity care | 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 | Recommended |
| Effective communication | Effective communication between maternity care providers and women in labour, using simple and culturally acceptable methods, is recommended. | Recommended |
| Companionship during labour and childbirth | A companion of choice is recommended for all women throughout labour and childbirth. | Recommended |
| Continuity of care | 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. | Context-specific recommendation |
First stage of labour
| Care option | Recommendation | Category of recommendation |
|---|---|---|
| Definitions of the latent and active first stages of labour | The use of the following definitions of the latent and active first stages of labour is recommended for practice.
|
Recommended |
| Duration of the first stage of labour | 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. | Recommended |
| Progress of the first stage of labour |
|
Not Recommended
Not Recommended
Not Recommended |
| Labour ward admission policy | 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. | Research-context recommendation |
| Clinical pelvimetry on admission | Routine clinical pelvimetry on admission in labour is not recommended for healthy pregnant women. | Not recommended |
| Routine assessment of fetal well-being on labour admission |
|
Not recommended
Recommended |
| Perineal/pubic shaving | Routine perineal/pubic shaving prior to giving vaginal birth is not recommended. | Not recommended |
| Enema on admission | Administration of enema for reducing the use of labour augmentation is not recommended | Not recommended |
| Digital vaginal examination | Digital vaginal examination at intervals of four hours is recommended for routine assessment of active first stage of labour in low-risk women | Recommended |
| Continuous cardiotocography during labour | Continuous cardiotocography is not recommended for assessment of fetal well-being in healthy pregnant women undergoing spontaneous labour. | Not recommended |
| Intermittent fetal heart rate auscultation during labour | 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. | Recommended |
| Epidural analgesia for pain relief | Epidural analgesia is recommended for healthy pregnant women requesting pain relief during labour, depending on a woman’s preferences. | Recommended |
| Opioid analgesia for pain relief | 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. | Recommended |
| Relaxation techniques for pain management | 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 | Recommended |
| Manual techniques for pain management | 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. | Recommended |
| Pain relief for preventing labour delay | Pain relief for preventing delay and reducing the use of augmentation in labour is not recommended. | Not recommended |
| Oral fluid and food | For women at low risk, oral fluid and food intake during labour is recommended | Recommended |
| Maternal mobility and position | Encouraging the adoption of mobility and an upright position during labour in women at low risk is recommended | Recommended |
| Vaginal cleansing | Routine vaginal cleansing with chlorhexidine during labour for the purpose of preventing infectious morbidities is not recommended | Not recommended |
| Active management of labour | A package of care for active management of labour for prevention of delay in labour is not recommended. | Not recommended |
| Routine amniotomy | The use of amniotomy alone for prevention of delay in labour is not recommended | Not recommended |
| Early amniotomy and oxytocin | The use of early amniotomy with early oxytocin augmentation for prevention of delay in labour is not recommended | Not recommended |
| Oxytocin for women with epidural analgesia | The use of oxytocin for prevention of delay in labour in women receiving epidural analgesia is not recommended. | Not recommended |
| Antispasmodic agents | The use of antispasmodic agents for prevention of delay in labour is not recommended | Not recommended |
| Intravenous fluids for preventing labour delay | The use of intravenous fluids with the aim of shortening the duration of labour is not recommended | Not recommended |
Second stage of labour
| Care option | Recommendation | Category of recommendation |
|---|---|---|
| Definition and duration of the second stage of labour | The use of the following definition and duration of the second stage of labour is recommended for practice.
|
Recommended |
| Birth position (for women without epidural analgesia) | For women without epidural analgesia, encouraging the adoption of a birth position of the individual woman’s choice, including upright positions, is recommended. | Recommended |
| Birth position (for women with epidural analgesia) | For women with epidural analgesia, encouraging the adoption of a birth position of the individual woman’s choice, including upright positions, is recommended. | Recommended |
| Method of pushing | Women in the expulsive phase of the second stage of labour should be encouraged and supported to follow their own urge to push. | Recommended |
| Method of pushing (for women with epidural analgesia) | 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. | Context-specific recommendation |
| Techniques for preventing perineal trauma | 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. | Recommended |
| Episiotomy policy | Routine or liberal use of episiotomy is not recommended for women undergoing spontaneous vaginal birth | Not recommended |
| Fundal pressure | Application of manual fundal pressure to facilitate childbirth during the second stage of labour is not recommended. | Not recommended |
Third stage of labour
| Care option | Recommendation | Category of recommendation |
|---|---|---|
| Prophylactic uterotonics |
|
Recommended
Recommended
Recommended |
| Delayed umbilical cord clamping | Delayed umbilical cord clamping (not earlier than 1 minute after birth) is recommended for improved maternal and infant health and nutrition outcomes | Recommended |
| Controlled cord traction (CCT) | 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. | Recommended |
| Uterine massage | Sustained uterine massage is not recommended as an intervention to prevent postpartum haemorrhage (PPH) in women who have received prophylactic oxytocin. | Not Recommended |
Care of the newborn
| Care option | Recommendation | Category of recommendation |
|---|---|---|
| Routine nasal or oral suction | 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 | Not Recommended |
| Skin-to-skin contact | 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. | Recommended |
| Breastfeeding | 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. | Recommended |
| Haemorrhagic disease prophylaxis using vitamin K | 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) | Recommended |
| Bathing and other immediate postnatal care of the newborn | 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. | Recommended |
Care of the woman after birth
| Care option | Recommendation | Category of recommendation |
|---|---|---|
| Uterine tonus assessment | Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women | Recommended |
| Antibiotics for uncomplicated vaginal birth | Routine antibiotic prophylaxis is not recommended for women with uncomplicated vaginal birth. | Not recommended |
| Routine antibiotic prophylaxis for episiotomy | Routine antibiotic prophylaxis is not recommended for women with episiotomy. | Not recommended |
| Routine postpartum maternal assessment | 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. | Recommended |
| Postnatal discharge following uncomplicated vaginal birth | 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. | Recommended |
Source : WHO recommendations Intrapartum care for a positive childbirth experience
Last Modified : 3/2/2020
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