WHO recommendations Intrapartum care for a positive experience WHO recommendations Intrapartum care for a positive childbirth experience WHO recommendations: intrapartum care for a positive childbirth experience ISBN 978-92-4-155021-5

© World Health Organization 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material with the reader. In no event shall WHO be liable for damages arising from its use. Contents

Foreword v Acknowledgements vi Acronyms and abbreviations vii Executive summary 1 Introduction 1 Target audience 1 Guideline development methods 1 Recommendations 2 1. Background 8 1.1 Target audience 9 1.2 Scope of the guideline 9 2. Methods 10 2.1 WHO Steering Group 10 2.2 Guideline Development Group 10 2.3 External Review Group 10 2.4 Technical Working Group 10 2.5 External partners and observers 11 2.6 Identifying priority questions and outcomes 11 2.7 Integration of recommendations from published WHO guidelines 13 2.8 Focus and approach 13 2.9 Evidence identification and retrieval 13 2.10 Quality assessment and grading of the evidence 14 2.11 Formulation of the recommendations 15 2.12 Decision-making during the GDG meetings 16 2.13 Declaration of interests by external contributors 17 2.14 Document preparation and peer review 17 2.15 Presentation of guideline content 17 3. Evidence and recommendations 19 3.1 Care throughout labour and 19 3.2 First stage of labour 35 3.3 Second stage of labour 120 3.4 Third stage of labour 159 3.5 Care of the newborn 162 3.6 Care of the woman after birth 165 4. Implementation of this guideline: introducing the WHO intrapartum care model 168 5. Research implications 171 6. Dissemination 173 7. Applicability issues 174 7.1 Anticipated impact of the guideline on the organization of intrapartum care 174 7.2 Monitoring and evaluating the impact of the guideline 174 8. Updating of the guideline 175 9. References 176 CONTENTS

iii iv WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE http://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/) Web annex. 4. Annex 3. Annex 2. Annex 1. Annex Evidence base (WHO/RHR/18.04; available at available at (WHO/RHR/18.04; base Evidence recommendations to individual specific considerations Implementation how they were managed and Technical members, Working Group and Group Development Guideline from of interest of declarations Summary guideline of this involvedpreparation in staff the WHO and experts External outcomes and questions guideline Priority 184 188 195 192 Foreword

It has been more than two decades since the World Health Organization (WHO) issued technical guidance dedicated to the care of healthy pregnant women and their babies – Care in normal birth: a practical guide. The global landscape for maternity services has changed considerably since that guidance was issued. More women are now giving birth in health care facilities in many parts of the world, and yet suboptimal quality of care continues to impede attainment of the desired health outcomes. While in some settings too few interventions are being provided too late to women, in other settings women are receiving too many interventions that they do not need too soon. WHO has released several recommendations to address specific aspects of labour management and the leading causes of maternal and newborn mortality and morbidity in response to the needs of countries. The focus of the global agenda has also gradually expanded beyond the survival of women and their babies, to also ensuring that they thrive and achieve their full potential for health and well-being. These efforts have been catalysed by the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030), and the Every Woman Every Child movement. In addition, the third goal of the 2030 agenda for sustainable development affirms global commitment to ensuring healthy lives and the promotion of well-being for all at all ages. One of the WHO strategic priorities over the next five years for achieving Sustainable Development Goal (SDG) targets is to support countries to strengthen their health systems to fast-track progress towards achieving universal health coverage (UHC). WHO is supporting countries to ensure that all people and communities have access to and can use the promotive, preventive and curative health services that are appropriate to their needs, and that are effective and of sufficient quality, while not exposing them to financial hardship. An integral part of these efforts is the design of the package of essential services across the spectrum of health disciplines, including reproductive, maternal, newborn, child and adolescent health, from which a set of basic service-delivery indicators can be identified for use in monitoring countries’ progress towards UHC. This guideline is a consolidated set of new and existing recommendations on essential labour and childbirth practices that should be provided to all pregnant women and their babies during labour and childbirth irrespective of socioeconomic setting. It promotes the delivery of a package of labour and childbirth interventions that is critical to ensuring that giving birth is not only safe but also a positive experience for women and their families. It highlights how woman-centred care can optimize the quality of labour and childbirth care through a holistic, human rights-based approach. By outlining a new model of intrapartum care that is adaptable to individual country contexts, the guideline enables substantial cost-savings through reduction in unnecessary interventions during labour and childbirth. We encourage health care providers to adopt and adapt these recommendations, which provide a sound foundation for the provision of person-centred, evidence-based and comprehensive care for women and their newborn babies.

Princess Nothemba Simelela Assistant Director-General Family, Women’s and Children’s Health (FWC) Cluster World Health Organization FOREWORD

v vi WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Editing: Green Ink, United Kingdom. United Ink, Green Editing: guideline. of this content the have influenced not bodies views funding of the The byexecuted WHO. the (HRP), programme Training Research and acosponsored Reproduction inHuman Development Research, of Programme Special UNDP–UNFPA–UNICEF–WHO–World the Bank and by USAID funded was work This (ERG). Review Group External of the members as document peer-reviewed Nabhan guideline the Hofmeyr, Ashraf and Homer, Vanora Caroline Levy Hundley, Barbara [USAID]), [RCOG]). Wright Alison (Royal Gynaecologists Justus and Dao, and of College Obstetricians Blami Development Fund International [UNFPA]); for Population Nations States Agency (United Stanton Ellen Mary (United [ICM]); of Confederation Petra ten (International Hoope-Bender Gross M. Mechthild [FIGO]); and of Gynecology Federation (International Ayres-de-Campos Diogo organizations: various represented who consultation, technical final the at following observers the We acknowledge GDG. the and Group Steering WHO of the it before was members reviewed by other document guideline final the drafted Oladapo Olufemi and Lawrie Theresa frameworks. evidence-to-decision and summaries narrative corresponding the prepared Group, Steering WHO the and TWG of the members with other reviews and, allsystematic from profiles evidence the double-checked Lawrie Theresa reviews guideline. to the inform systematic additional conducted that teams the led Gill Thomson and Shakibazadeh Elham Finlayson, Kenneth Downe, Soo Bohren, Meghan Bick, Debra Abalos, Edgardo reviews. from these evidence scientific of the appraisal quality performed Pasquale Julia Diaz and Virginia Chamillard, Monica Abalos, Edgardo and reviews, systematic Cochrane relevant of the updating the Kellie Frances coordinated Dowswell and Therese Thomson. Gill and Shakibazadeh Elham Pasquale, Julia Lawrie, Theresa Kellie, Frances Finlayson, Kenneth Dowswell, Therese Downe, Soo Diaz, Virginia Chamillard, Monica Bohren, Meghan Bick, Debra Abalos, Edgardo Technical of the (TWG): Working Group members as support methodological provided following experts The them. updating or inpreparing collaboration and assistance their for inthis reviews guideline systematic used Cochrane of the to authors the thanks Special process. development guideline of the part as exercise place took that scoping the during stakeholders of international by number alarge provided We feedback the appreciate consultations. technical the chairing for (GDG), Neilson Group James Development and to Guideline of and Pisake the Lumbiganon members as Tolosa served Wahabi, who E. Hayfaa Jorge and Singata-Madliki, Mandisa Sanghvi, Harshad Pattinson, Robert Olayemi, Oladapo Lavender, Obara, Tina Silke Hiromi Miller, Mader, Gogoi, Mori, Suellen Aparajita Rintaro Boulvain, Michel Amorim, Melania Althabe, Fernando to Abdel-Aleem, Hany thanks sincere extends WHO consultations. technical to guideline the contributed who advisors regional were WHO Ouedraogo Leopold and Nagai Mari Mucio, De Bremen Gholbzouri, Karima Tunçalp. Özge and Babamuradova, Mavjuda McConville Frances Khosla, Rajat stages: at various process development guideline to the contributed staff headquarters’ following WHO The process. development guideline the managed which Group, Steering WHO of the members were the Health, Adolescent Child and Newborn, of Maternal, Department of the Portela Anayda and Bucagu Maurice and Research, and Health of Reproductive VogelJoshua Department of the and Souza Paulo João Oladapo, Olufemi Gülmezoglu, A. Metin Bonet, Mercedes Betrán, Pilar Ana project. development guideline the coordinated Oladapo Olufemi Research. and Health of Reproductive Department of the Gülmezoglu Metin A. and Bonet Mercedes Oladapo, initiated was byWork Olufemi this guideline on of this guideline. to have development the made organizations and individuals many that contributions the (WHO) acknowledge gratefully World Organization of the Health Health Adolescent Child and Newborn, of Maternal, Department the and Research and Health of Reproductive Department The Acknowledgements Acronyms and abbreviations

ABO adverse birth outcome aOR adjusted odds ratio CERQual Confidence in the Evidence from Reviews of Qualitative research CI confidence interval cRCT cluster randomized controlled trial CTG DOI declaration of interest EB evidence base EtD evidence-to-decision FHR fetal heart rate FIGO International Federation of Gynecology and Obstetrics GBS group B streptococcus GDG Guideline Development Group GRADE Grading of Recommendations Assessment, Development and Evaluation GRC Guidelines Review Committee GREAT Guideline-driven, Research priorities, Evidence synthesis, Application of evidence, and Transfer of knowledge HIC high-income country HIE hypoxic-ischaemic encephalopathy HIV human immunodeficiency virus HRP UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in IA intermittent auscultation ICM International Confederation of Midwives IM intramuscular IV intravenous LMIC low- and middle-income country MCA Department of Maternal, Newborn, Child and Adolescent Health (at WHO) MD mean difference MLCC -led continuity of care NGO nongovernmental organization OASI obstetric anal sphincter injury OMBU on-site midwife-led birthing unit OR odds ratio PCA patient-controlled analgesia PCG and Childbirth Group (of the Cochrane Collaboration) PICO population (P), intervention (I), comparator (C), outcome (O)

PMNCH The Partnership for Maternal, Newborn & Child Health ABBREVIATIONS AND ACRONYMS

vii viii WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE WHO USAID USA UNICEF UNFPA TWG SMD RR RMC RHR RCT RCOG PPH

World Organization Health Development International for States Agency United States of America United Children’s Nations United Fund Fund Population Nations United Technical Working Group standardized difference mean ratio risk care maternity respectful (at Research and WHO) Health of Reproductive Department randomized controlled trial Gynaecologists Royal and of College Obstetricians haemorrhage postpartum Executive summary

Introduction clinically and psychologically safe environment with The majority of approximately 140 million continuity of practical and emotional support from a that occur globally every year are among women birth companion(s) and kind, technically competent without risk factors for complications for themselves clinical staff. It is based on the premise that most or their babies at the beginning and throughout women want a physiological labour and birth, and to labour. Nevertheless, the time of birth is critical have a sense of personal achievement and control to the survival of women and their babies, as the through involvement in decision-making, even when risk of morbidity and mortality could increase medical interventions are needed or wanted. considerably if complications arise. In line with the This up-to-date, comprehensive and consolidated targets of Sustainable Development Goal 3 – ensure guideline on essential intrapartum care brings healthy lives and promote well-being for all at all together new and existing World Health ages – and the new Global Strategy for Women’s, Organization (WHO) recommendations that, when Children’s and Adolescents’ Health (2016–2030), delivered as a package, will ensure good-quality global agendas are expanding their focus to ensure and evidence-based care irrespective of the setting that women and their babies not only survive labour or level of health care. The recommendations complications if they occur but also that they thrive presented in this guideline are neither country nor and reach their full potential for health and life. region specific and acknowledge the variations In spite of the considerable debates and research that exist globally as to the level of available that have been ongoing for several years, the health services within and between countries. The concept of “normality” in labour and childbirth is guideline highlights the importance of woman- not universal or standardized. There has been a centred care to optimize the experience of labour substantial increase over the last two decades in and childbirth for women and their babies through a the application of a range of labour practices to holistic, human rights-based approach. It introduces initiate, accelerate, terminate, regulate or monitor a global model of intrapartum care, which takes into the physiological process of labour, with the aim of account the complexity and diverse nature of pre­ improving outcomes for women and babies. This vailing models of care and contemporary practice. increasing medicalization of childbirth processes tends to undermine the woman’s own capability Target audience to give birth and negatively impacts her childbirth The recommendations in this guideline are intended experience. In addition, the increasing use of labour to inform the development of relevant national- and interventions in the absence of clear indications local-level health policies and clinical protocols. continues to widen the health equity gap between Therefore, the target audience includes national and high- and low-resource settings. local policy-makers, implementers and This guideline addresses these issues by identifying managers of maternal and child health programmes, the most common practices used throughout labour health care facility managers, nongovernmental to establish norms of good practice for the conduct organizations (NGOs), professional societies of uncomplicated labour and childbirth. It elevates involved in the planning and management of the concept of experience of care as a critical aspect maternal and child health services, health care of ensuring high-quality labour and childbirth care professionals (including nurses, midwives, general and improved woman-centred outcomes, and not medical practitioners and obstetricians) and just complementary to provision of routine clinical academic staff involved in training health care practices. It is relevant to all healthy pregnant professionals. women and their babies, and takes into account that childbirth is a physiological process that can be Guideline development methods accomplished without complications for the majority Throughout this guideline, the term “healthy of women and babies. pregnant women” is used to describe pregnant The guideline recognizes a “positive childbirth women and adolescent girls who have no identified experience” as a significant end point for all women risk factors for themselves or their babies, and undergoing labour. It defines a positive childbirth who otherwise appear healthy. The guideline was experience as one that fulfils or exceeds a woman’s developed using standard operating procedures in prior personal and sociocultural beliefs and expec­ accordance with the process described in the WHO tations, including giving birth to a healthy baby in a handbook for guideline development. Briefly, these SUMMARY EXECUTIVE

1 2 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE  below: defined following categories of intothe one recommendation each classified GDG the recommendation, of the context specific the instances insome and direction, the informed which EtD criteria, GRADE of the assessments on Based birth. after woman of the care immediate and ofthird labour, newborn, of the stage care immediate of labour, the stage during care second the during of labour,stage care first the during care birth, and labour namely, throughout they care relevant, are to which context care toaccording intrapartum the presented are Recommendations guidelines. WHO existing from integrated recommendations are 30 and recommendations newly developed are 26 care: of these intrapartum on recommendations to 56 led consultations technical WHO The Recommendations   providing a comprehensive document for end-users. end-users. for document providing acomprehensive of purpose the for into integrated this guideline and (GRC) Committee identified were systematically Review by Guidelines approved the guidelines WHO existing from recommendations relevant addition, In 2017. September inMay and consultations technical two –at this guideline of developing purpose the for assembled of experts group international an (GDG) Group Development – by Guideline the of recommendations formulation the to guide used was criteria, feasibility and equity, acceptability resources, values, effects, intervention includes tool that (EtD) evidence-to-decision an framework, evidence-to-decision GRADE The questions. priority for profiles evidence toreviews prepare were used systematic respectively. Up-to-date evidence, qualitative and quantitative for approaches, (CERQual) Reviewsfrom research of Qualitative in the Evidence Confidence and Evaluation (GRADE) Recommendations Assessment, Development and of Grading the using graded was recommendations the underpinning evidence scientific of the quality The guideline. of the updating and evaluation impact (v) planning dissemination, implementation, for and (iv) formulation recommendations; of the evidence; of the (iii) assessment synthesis; and (ii) evidence retrieval outcomes; and questions priority of (i) identification include: procedures    intervention or option should be implemented. be should option or intervention the that indicates category This Recommended: implemented. be not should option or intervention the that Not recommended: is applicable only to the condition, setting or or setting to condition, only the is applicable option or intervention the that indicates category This contexts: specific in only Recommended This category indicates indicates category This inclusion in future updates of the guideline. of the updates infuture inclusion for questions additional regarding suggestions welcomes WHO updated. will be recommendation the is identified, any recommendations) offor the base evidence current the potentially impact could (that event evidence new the that In employed. will be implementation following guideline gaps evidence bridging and of identifying process continuous and asystematic guidelines, health perinatal and maternal WHO updating for process with the accordance In levels care. of different at application its tools for monitoring labour will include of this guideline products Derivative approach. rights-based with ahuman accordance in care, such for foundation to asound and provide need, and they want that care of woman-centred type the to access all women tocare empower of intrapartum model this WHO aim to implement should systems Health available. are resources physical essential where working professionals care motivated health and competent by kind, inall settings, of care apackage as implemented be should inthis guideline recommendations the babies, their and women for experience childbirth to achieve that, apositive agreed GDG The were discussed. awhole as guideline the for and considerations for individual recommendations implementation the consultations, At technical the below. table inthe summarized are experience positive childbirth a for care intrapartum on recommendations The guideline. of the version full inthe recommendation each beneath directly presented are which remarks, to refer these should guideline of the Users respectively. to examined, be key needed issues which and context particular the about included was detail further research, of rigorous context in only the or contexts inspecific only option or intervention an recommended GDG the Where needed. where remarks additional provided experts contributing the inpractice, applied and understood is correctly To recommendation each that ensure   and its acceptability and feasibility. and acceptability its and option, or intervention of the toboth effectiveness related uncertainties and questions unanswered to is able address that of research form the takes it that provided scale, alarge on undertaken be still can implementation instances, such In option. or intervention the about uncertainties important are there that indicates research: category This rigorous of context the in only Recommended contexts. inthese implemented be only should and recommendation, in the specified population Summary list of recommendations on intrapartum care for a positive childbirth experience Category of Care option Recommendation recommendation Care throughout labour and birth Respectful 1. Respectful maternity care – which refers to care organized for Recommended maternity care 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. Effective 2. Effective communication between maternity care providers and Recommended communication women in labour, using simple and culturally acceptable methods, is recommended. Companionship 3. A companion of choice is recommended for all women throughout Recommended during labour and labour and childbirth. childbirth Continuity of care 4. Midwife-led continuity-of-care models, in which a known Context-specific midwife or small group of known midwives supports a woman recommendation throughout the antenatal, intrapartum and postnatal continuum, are recommended for pregnant women in settings with well functioning programmes.a First stage of labour Definitions of the 5. The use of the following definitions of the latent and active first Recommended latent and active stages of labour is recommended for practice. first stages of — The latent first stage is a period of time characterized by labour painful uterine contractions and variable changes of the , 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 and more rapid cervical dilatation from 5 cm until full dilatation for first and subsequent labours. Duration of the 6. Women should be informed that a standard duration of the latent Recommended first stage of first stage has not been established and can vary widely from labour 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. Progress of the 7. For pregnant women with spontaneous labour onset, the cervical Not recommended first stage of dilatation rate threshold of 1 cm/hour during active first stage labour (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 Not recommended 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 Not recommended threshold of 5 cm is reached. Therefore the use of medical interventions to accelerate labour and birth (such as oxytocin augmentation or ) before this threshold is not recommended, provided fetal and maternal conditions are reassuring. a Integrated from WHO recommendations on antenatal care for a positive pregnancy experience. EXECUTIVE SUMMARY EXECUTIVE

3 4 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE b a shaving Perineal/pubic admission labour on well-being fetal assessment of Routine admission on Clinical policy admission ward Labour Care option delay labour preventing Pain relief for management pain for techniques Manual management pain for techniques Relaxation relief pain for analgesia Opioid relief pain for analgesiaEpidural labour auscultation during rate heart fetal Intermittent labour during cardiotocography Continuous examination Digital vaginal admission on Enema labour management of Active Vaginal cleansing and mobility Maternal food and fluid Oral WHO recommendations for augmentation of labour of augmentation for Integrated from recommendations WHO Integrated from WHO recommendations for prevention and treatment of maternal infections peripartum

14. 13. 12. 11. 10. Recommendation 23. 22. 21. 20. 19. 18. 17. 16. 15. 27. 26. 25. 24.

recommended. is not birth vaginal to giving prior shaving perineal/pubic Routine admission. labour on being well- of fetal assessment the for is recommended stethoscope fetal Pinard or device ultrasound aDoppler using Auscultation labour. spontaneous in presenting women pregnant healthy in admission labour on well-being of fetal assessment the for recommended is not cardiotocography Routine recommended for healthy pregnant women. is not labour in admission on pelvimetry clinical Routine research. of rigorous context the in only recommended is stage first active until admission ward labour of delaying policy labour, a spontaneous in presenting women pregnant healthy For augmentation in labour is not recommended. of use the reducing and delay preventing for relief Pain awoman’s preferences. on labour, depending during relief pain requesting women pregnant healthy for recommended are packs, of warm application or massage as such techniques, Manual awoman’s preferences. on labour, depending during relief pain requesting women pregnant healthy for recommended are techniques, other and mindfulness music, breathing, relaxation, muscle progressive including techniques, Relaxation awoman’s preferences. on labour, depending during relief pain are recommended options for healthy pregnant women requesting pethidine, and diamorphine fentanyl, as such opioids, Parenteral preferences. awoman’s on labour, depending during relief pain requesting women pregnant healthy for is recommended analgesia Epidural labour. in women pregnant healthy for recommended is stethoscope fetal Pinard or device ultrasound a Doppler either with rate heart fetal of the auscultation Intermittent spontaneous labour. undergoing women pregnant healthy in well-being of fetal Continuous cardiotocography is not recommended for assessment women. low-risk in labour of stage first of active assessment routine for recommended is hours of four intervals at examination vaginal Digital augmentation is not recommended. of labour use the reducing for of enema Administration of delay in labour is not recommended. is not labour in of delay prevention for of labour management active for of care A package recommended. is not morbidities infectious of preventing purpose the for labour during chlorhexidine with cleansing vaginal Routine is recommended. low risk at women in labour during position upright an and of mobility adoption the Encouraging recommended. is labour during intake food and fluid oral low risk, at women For b a a a b . b b b Recommended Not recommended Not recommended recommendation Research-context recommendation of Category Recommended Recommended Recommended Recommended Recommended Not recommended Recommended Not recommended Not recommended Not recommended Not recommended Recommended Recommended Not recommended . Category of Care option Recommendation recommendation Routine 28. The use of amniotomy alone for prevention of delay in labour is Not recommended amniotomy not recommended.a Early amniotomy 29. The use of early amniotomy with early oxytocin augmentation for Not recommended and oxytocin prevention of delay in labour is not recommended.a Oxytocin for 30. The use of oxytocin for prevention of delay in labour in women Not recommended women with receiving epidural analgesia is not recommended.a epidural analgesia Antispasmodic 31. The use of antispasmodic agents for prevention of delay in labour Not recommended agents is not recommended.a Intravenous fluids 32. The use of intravenous fluids with the aim of shortening the Not recommended for preventing duration of labour is not recommended.a labour delay Second stage of labour Definition and 33. The use of the following definition and duration of the second Recommended duration of the stage of labour is recommended for practice. second stage of — The second stage is the period of time between full cervical labour 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. Birth position (for 34. For women without epidural analgesia, encouraging the adoption Recommended women without of a birth position of the individual woman’s choice, including epidural analgesia) upright positions, is recommended. Birth position 35. For women with epidural analgesia, encouraging the adoption of a Recommended (for women with birth position of the individual woman’s choice, including upright epidural analgesia) positions, is recommended. Method of pushing 36. Women in the expulsive phase of the second stage of labour Recommended should be encouraged and supported to follow their own urge to push. Method of pushing 37. For women with epidural analgesia in the second stage of Context-specific (for women with labour, delaying pushing for one to two hours after full dilatation recommendation epidural analgesia) 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. Techniques for 38. For women in the second stage of labour, techniques to reduce Recommended preventing perineal perineal trauma and facilitate spontaneous birth (including trauma perineal massage, warm compresses and a “hands on” guarding of the perineum) are recommended, based on a woman’s preferences and available options. Episiotomy policy 39. Routine or liberal use of episiotomy is not recommended for Not recommended women undergoing spontaneous vaginal birth. Fundal pressure 40. Application of manual fundal pressure to facilitate childbirth Not recommended during the second stage of labour is not recommended. a Integrated from WHO recommendations for augmentation of labour. EXECUTIVE SUMMARY EXECUTIVE

5 6 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE f e d c b a uterotonics Prophylactic stageThird of labour Care option oral suction or nasal Routine Care of the newborn massage Uterine (CCT) traction cord Controlled clamping cord umbilical Delayed the newborn of care postnatal immediate other and Bathing K vitamin using prophylaxis disease Haemorrhagic contact Skin-to-skin WHO recommendations on postnatal care of the mother and newborn and mother the of care postnatal on Integrated from recommendations WHO Integrated from WHO recommendations on newborn health pocket book recommendations of update technical for evidence conditions: childhood common of management for Integrated from Recommendations WHO Integrated from WHO Guidelines on basic newborn resuscitation outcomes nutrition and health infant and maternal improved for clamping cord delayed Guideline: WHO the from Integrated Integrated from WHO recommendations for the prevention and treatment of haemorrhage postpartum

41. Recommendation 43. 42. 47. 46. 45. 44. 51. 50. 49. 48. recommended for all births. is of labour third stage the during (PPH) haemorrhage of postpartum prevention the for of uterotonics use The ergometrine) or oral misoprostol (600 µ misoprostol oral or ergometrine) and of oxytocin combination drug fixed the or methylergometrine, ergometrine/ (if appropriate, uterotonics injectable of other use the is unavailable, oxytocin where settings In (PPH). haemorrhage of postpartum prevention the for drug uterotonic recommended is the IM/IV) IU, (10 Oxytocin not be performed. be not should nose and mouth of the suctioning birth, own after their on breathing start who fluid amniotic clear through born neonates In oxytocin. prophylactic received have who women in (PPH) haemorrhage to postpartum prevent intervention an as recommended is not massage uterine Sustained important. as of labour third stage of the duration the in reduction asmall and loss blood in reduction asmall regard woman parturient the and provider care ifthe births vaginal for (CCT) is recommended traction cord controlled available, are attendants birth skilled where settings In and nutrition outcomes. health infant and maternal improved for is recommended birth) after 1minute than (not earlier clamping cord umbilical Delayed 24 hours aday.24 hours room same the in stay should and separated be not should baby and mother The of hats/caps. use and adults, than more clothes of to layers two one means This is recommended. temperature ambient for baby of the clothing Appropriate six hours. least at for delayed be should bathing reasons, to cultural due possible is not this If birth. after 24 until delayed hours be should Bathing initiated). be should breastfeeding and mother the with contact skin-to-skin in be should infant the which by hour first the after (i.e. birth after Kintramuscularly of vitamin 1mg given be should newborns All ready. are baby and mother the and stable, clinically are they when birth after possible as soon as to breast the put be should to breastfeed, able are who babies (LBW) low-birth-weight including newborns, All breastfeeding. promote and to hypothermia prevent birth after hour first the during mothers (SSC) their with contact skin-to-skin kept in be should complications without Newborns . d f e c a b a . a . g) is recommended. a d . a . recommendation of Category Not recommended Recommended Recommended Recommended Recommended Recommended Recommended Recommended Recommended Recommended Not recommended . Category of Care option Recommendation recommendation Care of the woman after birth Uterine tonus 52. Postpartum abdominal uterine tonus assessment for early Recommended assessment identification of uterine atony is recommended for all women.a Antibiotics for 53. Routine antibiotic prophylaxis is not recommended for women Not recommended uncomplicated with uncomplicated vaginal birth.b vaginal birth Routine antibiotic 54. Routine antibiotic prophylaxis is not recommended for women Not recommended prophylaxis for with episiotomy.b episiotomy Routine 55. All postpartum women should have regular assessment of Recommended postpartum vaginal , , , temperature maternal and heart rate (pulse) routinely during the first 24 hours assessment 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.c Postnatal 56. After an uncomplicated vaginal birth in a health care facility, Recommended discharge following healthy mothers and newborns should receive care in the facility uncomplicated for at least 24 hours after birth.c,d vaginal birth a Integrated from WHO recommendations for the prevention and treatment of postpartum haemorrhage. b Integrated from WHO recommendations for prevention and treatment of maternal peripartum infections. c Integrated from WHO recommendations on postnatal care of the mother and newborn. d For the newborn, this includes an immediate assessment at birth, a full clinical examination around one hour after birth and before discharge. EXECUTIVE SUMMARY EXECUTIVE

7 8 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE shaving, enemas, amniotomy, intravenous fluids, amniotomy, fluids, intravenous enemas, shaving, perineal as such interventions, routine harmful potentially and to ineffective to subjected be 10) (9, episiotomy or birth vaginal operative section, caesarean augmentation, oxytocin induction, labour as such birth, and labour during intervention clinical one least at undergo women pregnant of healthy proportion have asubstantial that Studies shown of childbirth. process physiological with the interfere that interventions medical to unnecessary women pregnant healthy apparently may expose process, birthing the to provider control care health the enables which world, of the parts inmany care of intrapartum (8) services care intrapartum accessing to barrier asignificant also is but rights human their violates this only not and populations, underprivileged for particularly globally, settings facility inmany is prevalent care undignified and Disrespectful care. quality good guarantee may not facilities care inhealth care However, childbirth and arise. care labour accessing additional for need the should referral timely and professionals care health to skilled access ensure to facilities care inhealth to give birth encouraged have been women decades, two last the Over strategies (7) care postpartum or with antenatal compared deaths, newborn and maternal stillbirths, reducing for strategy impactful most as the identified been has inLMICs, especially of time birth, the around of care quality (HICs). the improving countries Therefore, to high-income (LMICs) compared countries income middle- inlow- and higher is disproportionately (6) childbirth and labour during complications from result deaths of neonatal aquarter and stillbirths 5) (4, sepsis or labour obstructed of haemorrhage, result as often period, postpartum immediate the or childbirth labour, during arise that to complications attributed are life-threatening conditions pregnancy-related of proportion asubstantial and deaths of maternal baby. and woman athird the both Over for increases death and morbidity labour, of risk serious the ever, during arise complications where insituations or their babies, at the onset of labour (2, 3) of labour onset the at babies, their or themselves for either complications, for factors risk identified with no women pregnant among births (1) year every occur Globally, births million approximately 140 1. . The burden of maternal and perinatal deaths deaths perinatal and of maternal burden . The Background . In addition, women in labour continue continue inlabour women addition, . In . . The majority of these are vaginal vaginal are of these majority . The . Similarly, approximately of half all . In addition, the prevailing model prevailing the model addition, . In . How . ­ proposed in the 1950s (15–18) 1950s inthe proposed limits slower the than be indeed can labour that suggest studies several of findings the as decade, last inthe into question called been has lines, action and alert the cervicograph, of its components however,WHO; important most of the validity the by promoted widely been has partograph of the use (14) is lacking labour of “normal” stages and phases different of the duration and onset of the However, definitions the around consensus is essential. progress and onset labour normal constitutes of what understanding aclear setting, inany To childbirth and labour monitor safely (13) minimize potential harms and improve theyoutcomes can that evidence clear is there when only implemented are interventions clinical intrapartum that important is therefore It outcomes. birth poor and care of intrapartum quality poor with resultant front-line workers, health overburden can childbirth of normal medicalization the settings, inlow-resource professionals care health of skilled of ashortage context the In family. her and to woman provided the of care quality the to optimize interventions clinical any necessary complement should that of care experience the of components essential are care childbirth and of labour aspects non-clinical These provided. consistently not are of labour stages second and first the during choice promote and women’s values respect that Similarly, options birthing settings. inmany priorities as regarded not are implement, to inexpensive fairly may be which care, respectful and communication effective companionship, labour through support provision as of emotional such (12) outcomes person-centred desired the achieving provision in care clinical as is important as of care experience childbirth, during women pregnant for of care quality improving (WHO) for framework World Organization inthe highlighted Health As populations. disadvantaged in newborns and women pregnant for gap equity the widened areunclear, further has benefits clinical the even when settings, in high-resource of technologies use questionable the Furthermore, (11) experience childbirth her impact negatively and childbirth during own capability weaken her can and preferences, and values needs, family’s) personal sensitive to woman’s the adequately (andnot her (11) births vaginal uncomplicated for antibiotics and antispasmodics . However, non-clinical intrapartum practices, practices, . However, intrapartum non-clinical . This interventionist approach is approach interventionist . This , on which these lines lines these which , on . . The routine routine . The . are based. The question of whether the current 1.2 Scope of the guideline cervicograph design can safely and unequivocally This guideline focuses on the care of all healthy identify healthy labouring women at risk of adverse pregnant women and their babies during labour outcomes has become critical to clinical guidance on and childbirth in any health care setting. Based on intrapartum care, and a careful consideration of the the premise that all women deserve high-quality evidence supporting its use was required. intrapartum care, the guideline includes practices This up-to-date, comprehensive and consolidated that are essential for the care of all pregnant women, guideline on intrapartum care for healthy pregnant regardless of their risk status. For the purposes women and their babies brings together new of this guideline, the term “healthy pregnant and existing WHO recommendations that, when women” is used to describe pregnant women and delivered as a package of care, will ensure good adolescent girls who have no identified risk factors quality and evidence-based care in all country for themselves or their babies, and who otherwise settings. In addition to establishing essential clinical appear to be healthy. The management of pregnant and non-clinical practices that support a positive women who develop labour complications and those childbirth experience, the guideline highlights with high-risk who require specialized unnecessary, non-evidence-based and potentially intrapartum care is outside the scope of this guide­ harmful intrapartum care practices that weaken line. This guideline is therefore complementary to women’s innate childbirth capabilities, waste existing WHO guidance on Managing complications resources and reduce equity. in pregnancy and childbirth: a guide for midwives and doctors (19). 1.1 Target audience The priority questions and outcomes that guided The primary target audience for this guideline is evidence synthesis and decision-making for this health care professionals who are responsible for guideline are listed in Annex 1. They cover essential developing national and local health protocols and care that should be provided throughout labour and those directly providing care to pregnant women childbirth, and interventions specific to the first and and their newborns in all settings. This includes second stages of labour. The priority questions and midwives, nurses, general medical practitioners, outcomes for existing WHO recommendations that obstetricians and managers of maternal and child have been integrated into this guideline, including health programmes. The guideline will also be of those relevant to the third stage of labour and care interest to professional societies involved in the care of the woman and newborn after birth, can be found of pregnant women, nongovernmental organizations in the respective guidelines from which they have (NGOs) involved with promotion of woman-centred been drawn. maternity care, and implementers of maternal and child health programmes. 1. BACKGROUND 1.

9 10 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE and updating of the guideline. guideline. of the updating and evaluation impact implementation, dissemination, (v) planning and recommendations; the the for (iv) formulation evidence; of the synthesis of and (ii) retrieval (iii) assessment evidence; of the outcomes; and questions priority (i) identifying development guideline for WHOhandbook inthe described procedures operating standard the using developed was document This inall countries. practices and policies evidence-informed using for support WHO’s normative represents document This scoping meeting held in April 2016, and provided provided and 2016, inApril held meeting scoping ina participated of this group members Selected meeting. GDG to first the prior review comment and website public for departmental RHR WHO the on published was members GDG of the biography short 2.13). of interest section (see conflicts A important no they had and balance, gender and representation geographic ensured ina way that were identified patient/consumer representatives. The members to delivery, two inaddition service and practices care relating to intrapartum methods development guideline and programmes, and policy practice, clinical inresearch, with expertise of individuals group adiverse was This GDG. to the regions form six the WHO from stakeholders and experts external 18 identified Group Steering WHO The 2.2 listedare inAnnex 2. Group Steering of the members The dissemination. and publication its managed and document, toguideline review, GDG the final for the prepared recommendations consultations), draft prepared (technical meetings GDG the organized synthesis, and retrieval, assessment evidence the supervised (GDG).Group Additionally, Group Steering the Development Guideline of the members and methodologists guideline reviewsystematic teams, identified and proposal, planning guideline the prepared outcomes, and questions priority identified guideline, of the initial the scope drafted group The process. development guideline the supervised Women’s Children’s (FWC) and Cluster, Health (MCA), Health Family, of the Adolescent and Child Newborn, of Maternal, Department WHO the and (RHR) Research and Health Reproductive members from the WHO Department of staff comprising Group, Steering WHO The 2.1 2. Methods Guideline Development Group WHO Steering Group (20) . In summary, the process included: included: process the summary, . In the ERG listed are inAnnex 2. the of members The by GDG. the werethat formulated recommendations to of this remit change group the within not was It policy-makers. and professionals care health girls, adolescent and women pregnant including recommendations, by the affected of persons preferences and values contextual processes considered and incorporated the decision-making guideline the that ERG ensured The implementation. for implications and issues contextual language, of the clarity on comment and errors any factual to identify document (ERG)Group peer-reviewedguideline final the 2.13). Review (see interest section External The of conflicts important no had members the and balanced, gender and representative geographically was group The care. intrapartum evidence-based provision inthe of interest with an stakeholders and experts six technical included group This 2.3 Annex 2. in found be can members list of GDG The document. guideline final the reviewed approved also and group 2017. September inMay and to-face The meetings twoface- at recommendations final the formulated and evidence the interpreted and examined GDG review. evidence the The guided that outcomes and questions priority of the intoversion final the input and other considerations relevant to the domains of to relevant domains the considerations other and questions priority for (Cochrane non-Cochrane) or reviews systematic suitable were no there Where (21) methodology Evaluation (GRADE) Recommendations Assessment, Development and of reviews systematic Grading the using these from evidence the appraised CREP from methodologists The Collaboration. Cochrane of the processes reviewssystematic standard following the of relevant updating the supervised and questions priority guideline of the scoping the on input (PCG) Group provided Childbirth and Pregnancy Cochrane the prioritized interventions, different of effects the on torelation evidence quantitative In methodologists. guideline as served Argentina, (CREP) Perinatales Estudios in Rosario, de Rosarino Centro from experts technical and Kingdom, United inBath, Consultancy Evidence-Based the from consultant independent An teams. review systematic and methodologists guideline Technical The (TWG) comprised Working Group 2.4 External ReviewExternal Group Technical Working Group . the GRADE evidence-to-decision (EtD) frameworks, United Kingdom’s National Institute for Health and new systematic reviews of quantitative or qualitative Care Excellence [NICE], the Agency for Healthcare studies were conducted by experts from CREP, Research & Quality [AHRQ] of the United States Argentina, and from the University of Central Department of Health & Human Services, and the Lancashire and King’s College London, United Institute for Clinical Systems Improvement [ICSI], Kingdom, in collaboration with the WHO Steering based in the United States of America]. Group. This exercise generated about 140 potential The Steering Group worked closely with members interventions that could be applied during the of the TWG to review the evidence and prepare the intrapartum period, starting before labour admission GRADE EtD frameworks. Members of the TWG are through to the immediate . The listed in Annex 2. interventions were then classified according to the WHO quality of care framework for maternal and 2.5 External partners and observers newborn health (Figure 2.1) (12) to ensure that the ensuing recommendations would respond to the Representatives of the International Federation of domains of intrapartum care quality in terms of both Gynecology and Obstetrics (FIGO), the International provision and experience of care. Confederation of Midwives (ICM), the Royal College of Obstetricians and Gynaecology (RCOG), The scoping exercise also informed the choice of the United Nations Population Fund (UNFPA) potential outcomes for the guideline, particularly and the United States Agency for International through the review of outcomes used in Cochrane Development (USAID) were invited to the final face- systematic reviews related to intrapartum care to-face GDG meeting in September 2017 to serve interventions. To prioritize outcomes, a total of 44 as observers (see Annex 2). These organizations international experts and stakeholders in the field of are potential implementers of the guideline with maternal and child health, including those who later a history of collaboration with the WHO RHR and participated in a guideline scoping meeting, were MCA Departments in guideline dissemination and invited to rank the potential outcomes identified implementation. through the above exercise, using an electronic survey. Survey participants ranked the relative 2.6 Identifying priority questions and importance of outcomes on a 9-point scale ranging outcomes from 1 (not important) to 9 (critical). Using all the responses, the median score was calculated for The WHO Steering Group, in consultation with the each outcome, to identify a set of outcomes that are systematic review teams, guideline methodologists “critical” (median scores 7) and “important but not and selected members of the GDG, drafted the ≥ critical” (median scores 4–6) as a basis for making priority questions for this guideline. To develop these decisions about the recommendations. questions, a rigorous scoping exercise to identify and map clinical practices, interventions and health Based on these initial steps, the WHO Steering outcomes related to intrapartum care commenced Group developed a framework for discussion at a in January 2016. First, a scoping literature review guideline scoping meeting, held in Geneva in April was performed to define the population of interest 2016, the aim of which was to prioritize guideline for the guideline and to explore what constitutes questions and to define the scope of the guideline in “normal” labour and childbirth in clinical practice terms of focus, population of interest, interventions across settings, based on a search of the PubMed and outcomes. At this meeting, it was decided and Latin American and Caribbean Health Sciences that the scope of this guideline should prioritize Literature (LILACS) databases. Next, a preliminary essential interventions that can be applied in low-, literature search of existing clinical guidelines and middle- and high-income settings, and that would key systematic reviews on intrapartum interventions be applicable to all pregnant women, regardless of was performed, using the following sources: their risk status (“low” or “high”) at the beginning of Cochrane Database of Systematic Reviews, LILACS, labour. Highly specialized labour interventions for National Guidelines Clearinghouse, PubMed, and the management of complications such as labour web pages of professional societies (including FIGO, dystocia, fetal distress and meconium staining were the European Board & College of Obstetrics and considered beyond the scope of this guideline. Gynaecology [EBCOG], the American College of The key thematic areas for essential intrapartum Obstetricians and Gynecologists [ACOG], RCOG, care were discussed in the light of interventions that the Royal Australian and New Zealand College of are already covered in existing WHO guidelines. Obstetricians and Gynaecologists [RANZCOG] Considering the resources available, the group

and the ICM) and health agencies (including the METHODS 2.

11 12 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE centred interventions and outcomes for intrapartum intrapartum for outcomes and interventions centred women- to identify need the highlighted process scoping the focus, guideline the determining In review (22) Cochrane supporting of the publication following the were identified trials new several which for childbirth, and labour during related to companionship question of the However, exception to the prioritization this the was document. guideline into final integrated the be procedures) would to standard according WHO (that were developed existing recommendations caveat that with the guidelines, by existing WHO addressed been haveto that already not those of questions prioritized to scope the limit agreed 2.1 Figure needed or wanted. are interventions medical even when making, indecision- involvement through control and achievement to of personal and have asense birth, and labour aphysiological want women Most staff. clinical competent technically companion(s) kind, birth and from support emotional and of practical with continuity environment safe psychologically clinically and to in a baby ahealthy birth giving includes This expectations. and beliefs sociocultural and personal prior their exceeds or fulfils that experience Women apositive want childbirth experience Positive childbirth 2.1 BOX

Outcome Process Structure WHO quality of care framework for maternal and newborn health newborn and maternal for framework care of quality WHO 3. 2. 1.

Functional referral systems referral Functional Actionable information systems complications of management and care routine for practices based Evidence Coverage of key of practices Coverage . Provision of care 7. Competent, motivated human resources human motivated 7. Competent, Individual and family-level outcomes 8. Essential physical resources available resources physical Essential 8. Health outcomes Quality of care of Quality Health system Health thresholds, respectively. thresholds, of test specificity and of labour, sensitivity and of phases duration and features characteristic include outcomes the threshold, dilatation cervical of 1-cm/hour performance diagnostic and labour of stages and phases of duration and definitions related to questions For prioritized. interventions all for of care quality of the women’s perception of to control) reflect sense and experience, of rating childbirth assessment, health logical psycho and women’s mental with care, satisfaction maternal (including experience” birth “maternal outcome with the complemented was outcomes qualitative reviewthe list of of the women’s views, by Informed questions. guideline individual for separately prioritized were further outcomes these labour, undergoing women to pregnant matters what for consideration with due and outcomes, of potential range the and interventions prioritized of types the between differences to important due However, period. intrapartum the for prioritized was (and to women families) their important and critical were that considered of outcomes aset meeting, scoping the at discussions above and described exercise prioritization outcome the on Based Box2.1). (as in experience” defined childbirth is a“positive childbirth undergoing women pregnant all for outcome primary the that review suggested (23) childbirth during value and need want, women what to understand conducted Tocare. review aqualitative systematic was this end, Emotional support Emotional 6. 5. 4. Effective communication Effective Respect and preservation of dignity of preservation and Respect People-cented outcomes Experience of care of Experience . The findings of this findings . The ­ Table 2.1 WHO intrapartum care guideline work streams

Work streams Methodology Assessment of evidence Definitions and duration of first and second stages of Systematic reviews of Modified GRADE labour; patterns of normal labour progression observational studies Diagnostic test accuracy (DTA) of 1-cm/hour cervical DTA reviews GRADE dilatation threshold Effects of individual interventions for clinical and non- Systematic reviews of GRADE clinical practices from labour admission until birth effectiveness studies Woman- and maternity staff-centred domains for Qualitative evidence values, acceptability, feasibility of implementing synthesis; mixed- GRADE-CERQual; GRADE practices, and equity issues related to intrapartum care methods reviews Systematic reviews or Resource implications for individual interventions As applicable single studies CERQual: Confidence in the Evidence from Reviews of Qualitative research (25); GRADE: Grading of Recommendations Assessment, Development and Evaluation (21)

In summary, this scoping and consultation process and harms), values, resources, equity, acceptability led to the identification of priority questions and and feasibility (24). The preparatory work for the outcomes related to the effectiveness of clinical and guideline was organized into five work streams to non-clinical practices aimed at achieving a positive synthesize and examine evidence across the EtD childbirth experience that includes a healthy mother framework domains (Table 2.1). and a healthy baby. These questions and outcomes are listed in Annex 1. 2.9 Evidence identification and retrieval Evidence to support this guideline was derived 2.7 Integration of recommendations from from a number of sources by the systematic review published WHO guidelines teams and methodologists working in collaboration In order to harmonize and consolidate all with the WHO Steering Group. Evidence on effects recommendations that are relevant to the care was mainly derived from Cochrane systematic of healthy pregnant women and their newborn reviews of randomized controlled trials (RCTs). The babies into a single document, existing WHO Steering Group, in collaboration with the Cochrane recommendations that were within the scope of PCG and methodologists from CREP, first identified essential intrapartum care were identified and all relevant Cochrane systematic reviews that integrated into this guideline. Only recommen­ addressed the prioritized questions. The Cochrane dations published from 2012 onwards in other systematic reviews were based on studies identified WHO guidelines approved by the Guidelines Review from searches of the Cochrane PCG Trials Register.1 Committee (GRC) were included. These integrated In instances where the Cochrane reviews identified recommendations cover other critical components were found to be out of date, review authors of intrapartum care for which questions were not were invited to update their Cochrane reviews prioritized. These include third stage of labour, care in accordance with the standard process of the of the newborn immediately after birth, and care Cochrane PCG and with the support of Cochrane of the woman after birth. Recommendations and PCG staff. their corresponding remarks have been integrated Where no systematic review was identified for a from their parent guidelines without modification, priority question, a new systematic review was as these recommendations were considered to be current. 1 The Cochrane Pregnancy and Childbirth Group (PCG) Trials Register is maintained by the Cochrane PCG’s 2.8 Focus and approach Trial Search Coordinator and contains trials identified The focus of this guideline is on the essential from: monthly searches of the Cochrane Central intrapartum care practices that all pregnant Register of Controlled Trials (CENTRAL); weekly searches of MEDLINE; weekly searches of Embase; women and adolescent girls should receive to hand-searches of 30 journals and the proceedings of facilitate a positive childbirth experience. To major conferences; weekly “current awareness” alerts help decision-makers consider a range of factors for a further 44 journals; and monthly BioMed Central relating to each intervention or option evaluated, email alerts. For further information, see: the GRADE EtD framework tool was used, which http://pregnancy.cochrane.org/pregnancy-and-

childbirth-groups-trials-register METHODS 2. includes the following domains: effects (benefits

13 14 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE studies. studies. relevant additional to identify used was of PubMed feature “related articles” The relief methods. pain episiotomy and positions, birth companionship, communication, pelvimetry, clinical monitoring, fetal including interventions, intrapartum specific of cost-effectiveness and in general, care of intrapartum cost-effectiveness and costs retrieved was Evidence on database. electronic 2017, to 20 February 1996 MEDLINE the using 1January review from systematic literature, of the bya identified was cost-effectiveness on Evidence publications. respective inthe found be reviewscan retrievalthese and for identification evidence for strategies search The conducted. was review mixed-methods afurther providers, care health by communication effective on question 28) (27, questions these addressing reviews qualitative systematic two specifically from were (RMC) derived care maternity respectful and companionship related to labour qualitative evidence (26) prioritized to interventions the relating equity on perceptions specific or general and stakeholders; other and by women valued are by intervention an impacted outcomes the how interventions; the of implementing feasibility professionals; care health and to women practices of acceptability interventions; care of intrapartum to delivery uptake facilitators and and of barriers views professionals’ care health care; intrapartum of interms providers care health and to women Qualitative reviews on: what matters focused solutions. on agree and challenges to discuss Group Steering with the communication inconstant methodologists with the iterative, was process review development systematic entire The members. GDG the among experts content selected and Group Steering by the protocol reviewed was endorsed and The plan. analysis adata of risk and bias; assessing for methods databases; bibliographic different for strategies search including studies, of identification comparator, for criteria outcome) question; intervention, PICO (population, aclear including: review, the on embarking protocol before a standard were asked to prepare experts external the instance, this In experts. external from commissioned explicit method of risk-of-bias method explicit six using assessment and reviews follows a specific inCochrane included studies of individual quality of the assessment The reviews the in included studies of primary assessment Quality 2.10 the evidence Quality assessment grading and of . In addition, addition, . In . To the inform CERQual tool, which uses a similar approach a similar approach uses which tool, CERQual research) tool (25) Qualitative from Reviews (Confidence of in the Evidence GRADE-CERQual the using quality for appraised qualitative of reviewsthe were findings The Group. Steering by WHO approved the procedures operating with standard review inaccordance evidence quantitative the graded CREP from methodologists review systematic and teams The downgrading. for aneed indicated that limitations were no there rating if of the upgrading to lead could of effect, magnitude as such considerations, other studies, observational For bias. publication and indirectness (risklimitations of bias), inconsistency, imprecision, downgraded based on consideration of study design then was rating quality baseline This evidence. low-certainty provide studies observational and trials non-randomized while evidence, certainty RCTsdefault, to high- provide were considered By low”, of criteria. aset on “very based or “low” “high”, as rated was outcome each for “moderate”, of evidence Accordingly, certainty the question. priority each for outcome quantitative each for prepared was profile evidence aGRADE and PICO in the questions, identified outcomes critical (21) of evidence quantitative quality the to appraising approach GRADE The review of the evidence assessment Quality (30) quality of poor grounds on excluded D study. were scoring of the Studies confirmability and/or dependability transferability, credibility, the likelyaffect flaws arevery that to of significant Ato from D,presence the ranging with Dindicating score a allocated then and criteria pre-defined 11 against studies rated that instrument a validated using system appraisal to quality asimple subjected qualitative for reviews were identified Studies review methodology. toaccording Cochrane the of risk bias for assessed was study included each Group, Steering by WHO the were commissioned which of interventions, reviews effectiveness on new systematic the For review the findings. impact how is it likely biasand of the to direction and likely the magnitude indicates that study included overall an each of risk biasfor provides domains these along assessment The bias. publication as such of bias, sources other and reporting selective attrition, participants, and personnel of study blinding concealment, allocation generation, sequence of risk for bias low,to at be unclear or high by rated reviewers and is assessed study included systematic reviewsfor (29) of interventions Cochrane inthe outlined criteria handbook standard was used for all the all the for used was . The GRADE- . The . Each . Each . conceptually to other GRADE tools, provides a Values: This relates to the relative importance transparent method for assessing and assigning the assigned to the outcomes of the intervention by level of confidence that can be placed in evidence those affected by them, how such importance from reviews of qualitative research. The systematic varies within and across settings, and whether this review team used the GRADE-CERQual tool to importance is surrounded by any uncertainty. The assess the confidence in qualitative review findings question asked was: “Is there important uncertainty – a level of confidence was assigned to the evidence or variability in how much women value the main domains on values, acceptability and feasibility outcomes associated with the intervention/option?” according to four components: methodological Interventions that resulted in outcomes that most limitations of the individual studies; adequacy women consistently value regardless of settings of data; coherence; and relevance to the review were more likely to lead to a judgement in favour question of the individual studies contributing to a of the intervention. This domain, together with the review finding. “effects” domain (see above), informed the “balance of effects” judgement. 2.11 Formulation of the recommendations Resources: This domain addressed the questions: The WHO Steering Group supervised and finalized “What are the resources associated with the the preparation of evidence profiles and evidence intervention/option?” and “Is the intervention/ summaries in collaboration with the TWG using option cost-effective?” The resources required the GRADE EtD framework. The EtD tool includes to implement the reviewed intrapartum care explicit and systematic consideration of evidence interventions mainly include the costs of providing on prioritized interventions in terms of specified supplies, training, equipment and skilled human domains: effects, values, resources, equity, resources. A judgement in favour of or against acceptability and feasibility. For each priority the intervention was likely where the resource question, judgements were made on the impact of implications were clearly advantageous or the intervention on each domain, in order to inform disadvantageous, respectively. Cost evaluation and guide the decision-making process. Using the relied on reported estimates obtained during the EtD framework template, the Steering Group and evidence retrieval process; the OneHealth Model: TWG created summary documents for each priority intervention treatment assumptions report (31); the question covering evidence on each domain, as WHO compendium of innovative health technologies for described below. low-resource settings (32); as well as the experiences and opinions of the GDG members. Where available, Effects: The evidence on the critical outcomes direct evidence from systematic reviews of cost- was summarized in this domain to answer the effectiveness informed this domain. questions: “What are the desirable and undesirable effects of the intervention/option?” and “What is Acceptability: This domain addressed the question: the certainty of the evidence on effects?” Where “Is the intervention/option acceptable to women benefits clearly outweighed harms for outcomes and health care providers?” Qualitative evidence that are highly valued by pregnant women, or vice from the systematic reviews on women’s and versa, there was a greater likelihood of a clear providers’ views and experiences across different judgement in favour of or against the intervention, labour practices informed the judgements for respectively. Uncertainty about the net benefits this domain. The lower the acceptability, the or harms, and small net benefits usually led to a lower the likelihood of a judgement in favour of judgement that did not favour the intervention or the the intervention. If it was deemed necessary to comparator. The higher the certainty of evidence of recommend an intervention that was associated benefits across outcomes, the higher the likelihood with low acceptability, the recommendation is of a judgement in favour of the intervention. In accompanied by a strategy to address concerns the absence of evidence of benefits, evidence of about acceptability during implementation. potential harm led to a recommendation against Feasibility: The feasibility of implementing an the option. Where evidence of potential harm was intervention depends on factors such as the found for interventions that were also found to resources, infrastructure and training requirements. have evidence of important benefits, depending on This domain addressed the question: “Is it feasible the level of certainty and likely impact of the harm, for the relevant stakeholders to implement the such evidence of potential harm was more likely intervention/option?” Qualitative evidence from the to result to a context-specific recommendation for systematic reviews on women’s and providers’ views the intervention (and the context is explicitly stated and experiences across different labour practices within the recommendation).

was used to inform judgements for this domain. METHODS 2.

15 16 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE  below. defined following categories the of intoone recommendation each classified GDG (34-36), EtD using frameworks the guidelines WHO published recently with other line In members. GDG of the judgement the and EtD framework in each presented of evidence range of the consideration explicit on based context, specific the instances insome and direction its including recommendation, each on to was consensus reach meetings of the purpose The feedback. preliminary through received any comments and recommendations draft the reviewed frameworks, the collectively members GDG meeting, each for chairperson GDG of the 2017, September leadership the in May and under Switzerland, inGeneva, headquarters WHO the at face-to-face meetings the During meetings. GDG the before documents the on comments provide were asked to review electronically and members GDG The face-to-face of meetings. the in advance weeks several and were drafted, documents the as soon as members to GDG recommendation, each related to documents other and profiles, evidence GRADE summaries, evidence including frameworks, EtD the provided Group Steering WHO The sources. relevant other reviews systematic or studies, single from extracted were These evidence. of direct absence in the information pertinent provided but question priority the addressed have not directly might that studies from were derived considerations Such subsections. “additional considerations” inthe described are consequences unintended or of potential harms evidence additional above of the domains, each For families. their and of groups women different (or among reduce reduce) inequalities could health proven (or if its effects anticipated) recommended likely was to intervention be An this domain. inform to were used members, GDG of the opinions and (8) birth facility-based (33) health child and newborn maternal, in reproductive, inequalities on report WHO 2015 the experiences, views and reviews providers’ women’s on and qualitative systematic of findings The equity?” intervention/option of the on impact anticipated is the “What question: the addressed domain this Therefore, inequities. health reduce would intervention an not or to as whether considerations Equity: intervention. infavour of the made be would ajudgement that likelyless it was were identified, barriers Where  intervention or option should be implemented. be should option or intervention the that indicates category This Recommended: , and a review on facilitators and barriers to barriers and areview facilitators , and on This domain encompasses evidence or , as well as the experiences experiences well, as the as the subject. WHO staff at the meetings, external external meetings, at the staff WHO subject. the on to arecommendation not issue choose could Secretariat WHO the case inwhich concern, related to was asafety disagreement the unless of it, voted thirds insupport GDG two of the than if more stand would decision or recommendation A GDG. of the members among a showof hands to avote. put Voting be would by have would been decision, any other or recommendation, disputed the to aconsensus, reach were unable participants the If contexts. different across interventions harms) and the of (benefits effects on of evidence balance the about discussions on based consensus, of process by same the of recommendations context the determined GDG the meetings). required, Where inany GDG of the disagreement of record such no (there was guideline inthe such as recorded been have would Strong disagreements position. their about strongly feel not did disagreed who those that provided GDG, of the more or quarters by three agreement as the defined was Consensus revision. after recommendation each wording of final the on to aconsensus and reach Group, Steering WHO by the drafted recommendations of the each and evidence supporting the to discuss participants to allow were designed meetings protocol: the by following the were guided meetings GDG The 2.12 described above. above. described to according categorized typology the been also For consistency, integrated recommendations have remarks. accompanying inthe presented been has document guideline source the from evidence of the quality and strength the on information guidelines, existing from integrated recommendations For       and its acceptability and feasibility. and acceptability its and option, or intervention of the toboth effectiveness related uncertainties and questions unanswered to is able address that of research form the takes it that provided scale, alarge on undertaken be still can implementation instances, such In option. or intervention the about uncertainties important are there that indicates research: category This rigorous of context the in only Recommended contexts. inthese implemented be only should and recommendation, in the specified population or setting to condition, only the is applicable option or intervention the that indicates category This contexts: specific in only Recommended implemented. be not should option or intervention the that Not recommended: indicates category This GDG meetings GDG Decision-making during the technical experts involved in the collection and meetings, members were required again to state grading of the evidence, and observers were not any conflicts of interest openly to the entire group, eligible to vote. If the issue to be voted upon involved and were required to submit a signed and updated primary research or systematic reviews conducted version of their earlier DOI statements. A summary by any of the participants who had declared an of the DOI statements and information on how academic conflict of interest, those individuals were conflicts of interest were managed are included in allowed to participate in the discussion, but were not Annex 3. allowed to vote on the issue in question. 2.14 Document preparation and 2.13 Declaration of interests by external peer review contributors Following the final GDG meeting, an independent In accordance with the WHO handbook for guideline consultant and the responsible technical officer development (20), all GDG, TWG and ERG members, from the WHO Steering Group prepared a draft of and external collaborators were asked to declare in the full guideline document to accurately reflect writing any competing interests (whether academic, the deliberations and decisions of the GDG. Other financial or other) at the time of the invitation to members of the Steering Group provided comments participate in the guideline development process. on the draft guideline document before it was sent The standard WHO form for declaration of interests electronically to the GDG members for further (DOI) was completed and signed by each expert comments. The document was revised based on and sent electronically to the responsible technical the feedback received from the GDG and then officer. The WHO Steering Group reviewed all the sent to the ERG for peer review. The ERG members DOI forms before finalizing experts’ invitations to were asked to review the revised draft of the participate. All experts were instructed to notify guideline to identify any errors of fact, comment the responsible technical officer of any change in on the clarity of the language, and to raise any relevant interests during the course of the process, issues related to implementation, adaptation and in order to review and update conflicts of interest contextual considerations. The Steering Group accordingly. In addition, experts were requested carefully evaluated the input of the peer reviewers to submit an electronic copy of their curriculum for inclusion in the final guideline document and vitae along with the completed DOI form. The made further revisions to the draft as needed. Steering Group collated and reviewed signed After the GDG meetings and external peer review, DOI forms and curriculum vitae, and determined further modifications to the guideline by the Steering whether a conflict of interest existed. Where any Group were limited to corrections of factual errors conflict of interest was declared, the Steering Group and improvements in language to address any lack determined whether it was serious enough to affect of clarity. The revised final version was returned the individual’s ability to make objective judgements electronically to the GDG for their approval. about the evidence or recommendations. To ensure consistency, the Steering Group applied the criteria 2.15 Presentation of guideline content for assessing the severity of a conflict of interest A summary list of the recommendations is as provided in the WHO handbook for guideline presented in the executive summary of this development (20). guideline. For each recommendation, a summary of All findings from the received DOI statements the evidence on effects, values, resources, equity, were managed in accordance with the WHO DOI acceptability, feasibility, and other considerations guidelines on a case-by-case basis. Where a conflict reviewed at the two GDG meetings can be found of interest was not considered significant enough to in the “Evidence and recommendations” section pose any risk to the guideline development process (Section 3). The language used to interpret the or reduce its credibility, the expert was only required evidence on effects is consistent with the Cochrane to declare the conflict of interest at the GDG Effective Practice and Organization of Care (EPOC) meeting and no further action was taken. Conflicts approach (37). of interest that warranted action by WHO staff arose The WHO Steering Group has integrated where experts had performed primary research into this guideline a number of existing WHO or a systematic review related to any guideline recommendations that are relevant to routine recommendations; in such cases, the experts were intrapartum care from other recent WHO guidelines. restricted from participating in discussions and/or In all instances, these recommendations are formulating any recommendation related to the area identical to those published in the respective source of their conflict of interest. At the GDG face-to-face

guidelines. To ensure that the integrated information METHODS 2.

17 18 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE include an additional remark providing a direct providing adirect remark additional an include recommendations Such section. remarks in the included been has existing recommendation the for published originally as evidence of the certainty and recommendation of the strength the is complete, recommendations. integrated these on details more for guidelines source WHO to respective the referred are users Guideline guideline. source the for address web 3. Evidence and recommendations

This guideline includes 56 evidence-based The corresponding GRADE tables for the recommendations on intrapartum care – 26 new recommendations are referred to in this section recommendations adopted by the Guideline as “evidence base” (EB) tables, and are numbered Development Group (GDG) at the 2017 meetings, according to the specific recommendations to which and 30 existing recommendations relevant to they refer. These tables are presented separately intrapartum care that were integrated from in the Web annex of this document.1 Evidence- previously published WHO guidelines. Sections to-decision (EtD) tables with GDG judgements 3.1–3.6 outline the narrative summaries and the related to the evidence and considerations for corresponding recommendations, grouped and all domains are presented in the “Summary of presented according to the timing of the practice evidence and considerations” sub-sections for each ranging from labour onset through to the immediate recommendation. postnatal period.

3.1 Care throughout labour and birth 3.1.1 Respectful maternity care

RECOMMENDATION 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. (Recommended)

Remarks

 Provision of respectful maternity care (RMC) is in accordance with a human rights-based approach to reducing maternal morbidity and mortality. RMC could improve women’s experience of labour and childbirth and address health inequalities.  There is limited evidence on the effectiveness of interventions to promote RMC or to reduce mistreatment of women during labour and childbirth. Given the complex drivers of mistreatment during facility-based childbirth, reducing mistreatment and improving women’s experience of care requires interventions at the interpersonal level between a woman and her health care providers, as well as at the level of the health care facility and the health system.  Effective communication and engagement among health care providers, health service managers, women and representatives of women’s groups and women’s rights movements is essential to ensure that care is responsive to women’s needs and preferences in all contexts and settings.  Interventions should aim to ensure a respectful and dignified working environment for those providing care, acknowledging that staff may also experience disrespect and in the workplace and/or violence at home or in the community.

Summary of evidence and considerations cRCT with only 2 sites and the other with 10 sites) and three were before–after studies. Control (or pre- Effects of the interventions (EB Table 3.1.1) intervention) sample sizes ranged from 120 to 2000 Evidence on the effects of respectful maternity participants across studies and post-intervention care (RMC) interventions on birth outcomes was samples ranged from 105 to 1680 participants. Most derived from a systematic review of five studies of the interventions included multiple components, that were conducted in Africa (Kenya, South Africa with an emphasis on community engagement as well [2 studies], Sudan and the United Republic of Tanzania) (38). The review found no studies from 1 Available at: www.who.int/reproductivehealth/ high-income countries (HICs). Two of the included publications/intrapartum-care-guidelines/en/index. 3. EVIDENCE AND RECOMMENDATIONS studies were cluster randomized controlled trials (1 html 19 20 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE bias for all outcomes. for bias of risk for downgraded was evidence of the certainty level the of Therefore, of risk bias. high or unclear were at all studies of the and were relatively sparse Data outcomes. of reporting and definitions the and design instudy studies across heterogeneity to due pooled were Data not recommendation. this for decision-making guide to pre-specified outcomes clinical the on data provided studies episiotomy, on other of data the none presented but study One data. observational by researchers’ were accompanied data self-reported studies, two In women’s on self-report. based care respectful or of disrespectful aspects on reported studies All the studies. inany of these reported not was practice” nature of The “usual with staff. package acommunication-building on focused was one and RMC, in labour, on emphasis with an companionship on focused was intervention One rights. their on women educating and complaints; submitting for providing amethod abuse; and members who have experienced disrespect of community counselling resolution; dispute mediation/alternative workshops; days; community open maternity shift); on providing tea those for beds); conditions staff improving between (e.g. partitions or inwards (e.g. with curtains privacy improving mentorship; staff abuse; and of disrespect monitoring teams; improvement quality up setting skills; communication ininterpersonal training transformation; attitudes and invalues were: training interventions RMC inthe included components Types abuse. of and disrespect reduce and RMC to increase staff of the part the on changes on as respectively. groups, 89.7%, post- inthe pre-intervention and versus by 94.7% experienced was care respectful that reported other the follow-up, and postpartum at “excellent” as respect rated of participants 0% versus 22.8% that reported study before–after one studies: observational by the supported is finding This [aOR] ratio 95% CIodds 2.45–4.84). 3.44, adjusted participants, cRCT, approximately 3000 (1 interventions RMC without than interventions with RMC care respectful experiencing to report likely more probably are women that suggests evidence Moderate-certainty care. of respectful experience the on studies) reported before–after care: Respectful experience Birth Maternal outcomes (no intervention) practice usual RMC Comparison: intervention RMC compared with Three studies (1 cRCT and 2 and cRCT (1 studies Three abuse of 49%. abuse inverbal reduction absolute an showed third study the while abuse, inverbal of increase possibility the study) 1before–after included and cRCT (1 studies two in of effect estimates the as abuse, in verbal difference no or little may be there that suggests studies) cRCT, (1 studies 2before–after three and : to after. before 0% 4.3% from in“episiotomy anaesthesia” without reduction (459 tobefore 0.2% after, participants) well as a as (208 participants) 3.4% from pressure fundal inobserved areduction reported other the and (523participants), to 0.4%participants) afterwards (677 intervention RMC the before 3.5% from reduced abuse physical observed that found study (95% before–after CI 0.05–0.97). One of 0.22 aOR an reported (approximately participants) 3000 toaverage of 3% cRCT 4% other follow-up. at The abaseline from arm control inthe increase an to average of 2% 1% follow-up at and baseline a from arm intervention inthe abuse in physical areduction reported cRCT One abuse. physical reduce probably interventions RMC that suggests (2 cRCTs studies) studies four 2before–after and abuse: Physical were reported. findings inconsistent and measures however, low certainty, very of different arange as of was evidence the this outcome; reported studies Lack of privacy: another. in study, reduction a52% inone and intervention RMC the after care abusive or in disrespectful reduction cRCT,with the 40% estimated with an consistent are data Observational CI 0.21–0.57). 95% 0.34, aOR participants, approximately 3000 thirds cRCT, two (1 by about care abusive or of disrespectful experiences reduces probably RMC that suggests evidence Moderate-certainty this outcome. reported studies before–after two and cRCT care: abusive One or of disrespectful Experience ofExperience mistreatment with thisconsistent evidence. are data 6.19, 95% Observational CI 4.29–8.94). aOR overall (approximately participants, 3000 care of good-quality experiences frequent more to leads probably RMC that suggests cRCT one care: of Quality 0.98, 95% CI 0.91–1.06). care with satisfied (aOR very being reporting women of proportion of the interms having one not and intervention RMC an having between difference no or little may be there that suggests cRCT one from Maternal satisfaction: Low-certainty evidence based on on based evidence Low-certainty Moderate-certainty evidence from from evidence Moderate-certainty Moderate-certainty evidence from from evidence Moderate-certainty One cRCT and two before–after before–after two and cRCT One Low-certainty evidence derived derived evidence Low-certainty /abandonment: Low-certainty evidence consistent across countries and settings (high based on four studies (2 cRCTs, and 2 before–after confidence in the evidence). studies) suggest that RMC interventions may reduce The findings indicate that women consistently neglect and abandonment. One cRCT found a appreciate and value RMC, and providers perceive 64% reduction (approximately 3000 participants; RMC to be a critical component of providing safe, aOR 0.36, 95% CI 0.19–0.71) and the other cRCT good-quality care (high confidence in the evidence). reported an increase from 12% to 16%. The Globally, women’s and providers’ perspectives on observational studies found no clear difference. what constitutes RMC are also quite consistent. Non-dignified care: Low-certainty evidence from one These stakeholders identify the key components of cRCT suggests that RMC may reduce non-dignified RMC as: being free from harm and mistreatment; care (approximately 3000 women, aOR 0.58, having privacy and confidentiality; dignified care; 95% CI 0.30–1.12). This evidence is supported by a receiving information and being supported in the before–after study during which researchers found process of informed consent; continuous access to large reductions in various aspects of non-dignified family and community support; high-quality physical care (e.g. the provider not introducing herself to environment and resources; equitable maternity the woman, failure to provide a clean bed for the care; effective communication; having choices and woman, and the woman not being cleaned after the opportunity to make decisions; availability of birth). competent and motivated human resources; and receiving efficient, effective and continuous care. Non-consented care and detention: Evidence on these outcomes is of very low certainty, partly because it The evidence shows that there is some variability was derived from before–after studies with design in the relative importance of some aspects of RMC. limitations. For example, women living in HICs emphasize their rights to decision-making and active participation Perineal/vaginal trauma in their childbirth experience (moderate confidence Episiotomy: The findings of one small study in the evidence). Comparatively, women in lower- suggested that RMC interventions may reduce income countries are less likely to demand personal episiotomy (low-certainty evidence). The episiotomy choices and decision-making over their childbirth rate was reduced by an average of 13% (from 34% process (moderate confidence in the evidence). to 21%) in the RMC arm of this study compared with an average of just 1% (from 40% to 39%) in the Resources control arm. No research evidence was found on the costs or Mode of birth, duration of labour, use of pain relief cost-effectiveness of RMC. The review found no evidence on these outcomes. Additional considerations Fetal and neonatal outcomes Developing a policy that promotes RMC needs to address multiple RMC domains, in terms of Perinatal hypoxia-ischaemia: The review found no interactions between individual women and health evidence on this outcome. care providers, as well as interactions at the health system level. System-level quality improvement Additional considerations is likely to require resources to sustain staff The systematic review evidence on RMC is derived behaviour change. This may include restructuring from studies conducted only in Africa and might not clinical training curricula for midwives, nurses be generalizable to other regions. and physicians, increasing the numbers of health care providers on staff, improving remuneration Values and respect for staff, and upgrading the physical A qualitative review (28) on RMC included 67 environment. The design of the labour ward may qualitative studies conducted in 32 countries, present a key barrier to some components of RMC including countries in sub-Saharan Africa (6 (e.g. labour companionship) in many settings. countries), Asia (7), Oceania (1), Europe (8), the However, several aspects of RMC, particularly Middle East and North Africa (5), North America those at the interpersonal level (e.g. improving (2) and Latin America (3). The studies reported communication, respecting women’s choices on the experiences of women, family members, during labour and childbirth, reducing physical and and multiple cadres of health care providers and verbal abuse, improving privacy and maintaining administrators. The review concluded that women confidentiality), would require comparatively few placed high value on RMC, and this finding was resources to address them. 3. EVIDENCE AND RECOMMENDATIONS

21 22 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.1 Staff Resource Training Supplies Equipment Infrastructure monitoring and Supervision Main resource requirements for respectful maternity care (RMC) care maternity respectful for requirements resource Main Description                                       that are able to provide dignified and continuous care care all to women continuous and dignified to provide able are that teams multidisciplinary in working mix, skills appropriate an with attendants birth skilled remunerated adequately and supervised trained, of competent, numbers Adequate Other: orientation sessions for service users and companions and users service for sessions orientation Other: days open facility e.g. members, staff and management service the with interaction community for opportunities providing and voices women’s including on focus with a particularly engagement, community effective for training staff: Outreach staff of new orientation and training; (cultural pre-service competence); of women needs linguistic and cultural social, the meet that services of RMC delivery effective enable provision to RMC on training in-service practice-based, regular Staff: policies RMC apply and develop to trained and to RMC, oriented and sensitized management: facility care Health times in the labour and childbirth areas childbirth and labour the in times all at quantities sufficient in available care childbirth and labour for Essential companion her and woman the for leaflets) as e.g. (written pictorial, or Information A standard informed consent form facility care health by the served communities of the languages the in available and format pictorial or written accessible an in materials, education Health refreshments e.g. ward, in labour staff for Provisions RMC for mechanisms monitoring and plans operational goals, clear outline that benchmarks and standards up-to-date Written, quantities at all times in the labour and childbirth areas childbirth and labour the in times all at quantities sufficient in is available that childbirth and labour for equipment adequate and Basic managed by a trained pharmacist or dispenser or pharmacist by atrained managed is that system management stock supplies and amedicine and pharmacy On-site " " " " " " " Enhanced physical environment: Establishment of informed consent procedures violations or of mistreatment event the in redress for mechanisms of accountability Establishment to management complaints to submit providers and users (e.g. service abox) for mechanism accessible Easily practices RMC to review meetings Staff lead ward/facility by labour supervision supportive Regular " " " " " " " her companion and woman the for space private physical including companions, labour Facilities for capacity bed sufficient and partitions screens, Curtains, rubs hand alcohol-based or soap with station, water, hygiene ahand drinking and Safe labour in by women use for bathrooms accessible and Clean areas neonatal and labour, the in childbirth supply energy Continuous maintained and equipped adequately are and privacy for allow that areas neonatal and labour, ventilated childbirth well illuminated, appropriately Clean, together to remain babies their and to women allow Rooming-in Equity No direct evidence on the impact of RMC on equity BOX 3.1 was found. However, indirect evidence from a Selected statements from the UN Human qualitative review on facilitators and barriers to Rights Council indicating support of RMC facility-based birth (8) indicates that mistreatment  A human rights-based approach is about and abuse by health workers is a substantial barrier health and not isolated pathologies; it is to the use of facility-based birth services in low- and premised upon empowering women to middle-income countries (LMICs) (high confidence claim their rights, and not merely avoiding in the evidence). This suggests that mistreatment maternal death or morbidity. contributes to health inequalities related to the use  Measures are required to address the social of facility-based birth services. determinants of women’s health that affect Further indirect evidence from the RMC qualitative the enjoyment of civil, political, economic, review (28) indicates that respecting the culture, social and cultural rights. [This includes values and beliefs of individual women and gender discrimination, and marginalization local communities is important to women (high based on ethnicity, race, caste, national confidence in the evidence). The evidence also origin and other grounds.] indicates that providing the same standard of  Human rights require “particular attention maternity care for all, regardless of age, ethnicity, to vulnerable or marginalized groups”. race, sexuality, religion, socioeconomic status, HIV status, language or other characteristics is  Applying a rights-based approach to important to women (moderate confidence in the the reduction of maternal mortality and evidence). morbidity depends upon a just, as well as an effective, health system. Inequity can result from receiving judgemental care from health care providers, and ensuring non-  The design, organization and coordination judgemental care for women may be important to of the components of the health system improve equity (low confidence in the evidence). should be guided by fundamental human rights principles, including non- Additional considerations discrimination/equality, transparency, participation and accountability. A policy of RMC is in accordance with the general principles of the Human Rights Council’s 2012  Ensuring women’s sexual and reproductive Technical guidance on the application of a human- health rights requires meeting standards rights-based approach to the implementation of policies with regard to health facilities, goods and and programmes to reduce preventable maternal services. morbidity and mortality (39), as indicated by the  States are required to use “maximum statements presented in Box 3.1. available resources” for the progressive realization of economic, social and cultural Acceptability rights; if resource constraints make it Findings from a qualitative review (28) indicate impossible for the State to fulfil women’s that women appreciate RMC across countries sexual and reproductive health rights and settings (high confidence in the evidence). immediately, the State must demonstrate Stakeholders (including women, providers and that it has used all the resources at its administrators) emphasized the theoretical impor­ disposal to do so as a matter of priority. tance of providing and ensuring RMC for all women. Source: United Nations, 2012 (39). Review findings also suggest that efforts to address or improve RMC may be acceptable to health care providers (high confidence in the evidence). and the specific RMC intervention. The review found However, in environments where resources are little evidence on acceptability of specific RMC limited, health care providers believe that RMC interventions that have been implemented. could increase their workload and could reduce their ability to provide quality care to all women. For example, they perceive that RMC could require Additional considerations spending more time with individual women, which Mistreatment of women during childbirth is often may compromise care for other women who are left due to existing social norms and in some settings it unattended. Thus, acceptability among health care may be regarded by health care providers and other providers may vary, depending on the available time stakeholders as acceptable (40–42). 3. EVIDENCE AND RECOMMENDATIONS

23 24 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.2 likely to be feasible in settings where resources are are resources where likely insettings to feasible be is most policies of RMC introduction the Thus, settings. resourced limited inpoorly may be aspects of these sustainability and feasibility therefore and is likely staff, be resource-intensive, trained to of numbers adequate ensuring and environment physical the improving as such of RMC, aspects in evidence).the some Addressing (high confidence constraints to resource to due so do unable may feel but care and woman-centred dignified respectful, like would to providers care provide health most that aqualitative review from Evidence (28) Feasibility Feasibility Equity effectiveness Cost- Acceptability resources required of evidence of Certainty required Resources effects of Balance Values the evidence of Certainty effects Desirable effects Undesirable RMC intervention RMC no with compared intervention (RMC) care maternity Respectful judgements: of Summary No included included No No included included No Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know know Don’t Don’t know Don’t know studies studies ✓ ✓ ✓ – – – – – – – Varies Varies Varies Varies Varies Varies Varies Varies ✓ ✓ – – – – – – suggests suggests Favours usual usual Favours Favours usual usual Favours Large costs Large Reduced care care – – – – uncertainty or or uncertainty intervention intervention considered to be socially acceptable (40–42) acceptable to socially be considered is childbirth during of women mistreatment where insettings particularly challenging, is often facilities care inhealth behaviours established and norms cultural changing sense, inageneral stakeholders viewed positively may by be RMC While considerations Additional agenda. care health the on is prioritized system health inthe RMC increasing where feasible are they that implies settings inlow-resource conducted (38) policies of RMC impact demonstrating allstudies five that fact the Nevertheless, adequate. Important Important Moderate variability Probably Probably Probably Very low Very Very low Very reduced no RMC RMC no no RMC RMC no favours favours favours favours Trivial Large costs No No – – – – – – – – – – – uncertainty or or uncertainty Probably No Probably No intervention intervention favour RMC RMC favour favour RMC RMC favour Probably no no Probably or no RMC RMC no or or no RMC RMC no or Negligible important important Moderate variability Does not not Does Does not not Does Possibly costs or or costs savings impact Small Low Low ✓ – – – – – – – – – – uncertainty or or uncertainty favours RMC favours favours RMC favours Probably Yes Probably Yes Probably no no Probably important important Moderate Moderate Moderate Moderate variability increased Probably Probably Probably savings Small ✓ ✓ – – – – – – – – – uncertainty or or uncertainty Large savings Large No important important No Favours RMC Favours Favours RMC Favours variability Increased were were Trivial Large High High Yes Yes . ✓ ✓ ✓ – – – – – – - - 3.1.2 Effective communication

RECOMMENDATION 2

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

Remarks

 In the absence of a standardized definition of “effective communication”, the GDG agreed that effective communication between maternity care staff and women during labour and childbirth should include the following, as a minimum. "" Introducing themselves to the woman and her companion and addressing the woman by her name; "" Offering the woman and her family the information they need in a clear and concise manner (in the language spoken by the woman and her family), avoiding medical jargon, and using pictorial and graphic materials when needed to communicate processes or procedures; "" Respecting and responding to the woman’s needs, preferences and questions with a positive attitude; "" Supporting the woman’s emotional needs with empathy and compassion, through encouragement, praise, reassurance and active listening; "" Supporting the woman to understand that she has a choice, and ensuring that her choices are supported; "" Ensuring that procedures are explained to the woman, and that verbal and, when appropriate, written informed consent for pelvic examinations and other procedures is obtained from the woman; "" Encouraging the woman to express her needs and preferences, and regularly updating her and her family about what is happening, and asking if they have any questions; "" Ensuring that privacy and confidentiality is maintained at all times; "" Ensuring that the woman is aware of available mechanisms for addressing complaints; "" Interacting with the woman’s companion of choice to provide clear explanations on how the woman can be well supported during labour and childbirth.  Health systems should ensure that maternity care staff are trained to national standards for competency in interpersonal communication and counselling skills.

Summary of evidence and considerations and communication skills during the women’s labour and childbirth. The study from the United Kingdom Effects of the intervention (EB Table 3.1.2) evaluated the impact of training on patient-actor Evidence on the impact of effective communication perceptions of care from doctors and midwives on birth outcomes was sought from a mixed- during simulated obstetric emergencies. methods systematic review (43). The review authors considered interventions to improve communication The trial conducted in the Syrian Arab Republic between maternity staff and women – including the evaluated a specifically designed communication use of health education materials, job aids, training skills training package provided to all resident of providers on interpersonal communication and doctors at four (137 doctors), which counselling – in terms of their impact on the birth covered characteristics and principles of effective outcomes pre-specified for this guideline question. communication, how to overcome barriers to Two RCTs were included: a stepped-wedge cluster effective communication, and how to improve RCT (cRCT) from the Syrian Arab Republic (44) interactions with patients. Effectiveness was and a sub-analysis of an RCT from the United assessed among 2000 women who gave birth to Kingdom (45). The study from the Syrian Arab a live baby. The primary outcome was women’s Republic evaluated the impact of interventions to satisfaction with interpersonal and communication improve resident doctors’ communication skills on skills of doctors during labour and childbirth women’s satisfaction with doctors’ interpersonal measured at two weeks after birth using a modified 3. EVIDENCE AND RECOMMENDATIONS

25 26 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE were blinded to the group allocation. to group the were blinded who midwives were experienced inthis study actors communication”. to Patient- good due informed well felt “I as: such to statements responses actor patient- for used was scale Likert A five-point training. after weeks three emergencies simulated three the on respect, and safety communication, to inrelation of care quality the included assessed Outcomes own . intheir room delivery dystocia) ina shoulder [PPH] and haemorrhage (eclampsia, postpartum emergencies obstetric simulated standardized three managed participants post-training, and Pre- of teamwork. components to demonstrate activities clips and video lectures, Training centre. simulation a local included content with a2-day at teamwork training or course hospital, alocal witha 2-day at teamwork training course centre, asimulation at course a1-day hospital, local a at course a1-day interventions: training emergency obstetric of to four one were randomized doctors study, and midwives 140 Kingdom United The package. training of the implementation after to weeks three two measured and checklists observational using documented as of doctors behaviour communicative the included (MISS-21). outcomes Secondary Scale Satisfaction Interview Medical of the version certainty evidence suggests that there may be little little may be there that suggests evidence certainty low- very scenario, eclampsia the For centre. simulation acentral at with training compared when communication, and toin relation safety patient-actors among of care improved perceptions to may lead hospital local the at of teams training and individual; an team or byfor amultidisciplinary they were cared of whether regardless emergencies, obstetric three of the management for training clinician after of care patient-actors’ perceptions in improvement scenario: PPH the for outcomes following the for evidence low-certainty very found (45) study second The intervention. training the after and similar before clinicians) among were behaviour communicative (comparing post-interventionscores and pre- checklist observational that evidence low-certainty very also was There trial groups. were similar across to them?) talking when them at look doctor the Did them? greet examination? doctor the Did medical to a prior themselves identify (e.g. doctor the Did labour during with them communication doctor’s of their aspects related to women’s specific views on evidence). (very Findings scores low-certainty in satisfaction women’s difference no or little found (44) study first The care staff compared with usualpractice Comparison: Effective communication by health , from the Syrian Arab Republic, Republic, Syrian the Arab , from , from the United Kingdom, Kingdom, United the , from effective if they improve the quality of maternity maternity of if quality they improve the effective likely are to cost- be interventions Communication considerations Additional found. was interventions of communication effectiveness cost- or cost the on evidence research No Resources evidence). in the (high confidence of RMC key components of the one as communication effective value and consistently appreciate women that indicate RMC (28) synthesis evidence qualitative another of in evidence).the Findings confidence (high understand they can inamanner providers care health competent technically from information like would women to receivemost relevant required, are evidence).in the interventions Where (high confidence sensitive are to needs who their professionals care of health reassurance and support the they value and interventions, medical certain and outcomes birth adverse childbirth, and labour about apprehensive are time, first the for birth giving (23) care intrapartum during to women matters what at looking of a reviewqualitative studies of findings The Values question. this guideline for pre-specified outcomes any fetal/neonatal or maternal other the on evidence no review found The considerations Additional training. clinical the to teamwork added was when scenarios emergency obstetric any simulated of for the communication care related of to perceptions in difference no or little may be there that suggests evidence Very team. low-certainty multi-professional the of members between communication effective of importance the emphasized which activities, non-clinical clips and video lectures, including course, a1-day comprised teamwork training The scenarios. emergency obstetric simulated three of to teamwork inthe training training clinical addition by the influenced was to communication of patient-actors) (through use the care inrelation of perceptions evaluated whether study same The training. hospital-based following local in patient-actor of communications perceptions improvement no suggests also scores clinicians’ care individual on evidence low-certainty very dystocia, shoulder For related to communication. scores care patient-actors’of in perceptions difference no or indicate that most women, especially those those especially women, most that indicate that focused on on focused that Table 3.3 Main resource requirements for effective communication

Resource Description  Adequate numbers of skilled birth attendants with an appropriate skill mix, working in Staff multidisciplinary teams, and trained facilitators  Core education curricula at pre- and in-service levels, which include training on communication that reflects women’s social, cultural and linguistic needs, where relevant to labour and childbirth Training  Development or adaptation of training strategies to promote, sustain and assess the communication skills of maternity care staff during provision of labour and childbirth care  Regular in-service training on communication during labour and childbirth  Health education materials or tools to clearly communicate progress of labour (e.g. cervical Supplies dilatation 0–10 cm pictorial chart) to women and their companions of choice during labour and childbirth  No special equipment required Equipment  Some decision-support tools could be helpful (e.g. electronic screen-based tools)  Variable, depending on type and content of training  Training facilities to support development of skills and competencies in effective Infrastructure communication  Support for all clinical staff who provide care for women in labour to attend communication training Supervision  Regular supportive supervision and review by labour/facility lead with positive clinician and monitoring support  Regular multidisciplinary meetings to discuss and review communication approaches for women during labour and childbirth care, reduce medical interventions and improve equity if it discourages marginalized women, birth outcomes; however, direct evidence on their particularly in LMICs, from giving birth in a facility. impact is lacking. The main cost associated with Effective communication by health care providers communication interventions for women during that happens in partnership with women and their labour, childbirth and the immediate postnatal families could help women feel informed and could period is training of maternity staff, which can be plausibly also empower disadvantaged women to targeted at both pre- and in-service levels. This will speak up about the care they receive. require resources, as training to inform and sustain behaviour change among health care professionals Acceptability might require a variety of approaches, including lectures, workshops and one-to-one training From the mixed-methods systematic review (43), sessions. Sustaining clinical training will also require no direct evidence was found on the acceptability resources to provide ongoing practice development. of communication interventions provided to From the perspectives of women and their families, women in labour. However, findings from a resource requirements associated with effective qualitative systematic review of women’s views and communication interventions are likely to be experiences of intrapartum care (26) indicate that negligible. women appreciate communication in many forms including positive reassurance to allay anxiety, active Equity listening skills to accommodate women’s choices and concerns, and empathy to establish trust and No direct evidence on the impact of communication understanding (high confidence in the evidence). interventions on equity was found. Indirect evidence from a qualitative review of barriers and facilitators Findings on health care provider views from one of to uptake of facility-based birth services indicates the studies included in the mixed-methods review, that perceived poor quality of care is probably a from the Syrian Arab Republic (44), suggest that significant barrier to uptake by women in LMICs attendance at training to enhance competencies and (high confidence in the evidence) (8). Poor or skills in communication is acceptable to health care abusive health care provider communication could professionals and may be viewed positively by them influence decisions about where to give birth in (very low confidence in the evidence). subsequent pregnancies (8), and further undermine 3. EVIDENCE AND RECOMMENDATIONS

27 28 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.4 evidence). in the (high confidence want women that manner engaging sensitive, inthe with women communicate to capacity limit their sometimes considerations (26) care intrapartum of delivering experiences and views professionals care health review exploring evidence). aqualitative systematic from Evidence in (verythe low confidence of implementation feasibility the may impact also towardsstaff women of attitudes cultural and of facility type of women, in evidence).the status Lowsocial low confidence (very routines hospital and pressures workload pressures, time including workshops, training attending professionals care health for interventions of communication to implementation barriers several may be there that review suggest methods (44) study one from findings Again, Feasibility effects of Balance effectiveness Cost- effects Desirable effects Undesirable resources required of evidence of Certainty Values the evidence of Certainty required Resources Equity Acceptability Feasibility suggests that time pressures and workload workload and pressures time that suggests interventions communication no with compared interventions Communication judgements: of Summary No included included No No included included No Don’t know know Don’t Don’t know Don’t know Don’t know know Don’t Don’t know Don’t know Don’t know Don’t know studies studies ✓ ✓ ✓ ✓ ✓ – – – – – Varies Varies Varies Varies Varies Varies Varies Varies ✓ – – – – – – – in the mixed- inthe communica communica intervention intervention Large costs Large Favours no no Favours Favours no no Favours Reduced tion tion tion tion – – – – - - communication communication uncertainty or or uncertainty intervention intervention favours no no favours favours no no favours Important Important Moderate variability Probably Probably Probably Very low Very Very low Very reduced Trivial Large costs No No ✓ interventions are supported. are interventions influenceimportant on whether communication likely also are to have women, an marginalized especially towards women, attitudes Cultural term. longer inthe feasible be may not childbirth and labour during interventions of communication –implementation team working of lack and resources workforce poor volume, patient with high insettings –especially change systems necessary without that suggest Findings inpractice. change to “embed” istime needed how much and of interest outcomes communication enhance to interventions of training effects the sustain and monitor prepare, to how organizations to given be needs consideration weeks), further and (around time three inarelatively short intervention training evaluated their and implemented review (43) mixed-methods the In considerations Additional – – – – – – – – – – tion intervention tion tion intervention tion Does not favour favour not Does Does not favour favour not Does Negligible costs no communica no communica communication communication intervention or or intervention intervention or or intervention uncertainty or or uncertainty Probably No Probably No Probably no no Probably or savings important important Moderate variability Possibly impact Small Low Low ✓ – – – – – – – – – – - - communication communication uncertainty or or uncertainty Probably Yes Probably Yes intervention intervention Probably no no Probably important important Moderate Moderate Moderate Moderate variability increased Probably Probably Probably savings favours favours favours favours Small ✓ ✓ ✓ – – – – – – – – , both trials, both communication communication uncertainty or or uncertainty Large savings Large No important important No intervention intervention intervention intervention variability Increased Favours Favours Favours Favours Trivial Large High High Yes Yes – – – – – – – – – – – 3.1.3 Companionship during labour and childbirth

RECOMMENDATION 3

A companion of choice is recommended for all women throughout labour and childbirth. (Recommended)

Remarks

 The companion in this context can be any person chosen by the woman to provide her with continuous support during labour and childbirth. This may be someone from the woman’s family or social network, such as her spouse/partner, a female friend or relative, a community member (such as a female community leader, health worker or traditional ) or a (i.e. a woman who has been trained in labour support but is not part of the health care facility’s professional staff).  The GDG discussed the issues of privacy, cultural preferences and resource use, which are often raised as barriers to implementing this intervention, and agreed that simple measures to allow female relatives to accompany women during labour could be used as cost-effective and culturally sensitive ways to address these concerns. If labour companionship is implemented in settings where labour wards have more than one bed per room, care should be taken to ensure that all women have their privacy and confidentiality maintained (e.g. by consistent use of dividers/curtains).  The GDG noted that countries and policy-makers are often reluctant to implement this intervention in clinical practice in spite of the supporting evidence, which has been available for many years, even though the intervention is routinely applied in private facilities. The group agreed that extra efforts are needed to encourage potential implementers at various levels of health care delivery to implement this intervention.  It is important that women’s wishes are respected, including those who prefer not to have a companion.  Finding a companion of choice to support labour might not be easy for marginalized or vulnerable women, or if women live far from health care facilities, or if the companion requires payment. Health care facilities need to take this into account and consider steps to ensure that support is always available for all women during labour.  A number of WHO guidelines recommend continuous companionship during labour and childbirth, including WHO recommendations: optimizing heath worker roles to improve access to key maternal and newborn health interventions through task shifting (34), WHO recommendations for augmentation of labour (46) and WHO recommendations on health promotion interventions for maternal and newborn health (47).

Summary of evidence and considerations praise and encouragement – and they were usually continuously provided during established labour. Effects of the intervention (EB Table 3.1.3) Epidural analgesia was available to women in 14 of Evidence for this recommendation was derived the trials, was not available in eight trials and its from a Cochrane systematic review in which 26 availability was unknown in four trials. trials involving 15 858 women contributed data (22). The trials were conducted in Australia, Belgium, Comparison: Companionship during labour and Botswana, Brazil, Canada, Chile, Finland, France, childbirth compared with usual practice Greece, Guatemala, Iran, Mexico, Nigeria, South Maternal outcomes Africa, Sweden, Thailand, Turkey and the USA. Most trials (20) recruited women around the time Mode of birth: Low-certainty evidence suggests that of admission to hospital for childbirth. In 15 of the companionship during labour and childbirth may trials, the facility setting did not usually permit increase spontaneous vaginal birth (21 trials, 14 369 women to have someone with them in labour, women, RR 1.08, 95% CI 1.04–1.12; absolute effect: whereas in 11 trials, the facility permitted women 54 more per 1000 [from 27 to 81 more]) and reduce to be accompanied by a partner or family member. caesarean section (24 trials, 15 347 women, RR 0.75, Labour support interventions were very similar 95% CI 0.64–0.88; absolute effect: 36 fewer per across the trials – including comforting touch, 1000 [from 17 to 52 fewer]). A subgroup analysis by 3. EVIDENCE AND RECOMMENDATIONS

29 30 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE chosen by the woman. by woman. the chosen was person not the or whether of regardless staff, hospital of the amember is not person support the when greatest is effect this that indicate differences [from 37 fewer]). to 73 1000 fewer per Subgroup 55 effect: 0.69, absolute RR 95% CI 0.59–0.79; women, 11 133 trials, (11 experience childbirth of ratings negative reduces probably childbirth and labour during companionship that suggests experience: Birth person. support of type according to the differ not may effect this that suggest findings Subgroup 0.97, RR women, 12 833 trials, 95% CI 0.91–1.03). (17 oxytocin with synthetic of labour augmentation on effect no may have or little childbirth and labour during companionship that suggests Augmentation of labour: [from 7to fewer]). 83 1000 per 48 fewer effect: absolute 0.93, 95% CI 0.88–0.99; RR women, (9 11 444 is it used trials, where settings in analgesia of epidural use may reduce childbirth and labour during companionship that suggests also evidence Low-certainty this outcome. for person support of types between difference no or little be may fewer]).there that suggest findings Subgroup 30 to [from 120 1000 per 75 fewer effect: absolute 0.90, RR 95% CI 0.84–0.96; women, 12 433 trials, of relief (15 pain of any type use may reduce childbirth and labour during companionship that suggests evidence Low-certainty relief: pain of Use shorter). hours shorter, 95% CI 0.34–1.04 hours [MD] difference mean 0.69 women, 5429 trials, (13 of labour length the reduces probably childbirth and labour during companionship that suggests Duration of labour: 0.97, RR women, 8120 trials, 95% CI 0.92–1.01). (episiotomy trauma tears)perineal (4 perineal or to difference no or little makes probably childbirth and labour during companionship that suggests Perineal trauma: for person support this outcome. of by analysis type subgroup review perform not did 30 8 fewer]).[from to 1000 per 20 fewer effect: The absolute 0.90, RR 95% CI 0.85–0.96; women, 14 118 (19 trials, birth vaginal instrumental reduce may childbirth and labour during companionship that suggests also evidence Low-certainty 0.61, 95% CI RR 0.45–0.83). section: caesarean and 95% CI 1.15, 1.05–1.26; RR birth: vaginal (spontaneous effect may havewoman” greatest the by the chosen not and staff “not are hospital who people support that suggests person of support type Moderate-certainty evidence Moderate-certainty evidence Moderate-certainty evidence Low-certainty evidence evidence Low-certainty the time when many women experience anxiety anxiety experience women many when time the is as that effective, more be plausibly ward) could to labour the admission before or (e.g. home at labour inearly commenced companionship ward, to labour the admission trials upon included in most commenced was companionship labour Although labour. during acompanion permitted previously were not women where and performed, (CTG) cardiotocography routine where is not available, is not epidural where insettings and HICs, with compared countries inmiddle-income greatest experience”, may be “negative childbirth and section incaesarean reductions including outcomes, birth on several companionship of effects beneficial the that review in the suggest findings subgroup Other considerations Additional 95% 1.11, CI 0.98–1.26). RR women, 1025 trials, (3 exclusive any breastfeeding or increases probably childbirth and labour during companionship that indicate findings subgroup by the woman, chosen not was and member staff ahospital is not person However, support the when 95% CI 0.96–1.16). 1.05, RR babies, 5584 trials, exclusiveto anybreastfeeding or difference (4 no or may make little childbirth and labour during companionship that suggests evidence certainty Longer-term mother-infant outcomes: [from 2 to 9fewer]).1000 per 6 fewerlow scores effect: absolute 0.46–0.85; 95% CI 0.62, RR 12 615 (14 trials, 5 minutes babies, at scores low Apgar reduces probably childbirth and labour during companionship that suggests evidence Perinatal hypoxia-ischaemia: Fetal and neonatal outcomes data. contributing studies two the between to level ahigh due of inconsistency pooled were not depression 0.73–1.02). postpartum on Data 95% CI 0.86, RR women, 5571 trial, (1 outcome on this effect no or little has probably childbirth and labour during companionship staff, hospital are people support the when that suggests evidence However,95% CI 0.09–0.33). moderate-certainty 0.17, RR 159 trial, (1 women, by woman the chosen not was and member staff ahospital is not person support the when depression postpartum reduce may childbirth and labour during companionship that suggests evidence Low-certainty 95%(4 CI 0.83–1.21). 1.00, RR 2456 trials, women, pain of severe by labour women report postpartum to the difference no or little makes probably childbirth and labour during companionship that suggests evidence Moderate-certainty Moderate-certainty Low- about how to cope with contractions, when to go the cost of running their programme was “minimal” (49). hospital and other practical considerations. In 2015, the programme charged volunteers US$ 35 per training course; this fee included a “doula bag” Values containing a handbook, birth ball, yoga blocks and Findings from a review of qualitative studies various single-use comfort items, such as lotion and exploring perceptions and experiences of labour chewing gum. companionship indicate that women from both HIC and LMIC settings value the non-pharmacological Additional considerations pain relief measures that companions help to The evidence above suggests that the cost facilitate, including a soothing touch (holding and cost-effectiveness of providing a volunteer hands, massage and counter pressure), breathing companionship service in HICs can vary and relaxation techniques. Companions also help considerably, with the main cost being associated women to adopt alternative positions to ease pain, with service provision. The use of lay companions such as squatting, sitting on a ball and walking. (family members or female friends) might constitute Some women also find comfort in spiritual support, a relatively low-cost intervention from a provider when their companions read holy texts or pray (high perspective, as there are usually no remuneration confidence in the evidence) (27). costs for service or transport; however, user costs (companion transport costs and/or the loss of the This review also found that women from both HIC companion’s income from other activities) might and LMIC settings value feeling in control during be a barrier to uptake. From a provider perspective, labour and are confident in their ability to give birth. there would be costs associated with orientating/ The findings indicate that companions help women training both lay companions and and in to feel self-confident, and improve their self-esteem ensuring that the infrastructure is adequate to when they acknowledge and reinforce the women’s support them (see Table 3.5). efforts, provide encouragement and directions for how to maintain control, and ensure that women are The quantitative evidence on the effectiveness aware of their choices (moderate confidence in the of labour companionship suggests that labour evidence) (27). companionship can reduce caesarean section by 25%, instrumental vaginal birth by 10% and the Resources use of pain relief by 10%. These reductions could No evidence on the cost or cost-effectiveness of plausibly lead to substantial cost savings. companionship interventions in LMICs was found. In a high-income setting (USA) where doulas are Equity reimbursed for their services, a cost-effectiveness Evidence from a qualitative systematic review study reported potential cost savings with doula on perceptions and experiences of labour care, based on an average doula remuneration of companionship explored how women from minority US$ 986 per birth, and lower and groups experienced labour companionship. caesarean section rates. In contrast, a 2015 cost- Immigrant, refugee and foreign-born women in effectiveness analysis of volunteer companion HICs highlighted how lay companions from their support for disadvantaged childbearing women own ethnic/religious/cultural community, who are in the United Kingdom reported substantially trained as labour companions, were an important higher costs per birth (£1862) (48), as reductions way for them to receive culturally competent care. in caesarean section and epidural use were small These lay companions empowered women to ask where they occurred. The major cost attributed questions, acted as their advocates, and ensured to the United Kingdom programme was service that their customs and traditions were respected. provision (including: salaries/wages, premises, When women received this type of care, they felt equipment and consumables), with other costs more confident to give birth and less like “outsiders” including volunteer recruitment, training (materials, in their new community (low confidence in the catering, childcare) and travel expenses. The evidence) (27). authors suggested that volunteer companion Evidence from a review of barriers and facilitators payment in the region of the United Kingdom to facility-based birth indicates that a lack of national minimum wage could be considered (about supportive attendance at facilities is probably a £8 per hour). significant barrier to the uptake of facility-based A study on the establishment of a volunteer birth by women in LMICs (moderate confidence companion programme among student nurses and in the evidence) (8). Facility policies that limited community members in the USA reported that the the involvement of family members and traditional 3. EVIDENCE AND RECOMMENDATIONS

31 32 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.5 in these settings would increase equity. increase would settings in these women to of choice underprivileged companionship (51) privately them pay for doulas want who women HICs, particularly countries, many In settings. inhigh-resource women use) among epidural birth, vaginal instrumental section, (e.g. caesarean of childbirth medicalization the reduces if companionship increased be also could Equity birth. of facility-based by women uptake increased indirectly,advocacy, and through and directly, empowerment through equity increase could doulas community-based or friends members, by family inlabour women for companionship ensure that inLMICs facilities that suggest (27) companionship of labour experiences and qualitative of a perceptions reviewon findings The 39) human rights-based approach (28, with a is inaccordance and (RMC) care maternity of respectful component important is an companion awoman’sfacilitating with to regard choice abirth and birth giving women for support Improving considerations Additional confidence in the evidence) (8) (high afacility at to give birth choosing from LMICs in women many deters facilities at experiences childbirth negative previous that evidence clear review found also The women. inmany anxiety inthis review were found to induce attendants birth Staff salaries Resource companion Training the of Supplies Infrastructure Time monitoring and Supervision

Main resource requirements for labourMain companionship resource requirements Description                       service companion the manage or support and companions labour To for orientation provide sessions for a family member or friend (50) friend or member afamily for sessions (e.g. 2-hour two techniques companionship labour supportive on session Orientation Other training costs, including transportation costs for participants and venue hire venue and participants for costs transportation including costs, training Other Refresher courses volunteers/doulas)trained Measures to support privacy and confidentiality, including dividers/curtains confidentiality, and including privacy to support Measures Incentives Information, education and communication materials on supportive techniques Private physical space for the woman and her companion at the time of birth time the at companion her and woman the for space physical Private to atoilet access clothes, achair, to change space including companions, for facilities accommodation Basic (49) (e.g. to 8- 12-hour shifts support of labour provision and training for time Companion health system health the within friends) or members family not are (those who companions paid and volunteer supporting and coordinating integrating, of registering, of asystem Establishment , either paid or unpaid) or paid , either . . . Extending . Extending

in the evidence)in the (27) (high confidence choices their restricting thus ward, inthe women of other privacy tothe protect order in allowedwere to only companion, have afemale women cases, some In beds. to separate a curtain only with possibly plans, floor open had wards often overcrowded. Labour become wards would and maintained be not could privacy that perceived was it as companionship, labour to implementing barrier akey wards as of labour constraints space physical the highlighted settings, inLMIC particularly partners, male and women providers, care Health settings. different across companionship labour of to implementation the enablers and barriers explored companionship of labour experiences and reviewA qualitative systematic perceptions on Feasibility companion (high confidence in the evidence) (27) of labour achoice women of giving importance the demonstrate settings, LMIC and inHIC populations within and between both women, among differences These people. of different acombination or doula, sister, partner, male or mother, mother-in-law, husband their including companion, desired their advocate. Women stated different preferences for trustworthy and compassionate acaring, be to this person for need the expressed present to companion have preferred Women alabour who companionship. labour for women’s preferences explored companionship of labour experiences and reviewA qualitative systematic perceptions on Acceptability , or a 1- or 2-day course (49) 2-day or a1- course , or . or longer for for longer or . Furthermore, in settings where labour conflict between the provider, the companion and/ companionship was implemented, providers were or the woman, or a feeling that the companion/ often not trained on how to integrate this person doula was “in the way” (moderate confidence in the into the woman’s support team. This could lead to evidence) (27).

Table 3.6 Summary of judgements: Companionship compared with usual practice

Desirable – – – – – ✓ effects Don’t know Varies Trivial Small Moderate Large Undesirable – – – – – ✓ effects Don’t know Varies Large Moderate Small Trivial Certainty of – – – ✓ – the evidence No included Very low Low Moderate High studies Values – – ✓ – Important Possibly Probably no No important uncertainty or important important uncertainty or variability uncertainty or uncertainty or variability variability variability Balance of – – – – – – ✓ effects Don’t know Varies Favours usual Probably Does not Probably Favours com- practice favours usual favour com- favours com- panionship practice panionship or panionship usual practice Resources – ✓ – – – – – required Don’t know Varies Large costs Moderate Negligible Moderate Large savings costs costs or savings savings Certainty – – ✓ – – of evidence No included Very low Low Moderate High of required studies resources Cost- Don’t know ✓ – – – – – effectiveness Varies Favours usual Probably Does not Probably Favours com- practice favours usual favour com- favours com- panionship practice panionship or panionship usual practice Equity – – – – – – ✓ Don’t know Varies Reduced Probably Probably no Probably Increased reduced impact increased Acceptability – – – – ✓ – Don’t know Varies No Probably No Probably Yes Yes Feasibility – ✓ – – – – Don’t know Varies No Probably No Probably Yes Yes 3. EVIDENCE AND RECOMMENDATIONS

33 34 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE 3.1.4  Remarks recommendation) (Context-specific programmes. midwifery functioning well with settings in women pregnant for a womansupports throughout the antenatal, intrapartum and postnatal continuum, are recommended midwives known of group small or midwife aknown which in models, continuity-of-care Midwife-led RECOMMENDATION 4                positive pregnancy experience antenatal on a for care WHOrecommendations the from integrated been has recommendation This available at: http://apps.who.int/iris/bitstream/10665/250796/1/9789241549912-eng.pdf document, guideline source inthe found be can this recommendation supporting evidence The provided. be should training necessary any and assessed, be should education and training or continuing one-off additional for need The process. implementation the aid also could organizations with professional consultation government-level settings, some involved. are In departments resources human and consulted are stakeholders allif relevant is likely effective to more be implementation this case, is the Where care. postnatal and antenatal for responsible have been who previously professionals care health other well as of as midwives responsibilities and of MLCC roles inthe to introduction may ashift lead The caseloads. with of reasonable midwives number to asufficient access has system health the to that ensure inresources ashift require may therefore model This childbirth. during and pregnancy her throughout of midwives group asmall only or one see womaneach to for numbers available are insufficient MLCC midwives well that trained requires settings. individual in sustainable more are models team care or caseload whether to determine workload, and burnout provider and use, to resource monitor is it important of care with this that noted model panel The of care. continuity value women because midwives, than other providers through care ways of providing continuous wish to might consider stakeholders (and addition, In quality) the improving midwives. of practising number the up scaling successfully after only this model implementing consider should programmes midwife well functioning without insettings Policy-makers of care. models inother practice midwife instandard enacted be not might or inMLCC might inherent models philosophy midwifery The both. or of care philosophy midwifery the of care, continuity is the positive outcomes these produce can that pathway the of influence whether is it unclear and interventions MLCC complex are models practices. parenting healthy and childbirth, and to pregnancy facilitate ahealthy period, postnatal and intrapartum antenatal, the throughout woman (case-loadmidwife midwifery), (team midwives a of known midwifery), group small or supports trusted and (MLCC) aknown inwhich of continuity-of-care care Midwife-led models are models Continuity of care of Continuity (35) . 3.2 First stage of labour 3.2.1 Definitions of the latent and active first stages of labour

RECOMMENDATION 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. (Recommended) ——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. (Recommended)

Remarks

 The GDG acknowledged that the “latent first stage” (or the “latent phase”) is sometimes described as the “early” or “passive” first stage. However, the group favoured the continued use of “latent first stage” (or the “latent phase”) since this is the oldest and most familiar terminology, and because introduction of a new term might require additional training with minimal or no additional value. Likewise, the use of “active first stage” (or the “active phase”) to describe the period of accelerative labour during the first stage is preferred to other terms such as “established” labour.

Summary of evidence and considerations studies (29), prospective cohort studies (18) and RCTs (7), while the remaining studies (8) employed Definitions of latent and active phases of the first stage of labour a range of qualitative, case–control, mixed methods or other research designs. No studies specifically investigating birth outcomes based on the use of different definitions of phases of The second systematic review (52) included 37 the first stage of labour were identified. Evidence on studies conducted in 17 low-, middle- and high- the definitions of onset of latent and active phases income countries (China, Colombia, Croatia, Egypt, of the first stage of labour was derived from three Finland, Germany, Israel, Japan, Republic of Korea, systematic reviews: (i) a systematic review of the Myanmar, Nigeria, Norway, Taiwan [China], Uganda, definitions of onset and features of latent and active the United Kingdom, the USA and Zambia), and phases of the first stage of labour as defined for involving over 200 000 women of different ethnic healthy pregnant women labouring spontaneously origins and socioeconomic status. These studies in research contexts and clinical practice, and the primarily evaluated the duration of phases and scientific rationale underpinning such definitions stages of labour among women who presented (14); (ii) a systematic review on the duration of with spontaneous labour and were considered to labour which also evaluated the definitions of be at low risk of developing complications, and phases of labour (52); and (iii) a systematic review secondarily evaluated the definitions of the phases of cervical dilatation patterns which provides of stages of labour as applied in the included studies. evidence on the dilatation threshold for the onset of The third systematic review (53) included seven active phase as indicated by the beginning of rapid observational studies conducted in China progression of cervical dilatation (53). (2 studies), Japan (1 study), Nigeria and Uganda The first review (14) included 62 studies conducted (1 study in both countries) and the USA (3 studies). in 24 low-, middle- and high-income countries: The studies reported data for 99 712 “low-risk” Australia (1 study), Austria (1), Bahrain (1), Canada women with spontaneous labour onset, vaginal (1), France (1), Germany (6), India (1), Iran (3), birth and no adverse perinatal outcomes, and they Ireland (1), Israel (2), Italy (4), Jordan (1), Kuwait (1), evaluated the time needed for cervical dilatation New Zealand (1), Nigeria (4), Norway (3), Pakistan to progress centimetre by centimetre through the (1), Philippines (1), Saudi Arabia (1), South Africa first stage of labour, and the corresponding rate of (2), Republic of Korea (2), Sweden (1) and the USA change (slope) from one level of cervical dilatation (22). Most of the studies were published between to the next. 2005 and 2013. They included retrospective cohort 3. EVIDENCE AND RECOMMENDATIONS

35 36 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Four studies characterized onset of the active phase phase active of the onset characterized studies Four respectively. studies, 10 in2and were used cm, 3–4 studies); and however, more, or of 2 cm definitions (14 more or of 4 cm dilatation as cervical defined commonly most was phase active of the onset The long. seconds 40 than more be should phase active in the contractions that stated studies two while inlength, 20–25 are that seconds by contractions is characterized labour of active onset that indicated study One insix studies. minutes in10 contractions least at as 2–3 described was but definition, the of part as contractions including studies among specified not largely was contractions uterine painful of frequency The definition. in the dilatation 27 while (82%) cervical contractions, included uterine painful of regular presence the included of labour stage first of the phase active the review, 20 (60%) defined that studies 33 of the Active phase onset and features: phase. latent of the definition the regarding information third additional review no The provides cm/hour”. >1.2 was progress dilatation cervical the of slope the where examination of time the until the contractions of regular onset reported the from time of length to “the was it hospital”, inanother while presentation before of labour duration “the as phase latent the defined study One 4cm. than less or 3 cm than less cm, 2.5 than less including dilatation, of cervical measures inconsistent using phase latent the review, second defined the In six studies definitions. in their leakage) fluid amniotic and show” (e.g.signs “bloody physiologic included Few studies women. parous for 4cm and women nulliparous for latent phase the of end the marked of 3 cm dilatation acervical that to according parity, latent phase of indicating the end the defined study, study one respectively. One and studies inthree were used to 2 cm, equal or than studies); (7 4 cm however, less and 3cm than less than less of dilatation as cervical defined commonly most was phase of latent Onset definition. their in contraction of each duration included studies of these none minutes; 10 every contractions painful two least at be should there stated study one and 8–10 every minutes, contraction uterine painful one least at be should there latent phase of the onset (23%) the during that studies stated Three definition. inthe dilatation cervical included 11 while contractions, uterine painful of regular presence the included of labour stage first of the phase latent the review, defined that all 13 studies Latent phase onset and features: Findings In the first first the In In the first first the In their perceived level of support (55) level of support perceived their and environment of nature the the experienced, pain level the of of inter-related including variety factors, a on likely is more to to dependent cope be ability (54) of labour phases time-bound defined, to recognize providers care likely health than less are women that suggests studies other from Evidence considerations Additional baby. and mother for outcomes with good (23) care intrapartum during to women matters what at looking areview from of qualitative studies Findings Values (53) outcomes perinatal normal and labour with spontaneous women areview on included that based was 5cm least at of threshold dilatation cervical by the defined as However, phase of outcomes. active onset the birth on phase of latent definition of any particular impact the or basis for the to support evidence is no There considerations Additional women). 56 823 studies, (3 cm/hour 1.49 rate dilatation became median the when reached, was of 5cm until a dilatation 1hour than longer ≥ 1) was (parity women by inparous 1cm advance to dilatation cervical for time median pooled the Likewise, rate dilatation doubled. median the which after 6cm, 5and between started progression dilatation cervical to rapid transition more The women). (6 42 648 studies, cm/hour 1.09 became rate dilatation median the when reached, was 5 cm of until adilatation 1hour than longer was women by innulliparous to 1cm dilatation advance cervical for time third the In review, median pooled the cm. 10 as phase active of the end the defined consistently All studies hospital. the at of arrival time the from dilatation to achieve cervical full spent as time the defined was study, phase active the (1), cm 2.5 (1), 3 cm (6) 4cm (1). 5cm or one In study), (1 cm of 1.5 thresholds dilatation cervical on based phase active of the onset the defined review, inconsistently second the In studies 11 phase. active of the onset of the definitions their leakage) in fluid amniotic and show” (e.g. “bloody physiologic signs included effacement. Twostudies 75% to up least labour, at 100% active from ranging of onset the of definition in the effacement cervical substantial hour. included per 1cm Sixthan studies to dilate begins more cervix the which at point the as indicate that most women want a normal birth birth anormal want women most that indicate . . , and their their , and Table 3.7 Main resource requirements for adopting new definitions of the latent and active phases of the first stage of labour

Resource Description  Practice-based training for health care providers to increase knowledge on in-hospital and Training outpatient supportive care for the latent phase of the first stage of labour  Revised training manuals and clinical protocols for health care providers and those in pre- service training Supplies  Educational materials for women on what comprises onset of the latent and active phases, and when to go to a facility for assessment  Revised paper partograph indicating the starting point of the active phase  Where all women are directly admitted to the hospital regardless of the phase of labour, sufficient beds should be provided in the maternity/antenatal ward where necessary Infrastructure supportive care (e.g. pain relief) can be provided to women prior to reaching cervical dilatation of 5 cm Supervision and  Ongoing supervision and monitoring with regular auditing and review of outcomes related monitoring to application of the new definition of the active phase

Resources Acceptability No review evidence on resource requirements in No direct evidence on acceptability of any specific direct relation to the definitions of the phases of the definition of the first stage of labour to stakeholders first stage of labour was found. – women and health care providers – was found.

Additional considerations Additional considerations Application of the 5-cm cervical dilatation threshold Evidence from other studies suggests that women as the benchmark for the onset of the active phase are less likely than health care providers to recognize of the first stage of labour might be cost-effective defined, time-bound phases of labour (54), and their because it has the potential to reduce the use ability to cope is more likely to be dependent on a of interventions to accelerate labour and birth variety of inter-related factors, including the level of (caesarean section, oxytocin augmentation) and pain experienced, the nature of the environment and linked interventions (e.g. cardiotocography, pain their perceived level of support (55). Given that 4 cm relief, antibiotics). This is supported by evidence of cervical dilatation has been widely adopted and from observational studies which shows that labour used in practice for decades as the limit of the latent interventions are reduced in women admitted in the first stage of labour, acceptance of a new cut-off by active phase of labour (based on a threshold of 4 cm clinicians is not expected to be rapid. or less) compared with the latent phase, without increasing maternal or perinatal morbidity. While Feasibility the new 5-cm threshold for the onset of active phase No direct evidence on the feasibility of adopting may further reduce the likelihood of interventions, it or implementing these definitions in labour ward might also increase health care costs as a result of protocols was found. reorganization of labour ward infrastructure, revision of labour ward admission policies, and additional Additional considerations training for health workers so that they can apply the new definitions in practice. While the implementation of a new threshold for recognizing the onset of the active first stage in labour protocols might be relatively straightforward Equity in settings where all women in labour are admitted No evidence on the impact on equity was found. at any phase of the first stage of labour, it is likely to face challenges in settings where the policy is Additional considerations to admit women only when they are in active first Unnecessary oxytocin augmentation of labour stage, due to the need for reorganization of care. and caesarean section are highly inequitable interventions that could be reduced if the standard care for the active first stage is only applied after the

woman has reached a cervical dilatation threshold 3. EVIDENCE AND RECOMMENDATIONS of 5 cm. 37 38 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.8 Equity effectiveness Cost- Acceptability resources required of evidence of Certainty effects of Balance Feasibility required Resources Values evidence the of Certainty effects Undesirable effects Desirable the first stage of labour of stage first the for definitions existing with compared definitions new Adopting judgements: of Summary No included included No No included included No Don’t know know Don’t Don’t know Don’t know know Don’t Don’t know Don’t know Don’t know Don’t know studies studies ✓ ✓ ✓ ✓ – – – – – – Varies Varies Varies Varies Varies Varies Varies Varies ✓ ✓ – – – – – – existing limits existing limits Large costs Large Reduced Favours Favours Favours Favours – – – – uncertainty or or uncertainty definitions definitions Important Important Moderate variability Probably Probably Probably Very low Very Very low Very reduced existing existing existing existing favours favours favours favours Trivial Large costs No No – – – – – – – – – – – uncertainty or or uncertainty Probably No Probably No Probably no no Probably neither new neither new definitions definitions or existing existing or or existing existing or Negligible important important Moderate variability Possibly costs or or costs Favours Favours Favours Favours savings impact Small Low Low ✓ – – – – – – – – – – uncertainty or or uncertainty Probably Yes Probably Yes favours new new favours favours new new favours Probably no no Probably definitions definitions important important Moderate Moderate Moderate Moderate variability increased Probably Probably Probably savings Small ✓ ✓ ✓ ✓ – – – – – – uncertainty or or uncertainty Large savings Large No important important No variability Increased increased increased Favours Favours Favours Favours Trivial Large limits limits High High Yes Yes – – – – – – – – – – - 3.2.2 Duration of the first stage of labour

RECOMMENDATION 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. (Recommended)

Remarks

 The GDG acknowledges the very low certainty of evidence on the duration of the latent phase of the first stage of labour, resulting in part from the difficulty in ascertaining the actual onset of labour, and chose not to establish a standardized duration for the latent first stage for the purpose of decision- making during labour.  The expected duration of the active phase of the first stage of labour depends on the reference threshold used for its onset. The established boundaries for the active first stage were rounded 95th percentile values from evidence on the duration of the progress of cervical dilatation from 5 cm to 10 cm.  The median duration of active first stage is 4 hours in first labours and 3 hours in second and subsequent labours, when the reference starting point is 5 cm cervical dilatation.  The GDG emphasized that the decision to intervene when the first stage of labour appears to be prolonged must not be taken on the basis of duration alone.  Health care professionals should support pregnant women with spontaneous labour onset to experience labour and childbirth according to each individual woman’s natural reproductive process without interventions to shorten the duration of labour, provided the condition of the mother and baby is reassuring, there is progressive cervical dilatation, and the expected duration of labour is within the recommended limits.  Health care professionals should advise healthy pregnant women that the duration of labour is highly variable and depends on their individual physiological process and pregnancy characteristics.

Summary of evidence and considerations characteristics, labour interventions and definitions of the onset of the different phases of labour. Duration of the first stage of labour

Evidence was derived from a systematic review of Findings 37 studies evaluating the duration of spontaneous Nulliparous latent phase: As shown in Table 3.9, labour in women without risk factors for very low-certainty evidence from two studies complications (52). The studies were published reported a median duration of the latent phase of between 1960 and 2016 in 17 low-, middle- and the first stage of labour of 6.0–7.5 hours without high-income countries (China, Colombia, Croatia, any indication of the percentile distributions. One of Egypt, Finland, Germany, Israel, Japan, Korea, these studies reported the latent phase as the period Myanmar, Nigeria, Norway, Taiwan [China], Uganda, from the onset of regular contractions until the slope the United Kingdom, the USA and Zambia), and of labour record was more than 1.2 cm/hour while involving over 200 000 women of different ethnic the other defined the latent phase as the “duration of origins and socioeconomic status. Most (34) of labour before presentation” (at hospital). the included studies were conducted in tertiary hospitals. Labour interventions such as amniotomy, Very low-certainty evidence from two studies oxytocin augmentation, epidural analgesia and presenting duration of the latent phase as mean instrumental vaginal birth for both nulliparous and and standard deviations reported mean durations parous women varied widely across studies. Studies of 5.1 and 7.1 hours, with estimated statistical were also considered for inclusion if the rate of first (“maximum”) limits of 10.3 and 11.5 hours, stage caesarean section was less than 1%. Studies respectively. One of these two studies reported the were not pooled due to heterogeneity in population latent phase as from admission to hospital until 4 cm 3. EVIDENCE AND RECOMMENDATIONS

39 40 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE presentation” (atpresentation” hospital). “duration before the as of latent phase labour the defined other the while cm/hour 1.2 than more was record of labour slope until the contractions of regular onset the from period the as latent phase the reported studies of these One were reported. (Table 3.9). However, distributions percentile no hours 5.5 and of 4.5 latent phase of the durations median reported data presenting studies two from Parous latent phase: points. reference any provide not did other the while dilatation cervical Table 3.9 Source: GM: grand multiparity; h: hour; NR: not reported; P: parity; SD: standard deviation; deviation; standard SD: parity; P: reported; not NR: hour; h: multiparity; grand GM: Velasco (59) 1985 (58) (GM) 1994 Juntunen (58) (P = 2/3) 1994 Juntunen Study (P =1) (56) 1985 Peisner Study PAROUS WOMEN (58) 1994 Juntunen (56) 1985 Peisner Study NULLIPAROUS WOMEN (56) (P ≥ 1) 1985 Peisner Velasco (59) 1985 (57) Ijaiya 2009 Ijaiya 2009 (57) Ijaiya 2009 Abalos et al., 2018 (52) 2018 al., et Abalos Duration of the latent first stage in nulliparous and parous women parous and nulliparous in stage first latent the of Duration Very low-certainty evidence evidence Very low-certainty 1544 720 581 163 42 42 42 74 75 37 N N N . Median cervical cervical Median cervical Median cervical Median Median cervical cervical Median admission (cm) admission (cm) admission (cm) admission (cm) dilatation on dilatation on dilatation on dilatation on 6.0 0.5 4.5 4.5 5.0 NR NR NR NR NR 4 cm until From admission Not defined Not defined cm/h > 1.5 record of labour slope until contractions of onset Reported Not defined cm/h >1.2 record of labour slope until contractions of onset Reported 4 cm until From admission presentation before of labour Duration record > 1.5 cm/h > 1.5 record of labour slope until contractions of onset Reported before presentation before of labour Duration Definition of reference reference of Definition reference of Definition reference of Definition Definition of reference reference of Definition points points points points starting reference point was 4 cm was 3.7–5.9 was 4cm was point reference starting the when phase active of the duration median the that suggests studies two from evidence certainty of labour.stage Moderate- first of the phase active of the completion and onset the for used points to according reference the of labour duration median Nulliparous active phase: dilatation. until 4 cm admission hospital from period the as phase latent the defined studies of these One hours. 5.4–8.7 as were estimated limits (“maximum”) statistical and to hours 5.7 2.2 from ranges phase latent of the duration mean the that suggests studies two from evidence Very low-certainty a Value estimated by systematic review authors. review systematic by estimated Value duration (h) duration (h) duration (h) duration (h) Median Median Median Mean Mean Mean Mean 6.0 4.5 5.0 5.5 3.2 2.2 5.7 7.5 5.1 7.1 Table the shows 3.10a percentile (h) percentile (h) SD (h) SD SD (h) SD 3.2 2.3 NR NR NR NR NR 5th 5th 5th 1.6 1.6 1.5 percentile (h) percentile (h) +2SD (h) +2SD +2SD (h) +2SD 10.3 5.4 95th 95th 95th 8.7 7.8 11.5 NR NR NR NR NR a a a Table 3.10a Duration of the active first stage: nulliparous women

Labour interventions 95th Reference Median 5th percentile Study N percentile Amniotomy Oxytocin Epidural points (cm) duration (h) (h) (%) (%) (%) (h) Zhang 8 690 NR 20 8 4–10 3.7 NR 16.7 2010 (17) Zhang 4 5 550 NR 47a 8a 5.3 NR 16.4 2010 (16) (or 4.5)–10 Oladapo 715 NR 40a 0.0 4–10 5.9 2.4 14.5 2018 (62) Zhang 5 2 764 NR 47a 84a 3.8 NR 12.7 2010 (16) (or 5.5)–10 Oladapo 316 NR 40a 0.0 5–10 4.3 1.6 11.3 2018 (62) Oladapo 322 NR 40a 0.0 6–10 2.9 0.9 9.3 2018 (62) Mean SD (h) +2SD (h) duration (h) Albers 347 NR 0.0 NR 4–10 7.7 5.9 19.4 1996 (63) Albers 806 0.0 0.0 NR 4–10 7.7 4.9 17.5 1999 (64) Jones 120 NR 0.0 0.0 4–10 6.2 3.6 13.4 2003 (65) Juntunen 42 57.1 0.0 42.9 4–10 3.1 1.5 6.1b 1994 (58) Velasco 74 0.0 0.0 0.0 4–10 3.9 1.6 7.1 b 1985 (59) Schiff 69 NR NR NR 4–10 4.7 2.6 9.9b 1998 (66) Kilpatrick 2 032 NR 0.0 0.0 NR 8.1 4.3 16.7b 1989 (67) Lee 2007 66 NR NR 0.0 NR 3.6 1.9 7.4 b (68) Schorn 18 NR 18.0 NR NR 15.4 6.6 28.6 1993 (69) NR: not reported; SD: standard deviation; a Value reported for entire study population; b Value estimated by systematic review authors. Source: Abalos et al., 2018 (52).

hours (with 95th percentile thresholds of 14.5–16.7 with a starting reference point of 3 cm. However, no hours). When the starting reference point was 5 cm, study reporting a mean duration of the active phase the median duration was 3.8–4.3 hours (with 95th with a starting reference point of 5 or 6 cm was percentile thresholds of 11.3–12.7 hours). The only included in the review. study reporting 6 cm as the starting reference point Parous active phase: According to Table 3.10b, reported the median duration of the active phase moderate-certainty evidence from two studies as 2.9 hours and the 95th percentile duration as 9.5 suggests that the median duration of the active hours. phase for women with parity of 1 and parity of more For studies reporting means, moderate-certainty than 1, with onset defined as 4 cm, was 2.2–4.7 evidence suggests that the mean duration of labour hours, with a range of 13.0–14.2 hours for 95th progressing from 4 to 10 cm dilatation was 3.1–8.1 percentile thresholds. One study presenting data hours, with statistical limits of 7.1–19.4 hours. One separately for women with parity of 1 and parity of study reported a mean duration of 4.7 hours and more than 1, with reference points for active phase

statistical limits of 9.9 hours for the active phase starting from 5 cm, reported median durations of 3. EVIDENCE AND RECOMMENDATIONS

41 42 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE GM: grand multiparity; NR: not reported; P: parity; SD: standard deviation; deviation; standard SD: parity; P: reported; not NR: multiparity; grand GM: (52) 2018 al., et Abalos Source: authors. review systematic by estimated points for the active first stage. stage. first active the for points starting the report not did inthis category studies Two 4.9–13.8 hours. from limits statistical other with 2.1–5.7 was 4cm was hours, point reference starting the when phase active of the duration mean the that suggests evidence moderate-certainty of labour, duration mean presenting studies For 6cm. was phase active the for point reference starting the respectively, when of 7.5 thresholds 7.4 95th and percentile and hours, hours 2.4 and of 2.2 durations median reported study same respectively. The hours, 10.1 10.8 and of thresholds 95th percentile and 3.1 hours, and 3.4 Table 3.10b (P =1) (62) 2018 Oladapo (P =1) (62) 2018 Oladapo (P =2+) (62) 2018 Oladapo (67) 1989 Kilpatrick (66) 1998 Schiff (59) Velasco 1985 (58) (GM) 1994 Juntunen (58) (P =2/3) 1994 Juntunen (65) 2003 Jones (64) 1999 Albers (63) 1996 Albers (P =2+) (17) 2010 Zhang (P =1) (17) 2010 Zhang Study (P =2+) (62) 2018 Oladapo (P =1) (62) 2018 Oladapo (P =2+) (62) 2018 Oladapo Schorn 1993 (69) 1993 Schorn Duration of the active first stage: parous women parous stage: first active the of Duration 11 765 6 373 3 767 1 705 602 320 N 626 385 292 414 491 120 94 30 42 42 37 . Amniotomy Amniotomy 69.0 71.4 0.0 0.0 (%) NR NR NR NR NR NR NR NR NR NR NR NR NR Labour interventions interventions Labour Oxytocin Oxytocin 29.8 29.8 29.8 26.7 26.7 26.7 20.0 18.0 12.0 0.0 0.0 0.0 0.0 0.0 (%) NR NR NR a a a a a a Epidural certainty of the evidence regarding the duration duration the regarding evidence of the certainty low of labour.stage Despite the very first of the latent phase of the durations mean and median reporting available studies inthe uncertain very were phase latent of the onset of the definitions The considerations Additional duration. labour median reporting any studies clude in not did analysis sensitivity This 4cm. at starting phase active the for durations of mean similar range a shows section) caesarean second-stage and birth vaginal instrumental (augmentation, intervention with any excluding studies analysis Sensitivity 0.0 0.0 0.0 0.0 0.0 0.0 0.0 (%) 2.4 9.5 NR NR NR 0.1 0.1 0.1 11 8 a Value reported for entire study population; population; study entire for reported Value Reference Reference defined points points 4–10 4–10 4–10 4–10 4–10 4–10 4–10 4–10 4–10 4–10 6–10 6–10 5–10 5–10 (cm) Not Not NR NR duration (h) duration (h) Median Median Mean Mean 13.2 4.4 4.6 3.4 2.4 2.4 2.8 4.7 5.6 2.2 2.2 3.3 5.7 5.7 2.7 3.1 2.1 percentile SD (h) SD 4.0 0.8 0.6 0.9 3.4 3.4 5.3 NR NR 1.4 1.4 5th 5th 4.1 1.2 1.5 1.9 (h) 1.7 1.7 b Value Value percentile +2SD (h) +2SD 23.9 10.8 14.2 13.0 13.0 13.8 13.8 4.9 5.8 12.5 95th 95th 5.5 13.7 10.1 11.6 7.1 7.4 7.5 (h) b b b b - of the latent phase in nulliparous and parous that women are less likely than health care providers women, the reported data compares favourably to recognize defined, time-bound phases of labour with the observations in Friedman’s pioneer work (54), and their ability to cope is more likely to be on “normal” duration of labour (60, 61), which did dependent on a variety of inter-related factors, not meet the criteria for inclusion in the review. including the level of pain experienced, the nature of Friedman reported the duration of the latent phase the environment and their perceived level of support in nulliparous women as a mean of 8.6 hours, (55). median of 7.5 hours and a statistical maximum of 20.6 hours; and in parous women as a mean of Resources 5.3 hours, median of 4.5 hours and a statistical No review evidence on resource requirements maximum of 13.6 hours. relating to duration of labour was found. While the data available for the duration of the active first stage of labour with reference points Additional considerations starting from 4 and 5 cm in nulliparous and Using limits of labour duration informed by the parous women are also consistent with the mean respective 95th percentile thresholds as the and median durations reported by Friedman, the benchmark for identifying unduly prolonged first statistical maximums reported by Friedman are stage of labour might be cost-effective as it has considerably shorter than the upper limits in the the potential to reduce the use of interventions to reports presented in the systematic review (53, accelerate labour and expedite birth (caesarean 60, 61). This substantial difference in the upper section, oxytocin augmentation). However, it might limits between Friedman’s earlier studies and those increase costs associated with supportive care such provided in the review cannot be accounted for as pain relief and labour companionship. by the fact that the “deceleration phase” was not included in the duration of active phase reported by In certain settings where physicians attend to all Friedman. women in labour, the use of limits of labour duration based on 95th percentile thresholds for managing labour might result in increased costs if women with Values longer labours are attended by professionals with Findings from a review of qualitative studies looking higher salaries. at what matters to women during intrapartum care (23) indicate that most women want a normal It is likely that facilitating the use of upper limits birth with good outcomes for mother and baby, would lead to increased bed costs for women but acknowledge that medical intervention may who have vaginal births due to longer labour ward sometimes be necessary. stays. The estimated cost of a facility bed per day varies widely across regions, as shown by the Additional considerations WHO-CHOICE example estimates (2007–2008) (70). Increases in bed costs associated with longer Women generally place a high value on the total labours might have less impact on health care costs duration of labour, although the relative importance in LMICs than in HICs, where bed costs form a of how long or how short labour is may be context larger proportion of costs for childbirth services. On dependent. Evidence from other studies suggests the other hand, if the use of oxytocin augmentation

Table 3.11 Main resource requirements for adopting new upper limits of duration of labour

Resource Description Training  Practice-based training for health care providers  Revised training manuals and clinical protocols for health care providers and those in pre-service training Supplies  Educational materials for women on what comprises “normal” labour in terms of its duration and when birth should be expected  Revised paper partograph  Sufficient beds in the labour ward to support women who labour for longer than the Infrastructure average for their population  Ongoing supervision and monitoring with regular audit and review of outcomes related Supervision and to extending the upper limits to diagnose prolonged labour, when fetal and maternal monitoring conditions are reassuring 3. EVIDENCE AND RECOMMENDATIONS

43 44 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.12 in the (low confidence labour ashorter prefer (23) care intrapartum during to women matters what at looking areview from of qualitative studies Findings Acceptability of childbirth. with over-medicalization is associated that inequity potential to the has reduce inlabour of all women management the for limits upper of safe Application settings. inresource-poor women by disadvantaged is it as unlikely received to promptly be intervention inequitable is ahighly However, section caesarean (71) 12 than hours longer last not 4 cm) should from (which of labour stage starts traditionally first of the phase active the that expectation the on based labour is prolonged section caesarean primary for indications common of the One considerations Additional found. was equity on impact the on evidence No Equity stays. postnatal to shorter due reduced be could use resource care health and of labour, costs duration of the overall the limits bed upper safe the of extending aresult as performed are sections fewer caesarean and is reduced effects of Balance Values effects Desirable the evidence of Certainty effects Undesirable resources required of evidence of Certainty required Resources indicate that most pregnant women would would women pregnant most that indicate duration of labour labour of duration for limits existing with compared limits upper new Adopting judgements: of Summary No included included No No included included No Don’t know know Don’t Don’t know Don’t know Don’t know studies studies ✓ – – – – – Varies Varies Varies Varies – – – – existing limits Large costs Large Favours Favours . – – uncertainty or or uncertainty existing limits longer hospital stays) hospital reduced. are longer (which interventions obstetric to lead if unnecessary particularly workload, staff increased an or facilities care health at stays to longer lead necessarily not might of labour duration alonger Allowing for considerations Additional (26) care personalized provide to staff care of health ability the limit may also rules informal in evidence).the protocolsand Local confidence (high pressures time organizational and shortages by staff constrained may be labours longer (26) care intrapartum of delivering experiences views and providers’ at areviewIn looking of qualitative evidence Feasibility (26, terms in negative 72, 73) labour long very and short very both likely to report more are women that to is suggest evidence There considerations Additional (moderate confidence in the evidence). limits time of standardized regardless individual to the is tailored of labour length optimal the where to if they able “go are flow” with the experience apositive labour likely more are towomen report evidence). However, childbirth, asked after when Important Important Moderate variability Probably Very low Very Very low Very favours favours Trivial Large costs ✓ – – – – – – neither new or uncertainty or or uncertainty existing limits important important Negligible Moderate variability Possibly costs or or costs Favours Favours savings Small Low Low ✓ – – – – – – , the capacity to accommodate to accommodate capacity , the uncertainty or or uncertainty adopting new upper limits upper Probably no no Probably important important Moderate Moderate Moderate Moderate variability Probably . savings favours favours Small ✓ ✓ ✓ ✓ – – – uncertainty or or uncertainty Large savings Large No important important No variability increased Favours Favours . Trivial Large limits High High – – – – – – – Cost- ✓ – – – – – – effectiveness Don’t know Varies Favours Probably Favours Probably Favours existing limits favours neither new or favours adopting new existing limits existing limits adopting new upper limits upper limits Equity – – – – – ✓ – Don’t know Varies Reduced Probably Probably no Probably Increased reduced impact increased Acceptability – – – – ✓ – Don’t know Varies No Probably No Probably Yes Yes Feasibility – ✓ – – – – Don’t know Varies No Probably No Probably Yes Yes

3.2.3 Progress of the first stage of labour

RECOMMENDATION 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. (Not recommended)

Remarks

 There is insufficient evidence to support the use of the alert line as a classifier to detect women at risk of adverse birth outcomes.  The GDG acknowledged that in hospital settings the use of the alert line and attempts to maintain cervical dilatation progression of 1 cm/hour lead to unnecessary interventions due to the perception that labour progress is pathologically slow.  While the GDG agreed to recommend not using the 1-cm/hour threshold and the alert line for assessing satisfactory cervical dilatation progress, the group identified the development and selection of an appropriate tool for monitoring labour progression (especially cervical dilatation patterns) as a research priority.  Women with suspected slow labour progress should be carefully evaluated to exclude developing complications (e.g. cephalo-pelvic disproportion) and to determine whether their emotional, psychological and physical needs in labour are being met.  The preset lines on the cervicograph are only one element of the existing WHO partograph. Health care professionals should continue to plot cervical dilatation versus time on the cervicograph as well as other partograph parameters (including fetal heart rate, caput succedaneum, moulding, status of , fetal descent, maternal temperature, blood pressure and urinary output) to monitor the well-being of the woman and her baby and identify risks for adverse birth outcomes. In health care facilities where interventions such as augmentation and caesarean section cannot be performed and where referral-level facilities are difficult to reach, the alert line could still be used for triaging women who may require additional care. In this instance, plotting should commence from a cervical dilatation of 5 cm, which signifies the onset of active first stage of labour for most women.  This recommendation supersedes the recommendation of active phase partograph with a four-hour action line in the WHO recommendations for augmentation of labour (46). 3. EVIDENCE AND RECOMMENDATIONS

45 46 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE of 10 women with ABOs (false negative) with ABOs the women of 10 when 4out may miss this strategy that shows test also evidence). table The women) (low-certainty 1000 is 5% (50 of per ABOs prevalence population the when births), with ABOs women of 50 28 out or 1000 is per 1% (10 of ABOs prevalence population (true positive) with ABOs the women 10 when of 6out identify may correctly rate threshold dilatation Table 1-cm/hour the 3.14 using that shows levels inTable prevalence ABO 3.14. different at results of the test to effects illustrate the (95% CI 50.1–52.2%), used respectively, have been 56.7% (95%of CI 49.7–63.5%)specificity 51.1% and and asensitivity and rate of 2.3%, ABO with an women) (n = 8489 study largest the from Findings applied. standard reference the on depending 93.1%, to 22.8% from ranges specificity the and to 100.0% 28.8% (alert line) from threshold ranges 1-cm/hour of the sensitivity the that suggest findings The DTA the presents studies. of individual results (DTA) Table accuracy test findings: Diagnostic 3.13 certainty. low as assessed being evidence inthe resulted and meta-analysis results, of the precluded findings and prevalence baseline definitions, outcome the with to regard studies the between inconsistencies The studies. any from of these excluded specifically rupture).uterine were not Women with factors risk or dystocia, with labour associated dysfunction organ or death maternal 5minutes, 6at than less score Apgar resuscitation, cardiopulmonary of use anticonvulsant, neonatal neonatal death, neonatal early stillbirth, of any following: of the occurrence as (the defined severe ABO and latter asphyxia, birth and stillbirths fresh 5minutes, at than 7 less score Apgar and stillbirths fresh minute, 1 at less of 7or score Apgar and stillbirths fresh resuscitation, neonatal and stillbirths fresh including outcomes adverse composite and asphyxia, birth 5minutes, 7at than less score Apgar 1minute, at 7 than less score Apgar studies: in these defined were variously ABOs for standards reference The facilities. care tertiary or insecondary conducted (74) Uganda and Thailand Africa, South Senegal, Nigeria, Mali, Malaysia, conducted in Brazil, Ecuador, India, Indonesia, Iran, involving over 17,000 werestudies, which women, observational eleven reviewsystematic included that a (ABOs) from outcomes derived was birth adverse of risk to diagnose threshold 1-cm/hour the using (DTA) accuracy test diagnostic the on Evidence of (Table dilatation rate threshold cervical 3.13) 1-cm/hour of the accuracy test Diagnostic a. ofSummary evidence and considerations . All the studies were studies . All the the certainty about this link. about certainty the to and according result that managed be not) would (crossing result or with test agiven line women alert whether i.e. decisions, management subsequent the and results test the between link the on evidence management: subsequent and results test on evidence the of Certainty ABOs. they reduce that evidence is no there section, caesarean reduce might oxytocin amniotomy and while that showed which (75) women) 280 trials, (3 delay of labour treatment the for care with routine compared augmentation oxytocin of amniotomyreview and use the on a Cochrane from derived was evidence Indirect labour. during of risk at ABOs women toline identify 1-cm/hour the with using associated management of effects the review on evidence direct is no There effects: management’s of evidence of Certainty infection. of peripartum risk additional carry and to woman the inconvenient are which examinations, pelvic additional necessitate could to make this comparison need However, the that assumed panel the partograph. the on line alert apre-set against woman of the plots dilatation cervical the comparing requires inlabour, to woman the harm it as ofa risk direct bear not does by itself strategy test strategy. The using withthe test associated risks or benefits strategy: test the of effects the on evidence the of Certainty studies. different employed by the ABOs of definitions the in to heterogeneity due inpart studies, included DTAand the across inconsistent were findings studies observational from is derived evidence DTA on evidence of the is low overall, the as DTA: on evidence certainty the of The Certainty interventions. labour potentially harmful and unnecessary inappropriate, offered be could of risk ABOs atrue without of women proportion a large misclassification, such of evidence). aconsequence As (low-certainty is 5% of ABOs prevalence population the when they not are when risk at being as ABOs without women of 950 out 465 identify may incorrectly or is 1%, of ABOs prevalence population the when (false they not are positive) when risk at being as ABOs without women of 990 out 484 identify may incorrectly strategy test the addition, In evidence).is 5% (low-certainty of ABOs prevalence population the when women 50 of out 22 or is 1%, of ABOs prevalence population . This review found very low-certainty evidence evidence low-certainty very review. This found There is no review evidence of direct review of direct is no evidence There There is no direct review direct is no There Table 3.13 Diagnostic test accuracy of using the 1-cm/hour threshold (alert line) to diagnose risk of adverse birth outcomes (ABOs) for 11 included studies

Country reference (year of ABO Percentage Positive Negative Diagnostic Alert line Prevalence Sensitivity Specificity J statistic publication) crossing likelihood ratio likelihood ratio Odds Ratio status Present Absent of ABO (95% CI) (95% CI) (95% CI) [ABO as defined in the study] alert line (95% CI) (95% CI) (95% CI)

Senegal (1992) (78) Crossed 19 62 [Fresh stillbirths and 28.8% 93.1% 4.18 0.76 5.47 21.9% 8.4% 6.8% neonatal resuscitation at (19.3–40.6) (91.3–94.6) (2.67–6.56) (0.66–0.89) (3.03–9.89) (10.9–33.0) birth] Not crossed 47 839

Indonesia, Malaysia and Crossed 65 585 Thailand (1994) (79) 44.2% 84.4% 2.84 0.66 4.30 28.7% [Fresh stillbirths and 16.6% 3.8% (36.4–52.3) (83.2–85.6) (2.34–3.46) (0.57–0.76) (3.07–6.03) (20.5–36.8) ≤ 7 at 1 82 3175 Not crossed minute]

South Africa 2006 (80) Crossed 30 433 [Fresh stillbirths and 61.2% 22.8% 0.79 1.70 0.47 -16.0% 75.9% 8.0% Apgar score < 7 at 5 (47.3–73.6) (19.5–26.5) (63.2–99.6) (1.16–2.49) (0.25–0.86) (-30.0 to -1.9) minutes] Not crossed 19 128

Ecuador 2008 (81) Crossed 3 289 100.0% 41.9% 1.72 41.9% [Apgar score < 7 at 5 58.4% 0.6% NA NA (43.9–100.0) (37.6–46.2) (1.60–1.85) (37.6–46.2) minutes] Not crossed 0 208

Nigeria (2008) (82) Crossed 27 186 51.9% 54.7% 1.15 0.88 1.31 6.7% [Fresh stillbirth and birth 46.0% 11.2% (38.7–64.9) (49.9–59.5) (0.87–1.52) (0.65–1.18) (0.73–2.33) (-7.7–21.1) asphyxia] Not crossed 25 225

Brazil (2009) (83) Crossed 441 107 32.0% 26.7% 0.44 2.54 0.17 -41.2% [Apgar score < 7 at 5 36.0% 90.4% (29.64– (20.2–34.42) (0.39–0.50) (1.94–3.34) (0.12–0.25) (-48.8 to -33.6) minutes] Not crossed 935 39 34.56)

Mali (84) Crossed 2 98 66.7% 57.4% 1.56 0.58 2.69 24.1% [Apgar score < 7 at 1 42.9% 1.3% (20.8–93.9) (50.9–63.6) (0.69–3.53) (0.12–2.89) (0.24–30.13) (-29.7–77.8) minute] Not crossed 1 132 3. EVIDENCE AND RECOMMENDATIONS

47 48 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE a Source:

[Birth asphyxia] [Birth India (2016) minutes] [Apgar 5 < 7at score (2014) (85) India study] the in [ABO defined as publication) of (year reference Country hospital stay]hospital resuscitation during neonatal or minutes 5 < 7at score Apgar and [Fresh stillbirths (2018) Nigeria and Uganda [Severe ABO] (88) (2018) Nigeria and Uganda minute] 1 < 7at score (Apgar (86) (2006) Iran Severe ABO was defined as the occurrence of any of the following: stillbirth, early neonatal death, neonatal use of anticonvulsant, neonatal cardiopulmonary resuscitation, Apgar score less than 6 at 5 minutes, rupture. minutes, at 5 6 uterine or than less score dystocia, Apgar labour with associated resuscitation, dysfunction organ or cardiopulmonary death neonatal maternal anticonvulsant, of use neonatal death, neonatal early stillbirth, following: the of any of occurrence the as defined was ABO Severe Bonet et al., 2018 (74) 2018 al., et Bonet (88) (87) a . Not crossed Not Not crossed Not Not crossed Not Not crossed Not crossed Not Crossed Crossed Crossed Crossed Crossed Alert line line Alert status Present 102 152 110 84 43 43 10 2 7 3 ABO Absent 4053 4224 4242 4011 106 361 30 85 93 53 Percentage alert line alert crossing crossing 49.0% 49.0% 56.5% 29.4% 19.2% Prevalence of ABO of 17.2% 4.5% 3.0% 2.3% 9.6% (39.7–60.3) (45.3–93.7) (49.7–63.5) (53.7–65.7) (49.7–91.8) Sensitivity Sensitivity (95% CI) (95% 50.0% 56.7% 59.8% 76.9% 77.8% (83.6–90.0) (50.2–52.4) (67.3–82.4) (50.1–52.2) (37.6-51.6) Specificity Specificity (95% CI) (95% 44.5% 75.6% 87.2% 51.3% 51.1% likelihood ratio (2.05–4.85) (0.97–2.03) (2.81–5.42) (1.02–1.32) (1.11–1.36) (95% CI) (95% Positive Positive 1.23 3.91 3.15 1.16 1.4 likelihood ratio (0.46–0.71) (0.67–0.91) (0.11–0.83) (0.72–100) (0.15–1.71) (95% CI) (95% Negative Negative 0.85 0.57 0.78 0.31 0.5 (0.57–13.86) (4.08–11.36) (2.67–40.0) (1.22–2.02) (1.03–1.83) Odds Ratio Ratio Odds Diagnostic (95% CI) (95% 10.33 6.81 1.57 1.37 2.8 (-5.8%–50.3%) (26.2–48.2%) (0.80–14.9%) (28.4–76.7) (5.0–17.3) J statistic (95% CI) (95% 22.3% 52.5% 37.2% 7.8% 11.1% Table 3.14 Illustrative test results at different prevalence levels of adverse birth outcomes (ABOs) based on diagnostic test accuracy of the largest study Sensitivity: 56.7% (95% CI 49.7–63.5%) Specificity: 51.1% (95% CI 50.1–52.2%)

No. of results per 1000 women tested according to prevalence of ABOs (95% CI) Test result (crossing the alert line) ABO prevalence 1% ABO prevalence 2.5% ABO prevalence 5% True positives 6 out of 10 14 out of 25 28 out of 50 (women correctly identified as (5–6) (12–16) (25–32) having an ABO) False negatives 4 out of 10 11 out of 25 22 out of 50 (women incorrectly classified as (4–5) (9–13) (18–25) not having an ABO) True negatives 506 out of 990 498 out of 975 485 out of 950 (women correctly identified as not (496–517) (488–509) (476–496) having an ABO) False positives 484 out of 990 477 out of 975 465 out of 950 (women incorrectly classified as (473–494) (466–487) (454–474) having an ABO) Source: Souza et al., 2018 (88).

With the exception of trial settings, the implemen­ due to the high proportion of women falsely tation of a specific management protocol in a timely identified as being at risk of ABO (high false-positive fashion according to whether or not a woman rate), who might then be subjected to intensified crosses the 1-cm/hour threshold during labour monitoring, interventions to accelerate labour and is suboptimal. Evidence from cross-sectional and birth (particularly augmentation and caesarean qualitative studies suggests that the partograph is section), and consequent iatrogenic complications. incorrectly applied in many settings, and that even A review of childbirth costs shows that in HIC when it is correctly used health care providers face settings caesarean section costs ranged from challenges in initiating necessary actions due to lack €3909 to €7354, compared to vaginal birth costs, of resources (76, 77). which ranged from €1274 to €5343 (89). Data from a study in one low-income country, which was Values included in the review, reported that caesarean Findings from a review of qualitative studies looking section hospital costs (US$ 162) were four times at what matters to women during intrapartum higher than vaginal childbirth costs (US$ 40), and care (23) indicate that most women want a user costs were thrice as high for women undergoing normal childbirth with good outcomes for mother caesarean section (US$ 204) compared with those and baby, and do not appreciate unnecessary undergoing vaginal birth (US$ 79) (90). medical interventions, including additional vaginal Increased referral workload from lower-level to examinations that the test strategy may warrant referral-level health care facilities, as a result of high (high confidence in the evidence). Most women, false-positive rates, would require substantial health especially those giving birth for the first time, are care resources both at the source of the referrals apprehensive about labour and childbirth (high and the referral-level facilities. confidence in the evidence) and about particular medical interventions, such as caesarean section (high confidence in the evidence). Equity No review evidence on the impact of the test Resources strategy on equity was found. No direct review evidence on resource use or cost- effectiveness of using the 1-cm/hour threshold was Additional considerations found. The most common indication for oxytocin augmentation of labour and primary caesarean Additional considerations section is “failure of labour to progress” (71). However, unnecessary augmentation of labour The use of the 1-cm/hour threshold could have large

and caesarean section are highly inequitable 3. EVIDENCE AND RECOMMENDATIONS cost implications (and might not be cost-effective)

49 50 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.15 (76) of settings variety ina use review realist recent of partograph a more (77) LMICs in staff among use to incentives partograph and review barriers on of a with arethose consistent above findings The considerations Additional use. into practical translate necessarily not did of benefit acceptance (especially but referral) for indicator an as progression labour way of monitoring auseful was it that agreed generally professionals care health that showed inLMICs, mainly were conducted which (26) towards partograph the attitudes staff exploring of papers sub-analysis a separate with care, views of intrapartum professionals’ care health exploring areviewIn of qualitative studies Acceptability women. byreceived disadvantaged they as unlikely are to promptly be interventions effects Undesirable Test accuracy accuracy test of Certainty Desirable effects of effects effects of certainty Overall management test result/ of evidence of Certainty effects management’s of evidence of Certainty strategy of test effects of evidence of Certainty Values threshold rate dilatation cervical a1–cm/hour of accuracy test Diagnostic judgements: of Summary No included included No No included included No included No No included included No included No Don’t know Don’t know Don’t know studies studies studies studies studies ✓ ✓ – – – – – – . , and also consistent with consistent also , and Varies Varies Varies – – – , these studies, studies, , these or variability or uncertainty uncertainty inaccurate Important Important Very low Very Very low Very low Very low Very low Very Trivial Large Very Very (76) settings inlow-resource particularly use, partograph to potential barriers as training inadequate and limited knowledge use, on policy of clear lack levels, availability, staffing poor inadequate highlight findings use, review arealist In of partograph considerations Additional of litigation. potential fears to alleviate partograph to the complete compelled felt staff instances, labour. some In in advanced already arrived women when especially recording, and/or to completion inconsistent retrospective led often pressures andworkload use to difficult it They found partograph. using the in confidence lacked thus and trained they were that poorly felt Staff settings. inlow-resource concerns feasibility costs) ongoing (initial potential as and constraints resource and partograph the records who about confusion training, inadequate highlight use towardspartograph attitudes of staff sub-analysis (26) care intrapartum delivering of experiences views and professionals’ care health at areviewIn looking of qualitative evidence Feasibility ✓ ✓ ✓ – – – – – – . uncertainty or or uncertainty Inaccurate important important Moderate variability Possibly Small Low Low Low Low Low ✓ ✓ ✓ – – – – – – uncertainty or or uncertainty Probably no no Probably important important Moderate Moderate Moderate Moderate Moderate Moderate variability Accurate Small ✓ – – – – – – – – , findings from the from the , findings uncertainty or or uncertainty Very accurate No important important No variability Trivial Large High High High High High – – – – – – – – – Balance of effects – – ✓ – – – Don’t know Varies Does not Probably does Probably Favours the favour the not favour the favours the test strategy test strategy test strategy test strategy Resources – – ✓ – – – – required Don’t know Varies Large costs Moderate Negligible costs Moderate Large savings costs or savings savings Certainty ✓ – – – – of evidence No included Very low Low Moderate High of required studies resources Cost- – – – ✓ – – effectiveness Don’t know Varies Does not Probably does Probably Favours the favour the not favour the favours the test strategy test strategy test strategy test strategy Equity – – – ✓ – – – Don’t know Varies Reduced Probably Probably no Probably Increased reduced impact increased Acceptability – ✓ – – – – Don’t know Varies No Probably No Probably Yes Yes Feasibility – – ✓ – – – Don’t know Varies No Probably No Probably Yes Yes

RECOMMENDATION 8

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. (Not recommended)

RECOMMENDATION 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. (Not recommended)

Remarks

 These recommendations aim to prevent iatrogenic adverse maternal and perinatal outcomes by minimizing unnecessary medical interventions, and to improve maternal birth experience.  Evidence shows important variations in the distribution of cervical dilatation patterns among women without risk factors for complications, with many women experiencing progression slower than 1 cm/ hour for the most part of their labours and yet still achieving vaginal birth with normal birth outcomes.  Although this guidance offers health care professionals a benchmark against which to evaluate women in labour, it does not imply that labour facilitated accordingly cannot result in adverse outcomes. Other known and unknown variables can contribute to adverse outcomes.  Before considering any medical interventions, women with suspected delay in labour progression should be carefully evaluated to exclude developing complications (e.g. cephalo-pelvic disproportion) and to determine whether their emotional, psychological and physical needs in labour are being met. 3. EVIDENCE AND RECOMMENDATIONS

51 52 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.16 5th and/or and of median 95thterms percentiles, in data reported Six studies low at of risk bias. be to were assessed women parous examining studies All three of risk bias. high at one and risk moderate at two to low at of risk bias, be were considered four women, nulliparous examining seven studies the Of groups. parity both for studies to USA the restricted largely was use analgesia Epidural women. studies) USA (in two parous for 45% 12% and between and women; nulliparous for study) Chinese (in the 0% study) (in aUSA to 50% from ranged labour, augmentation during oxytocin received of interventions In terms cervix. effaced with awell of women proportion considerable with a 5cm and cm 3.5 between was it women parous for and of effacement, degrees with variable 4cm and 3cm between was dilatation cervical median the women, nulliparous for that showed admission labour at of women observations Baseline (n = 56 823).women parous for data provided also studies three while (n = 43 148) women nulliparous for data provided All studies women. Asian and Hispanic American, African mix of White, amultiracial including studies with USA were conducted, studies the to where corresponding nationality of the were generally populations study The facilities. care health tertiary or insecondary were conducted studies The outcomes. perinatal adverse without gaveand birth of labour stage first the completed who onset, labour with spontaneous women “low-risk” total of 99 971 2017 (53) and 2002 each), between study (1 were all of published which Uganda and studies), (3 USA Nigeria Japan, China, the from studies seven observational included that review asystematic from derived was Evidence (EB Table outcomes perinatal normal 3.2.3) with inwomen dilatation patterns b. Cervical ofSummary evidence and considerations Cervical dilatationCervical 9 – 10 cm 9 –10 8 –9cm 4 –5cm 3 –4cm 5 –6cm 7 –8cm 6 –7cm 2 –3cm

Time to advance centimetre by centimetre in nulliparous women . The studies reported data for a for data reported studies . The No. of studies of No. 6 6 6 6 6 5 5 3 Pooled median median Pooled traverse time time traverse (hours) 2.00 0.49 0.70 0.55 0.52 5.28 0.92 1.46 between 5 cm and 6 cm, it was only after 6 cm that that 6cm after only was it 6cm, and 5cm between started progress to rapid transition the more While cm/hour. 1.09 rate the became point which at reached, was until 5 cm 1cm/hour than less was rate dilatation cervical above, described times in nulliparous women by centimetre (slope) centimetre change of Rate medians. reporting those as by similar patterns showed to 1cm advance of time median) (instead mean reporting study One inall cases. high as assessed was times traverse these for of evidence certainty the to 2cm dilatation, the 3cm for Except to 9cm from 10 cm. to progress 1hour least at and to 4cm from 5 cm 4hours to 3cm from 4cm, hours 4 to 2cm from 3cm, to advance 7hours as long as to take women some for uncommon not was it that suggest studies by individual reported times the of 95th percentiles The dilatation. full yet attained and of labour stage first the even slower throughout progressed women some that suggests studies the However, of distribution of 95th percentile range the to 9cm cm. from 10 to progress hour an half was until it rapidly decreased next the and dilatation level of cervical one between interval time the which after hours, to 4cm 1.46 itwas from 5cm and hours, to 3cm 2.00 was it from 4cm while hours, to 2cm 5.28 was from 3cm to time progress median the that shows evidence This medians. pooled to the contributed that studies of the percentiles 95th corresponding of the range the shows also to (Table dilatation dilatation full 3.16).cervical It of 2cm from to advance women nulliparous took it how long shows six studies from times median The pooled Table (EB women 3.2.3[i]): nulliparous (traverse by in time) 1cm to advance Time Findings and standard deviation. of mean interms data reported study other the while 95th percentiles (range, hours) 4.00–15.70 2.50–10.70 7.20–15.00 4.20–17.70 1.40–6.80 1.30–4.40 1.00–2.60 1.80–9.30 dilatation (cm/ Median rate of of rate Median : Based on the pooled median median pooled the on : Based 0.50 0.68 2.04 hour) 1.09 0.19 1.82 1.43 1.92 Certainty of of Certainty evidence High High High High High High High Low the dilatation rate doubled. Based on the lowest of reached, at which point the rate became 1.49 cm/ the range of 95th percentile data across studies, hour. Compared to the dilatation rate between 4 cm there were always women whose rate of dilatation and 5 cm, the rate increased sharply and almost did not reach the 1-cm/hour threshold until they doubled between 5 cm and 6 cm and then rose reached 9 cm dilatation. The data show that it was rapidly as dilatation progressed towards 10 cm. not uncommon for women to achieve full cervical Based on the lowest of the range of 95th percentile dilatation despite rates slower than 1 cm/hour for data across studies, there were always women a larger part of their labours. The overall certainty whose rate of dilatation did not reach the 1-cm/hour of evidence was assessed as high except for the threshold until they reached 7 cm dilatation. The certainty of the evidence on the rate between 2 cm overall certainty of evidence was assessed as high and 3 cm, which was assessed as low. except for the certainty of the evidence on the rate between 3 cm and 4 cm, which was assessed as low. The only study reporting mean time to advance by 1 cm showed rates of change from one level of cervical dilatation to the next that were similar to Additional considerations those in studies reporting medians. Based on the review findings, the transition point at which labour starts to accelerate (correlating with Time to advance by 1 cm (traverse time) in parous the onset of the “active phase”) could be considered women (parity = 1+) (EB Table 3.2.3[ii]): The to be 5 cm in both nulliparous and parous women. pooled median times from three studies shows how The fastest dilatation rates occurred between 7 cm long it took parous women to advance from 3 cm of and 10 cm for both nulliparous and parous women, cervical dilatation to full dilatation (Table 3.17). This but were faster in parous women (i.e. steeper slope). evidence suggests that the median time to progress Cervical dilatation patterns before the transition from 3 cm to 4 cm was 2.38 hours, while from 4 cm point appear to be highly variable and individual to 5 cm it was 1.17 hours, following which the interval for both nulliparous and parous women. Labour decreased rapidly as cervical dilatation progressed progression demonstrates a hyperbolic rather than towards 10 cm. Similar to nulliparous women, the a linear curve, which is slower at the start of the range of 95th percentile distribution of the studies traditional active phase (e.g. at 4 cm dilatation) and suggests that some women progressed much slower faster in advanced first stage. throughout the first stage of labour and yet attained full dilatation. The 95th percentiles of the times reported by individual studies suggest that it was Values not uncommon for some women to take as long as Findings from a review of qualitative studies looking 14 hours to advance from 3 cm to 4 cm, 3 hours to at what matters to women during intrapartum advance from 4 cm to 5 cm, and only after 8 cm was care (23) indicate that most women want a normal the time to progress 1 cm always less than 1 hour. childbirth with good outcomes for mother and baby, Except for the time to progress from 3 cm to 4 cm but acknowledge that medical intervention may dilatation, the certainty of evidence for each of these sometimes be necessary. Most women, especially traverse times were all assessed as high. those giving birth for the first time, are apprehensive about childbirth (high confidence in the evidence) Rate of change (slope) centimetre by centimetre in and of certain interventions, although in certain parous women (parity = 1+): Based on the pooled contexts and/or situations women welcome medical median times described above, cervical dilatation interventions in order to shorten labour (low rate was less than 1 cm/hour until 5 cm was confidence in the evidence).

Table 3.17 Time to advance centimetre by centimetre in parous women

Pooled median Median rate of 95th percentiles Certainty of Cervical dilatation Number of studies traverse time dilatation (range, hours) evidence (hours) (cm/hour) 3 – 4 cm 1 2.38 14.18–17.85 0.42 Low 4 – 5 cm 3 1.17 3.30–8.05 0.85 High 5 – 6 cm 3 0.67 1.60–6.24 1.49 High 6 – 7 cm 3 0.44 1.20–3.67 2.27 High 7 – 8 cm 3 0.35 0.70–2.69 2.86 High 8 – 9 cm 2 0.28 0.60–1.00 3.57 High 9 – 10 cm 2 0.27 0.50–0.90 3.70 High 3. EVIDENCE AND RECOMMENDATIONS

53 54 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.18 a result of facilitation of slow-yet-normal of facilitation a result cervical as performed are sections fewer caesarean and is reduced augmentation of oxytocin use if the hand, other the On services. childbirth for of costs proportion alarger form costs bed where in HICs, than inLMICs costs care health on impact have less might labours with longer associated costs in bed (2007–2008) estimates example (70) by WHO-CHOICE shown as the regions, across widely day varies per bed of afacility cost estimated The women. ward for stays labour to longer due births vaginal for costs bed to increased lead would is likelyIt slow-yet-normal facilitating that labours use. resource care health in is likely to labour inincreases result managing of slow-yet-normal use for the patterns dilatation inlabour, to all women physicians attend where settings country high-income and middle- certain In antibiotics). cardiotocography,(e.g. relief, pain continuous linked interventions and augmentation) oxytocin section, (e.g. caesarean birth and labour accelerate to of interventions use the potential tothe reduce has cost-effectiveas it be might of labour stage first the managing for benchmark the as patterns of slow-yet-normal dilatation Application cervical considerations Additional found. was requirements resource review on No evidence Resources (55) level of support perceived their and environment of nature the the experienced, pain level the of of inter-related including variety factors, a on likely is more to to dependent cope be ability (54) of labour phases time-bound defined, to recognize providers care likely health than less are women that suggests studies other from Evidence considerations Additional monitoring and Supervision Infrastructure Supplies Training Resource

Main resource requirements for facilitatingdilatation patterns for slow-yet-normal cervical requirements resource Main application of slower dilatation patterns for labour management labour for patterns dilatation of slower application to related review of outcomes and audit regular with monitoring and supervision Ongoing labour longer wardsupport to labour the in beds Sufficient Revised paper partograph assessment for facility to to go a when and labour “normal” comprises what on women for materials Promotional training service pre- in those and providers care health for protocols clinical and manuals training Revised providers care health for training Practice-based Description . . Increases . Increases , and their their , and (26, 72, 73, 91) (26, terms in negative 72, 73, labour long very and short very both likely to report more are women that to suggest is evidence There considerations Additional (moderate confidence). limits time standardized of regardless to individual the is tailored of labour length optimal the where toable “go flow” with the if they are experience apositive labour to report likely more are women childbirth, asked after when (lowHowever, confidence). labour ashorter prefer (23) care intrapartum during to women matters what at looking areview from of qualitative studies Findings Acceptability of childbirth. medicalization with over- is associated that inequity to reduce potential the has all women for management labour of slow-yet-normal toApplication patterns dilatation indicated. even when women disadvantaged bythey unlikely are received to promptly be as interventions inequitable highly are section caesarean and of labour augmentation unnecessary (71) 4cm from starts traditionally which phase, active the during 1cm/hour least is at progression labour normal that expectation to progress”, the of labour on is “failure based section caesarean primary and augmentation oxytocin for indication common most The considerations Additional found. was equity on impact the on evidence No Equity stays. postnatal to shorter due reduced be could use resource care health and costs overall the bed patterns, dilatation indicate that most pregnant women would would women pregnant most that indicate . . However, . Feasibility Additional considerations In a review of qualitative evidence looking at In a realist review of partograph use, findings providers’ experiences of delivering intrapartum highlight poor availability of equipment, inadequate care (26), the capacity to accommodate longer staffing levels, lack of clear policy on use, limited labours may be constrained by staff shortages and knowledge and inadequate training as potential organizational time pressures (high confidence in barriers to partograph use, particularly in low- the evidence). Local protocols and informal rules resource settings (76). may also limit the ability of health care staff to provide personalized care (26).

Table 3.19 Summary of judgements: Application of slow-yet-normal cervical dilatation patterns for labour management

Desirable – – – – ✓ – effects Don’t know Varies Trivial Small Moderate Large Undesirable – – – – ✓ – effects Don’t know Varies Large Moderate Small Trivial Certainty of – – – ✓ – the evidence No included Very low Low Moderate High studies Values – ✓ – – Important Possibly Probably no No important uncertainty or important important uncertainty or variability uncertainty or uncertainty or variability variability variability Balance of – – – – – ✓ – effects Don’t know Varies Favours the Probably favours Favours neither Probably Favours slow– alternative the alternative slow–yet– favours slow– yet–normal options option normal nor yet–normal alternative option Resources – ✓ – – – – – required Don’t know Varies Large costs Moderate costs Negligible costs Moderate Large savings or savings savings Certainty – ✓ – – – of evidence No included Very low Low Moderate High of required studies resources Cost- – ✓ – – – – – effectiveness Don’t know Varies Favours the Probably favours Favours neither Probably Favours slow- alternative the alternative slow-yet- favours slow- yet-normal option option normal nor yet-normal alternative option Equity – – – – – ✓ – Don’t know Varies Reduced Probably Probably no Probably Increased reduced impact increased Acceptability – – – – ✓ – Don’t know Varies No Probably No Probably Yes Yes Feasibility – ✓ – – – – Don’t know Varies No Probably No Probably Yes Yes 3. EVIDENCE AND RECOMMENDATIONS

55 56 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE 3.2.4 greater than 3 cm), the women in the intervention 3cm), than greater intervention inthe women the dilatation cervical and regular, contractions painful of presence as (definedthe study in the labour inactive were not women the that ascertaining (93) below trial is described this from evidence the question; to this guideline relevant directly was women, pregnant nulliparous involving 209 Canada, inthe trial conducted one . Only (92) labour inearly factors risk without women pregnant reviewsystematic included that aCochrane from derived was evidence The intervention (EB the of 3.2.4) Effects Table ofSummary evidence and considerations          Remarks (Research-context recommendation) research. rigorous of context the in only recommended is stage first active until admission For healthy pregnant women presenting in spontaneous labour, a policy of delaying labour ward RECOMMENDATION 10          policy of delaying labour ward admission. labour of delaying policy labour, inearly of a of instead women needs the (AMUs), to units meet considered be midwifery could (OMBUs) units alongside birthing and midwife-led on-site as such strategies, Facility reorganization water. drinking and food and toilets, serviced to clean, access easy and to walk around, women for with space available, be should waiting rooms comfortable clean, companions, their and of labour stage latent first inthe women For preferences. and to according woman’s to individualized the be needs need plans Birth ward. to labour awaiting the admission women all on needed as performed be should well-being fetal and maternal to assess observations Routine labour. active of onset of the definition revised of the light inthe recommendation this research-context implementing consider should ward admission labour of delaying apolicy Facilities applying currently excluded. are complications developing or to undiagnosed ensure is essential afacility at presentation on professional care by ahealth assessment fetal and maternal Acomprehensive admission. on delayedassessment or provider care health with a contact first delayed mean not does admission ward labour delaying facility. care addition, to In await labour, health the active admission delaying or labour inearly women where waiting areas, area), to maternity the admission delaying childbirth not to the ward (i.e. to labour to the admission refers delaying this that recommendation clear be should It priority. this noted aresearch as group The inthis guideline. recommended as more, or cm of5 dilatation cervical bya defined onset with stage to first not active and less, or 4 cm of dilatation cervical by a defined onset with labour ofstage first active to applies effects on evidence limited the that concerned was it as recommendation this a“research-context” made GDG The reassuring. are well-being fetal and if avoided maternal be should childbirth and labour accelerate to interventions medical stage, latent first ward during to labour the admitted women For home. at labour active is to await preference labour, her appropriately, inearly even unless when supported and admitted be should to inlabour facilities presenting awoman available, becomes evidence further Until

Labour ward admission policy . In this trial, after this after . In trial, initial assessment. initial assessment. the ward after to labour directly were admitted who of women group with acontrol compared was group intervention The until re-assessment. partner, her were and available to her magazines and armchairs where hours, several for area assessment in the asked was to she remain not, or labour inactive was group intervention inthe awoman whether clear not was it If to return. when on with instructions active, more became until labour home return or facility the outside to walk around instructed and advice, and encouragement were support, given group Comparison: delaying admission compared with Duration of the second stage of labour: This was direct admission to the labour ward shorter for the women in the group where admission Maternal outcomes was delayed compared with the direct admission Mode of birth: Evidence on the effect of delaying group (76.8 vs 95 minutes; P = 0.045); and versus direct admission to the labour ward on Amniotomy: This occurred with similar frequency in caesarean section and instrumental vaginal birth is both groups (49/105 vs 56/104; P = 0.368). of very low certainty, mainly due to small sample The effects of delaying admission to the labour ward size and few events. as presented in the Cochrane systematic review Duration of labour: Low-certainty evidence depend on the health system model of intrapartum suggests that the duration of labour from the point care for healthy pregnant women and may not be of hospital admission may be shorter for women in applicable to countries where uncomplicated births the group where admissions were delayed (1 trial, occur in primary care facilities, such as clinics and 209 women; MD -5.20 hours [shorter], 95% CI on-site midwife-led birthing units (OMBUs), which -7.06 to -3.34 hours shorter). tend to offer less medicalized care than hospital- Use of pain relief options: Low-certainty evidence based intrapartum care (94). suggests that there may be a reduction in the Several observational studies with sample sizes use of epidural analgesia with a policy of delaying ranging from 120 to 6121 women have evaluated the admission (1 trial, 209 women, RR 0.87, 95% relationship between cervical dilatation at admission CI 0.78–0.98). In this trial, with an epidural rate and subsequent medical interventions, including of approximately 90% in the control group, the caesarean section and labour augmentation (95–99). absolute difference in epidural is estimated at 118 The findings across these studies are consistent. fewer epidurals per 1000 (from 18 to 199 fewer) with They show that women admitted in the latent a policy of delaying admission. phase of labour are more likely to have caesarean Augmentation of labour: Low-certainty evidence section, with caesarean section rates for the latent suggests that delaying admission may reduce and active phase admission groups of these studies oxytocin augmentation compared with direct reported as 14.2% versus 6.2% (n = 6121 women) admission (1 trial, 209 women, RR 0.57, 95% (96), 18% versus 4% (n = 1202 women) (97), 34.8% CI 0.37–0.86). In this trial, with an oxytocin versus 18.6% (n = 354 women) (98), 15.8% versus augmentation rate of 40% in the control group, 6.9% (n = 216 women) (95), and 10.3% versus the absolute difference in oxytocin augmentation 4.2% (n = 3220 women) (99), respectively. These is estimated at 174 fewer per 1000 (from 57 to 271 observational studies also consistently showed fewer) with a policy of delaying admission. higher rates of oxytocin augmentation and a variety of other medical interventions (e.g. scalp pH, fetal Birth experience: Low-certainty evidence suggests scalp electrode monitoring of fetal heart rate, that satisfaction scores may be higher with a policy amniotomy, epidural) among the women admitted of delaying admission than direct admission (1 trial, to the labour ward in early labour compared with 201 women, MD 16 points higher, 95% CI 7.53– those admitted in established, active labour. 24.47 higher). The Cochrane systematic review (92) also evaluated “home assessment and support” for Fetal and neonatal outcomes women in early labour versus telephone triage (a Perinatal hypoxia-ischaemia: Evidence on Apgar telephone call between a woman and a health care scores less than 7 at 5 minutes is of very low professional to determine if a woman needs labour certainty, mainly due to the small sample size and ward admission). Three trials (6096 participants) few events. conducted in the United Kingdom and Canada Birth before arrival: The evidence is very uncertain contributed data to this comparison. Women in the due to no events occurring in this small trial. home assessment groups were given support and advice in their homes by a midwife or other trained Perinatal mortality: The trial did not report this health care professional, including advice on pain outcome. management techniques and when to proceed to No other perinatal outcomes were reported in this the hospital. Women in the telephone triage group trial. made their own decision to go to hospital, based on their telephone conversation with a nurse or other Additional considerations health care professional. The review found evidence Other relevant outcomes were reported in the trial (mainly graded as low certainty) suggesting that 3. EVIDENCE AND RECOMMENDATIONS (93) but not in the Cochrane review (92). these interventions have little or no effect on

57 58 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.20 ward admission. labour with delaying associated rates augmentation labour and lower epidural the appreciate might women labour. that plausible is also It await established to home alternative if the is to sent be particularly ward, to labour the admission direct prefer might ward stay, of labour duration and on admission delaying of effect the value not might birth giving about anxious are who women above, the Given considerations Additional confidence in the evidence). to (low pain or relief from provide labour to shorten interventions may welcome women situations, or and/ contexts evidence). in certain in the addition, In (high baby confidence of ahealthy birth facilitate the to necessary is sometimes intervention medical that they understand childbirth, anormal want women most while review that, showed also The evidence). in the (high confidence interventions of particular and childbirth about apprehensive are time, first the for birth giving those especially women, most (23) care intrapartum during to women aqualitative review from matters of what Findings Values intervention. support and assessment home with the increased may be satisfaction maternal that review suggests the from However, evidence death. low-certainty perinatal and 5minutes, 7at than less scores Apgar morbidity, maternal serious analgesia, epidural augmentation, oxytocin birth, vaginal instrumental section, caesarean including outcomes, childbirth monitoring and Supervision Infrastructure Equipment Supplies Training Staff Resource Main resource requirements for delaying labour ward admission until active first stage first active until admission ward labour delaying for requirements resource Main Audit and review of babies born before arrival in the labour ward, and other key outcomes other and ward, labour the in arrival before born review of babies and Audit supervision to medical access Good accessible easily be should water Toilets drinking and to around walk women for space with companions, their and women for room waiting comfortable Clean, monitors pressure blood e.g. equipment, medical in difference No period waiting the during to woman the comfort to provide magazines set, atelevision music, aradio, as such resources supportive other and Armchairs fluids) [IV] intravenous sets, drip (oxytocin, of augmentation use reduced and (gloves) examinations to vaginal fewer due admission, direct with than admission of delaying apolicy with needed Fewer supplies admission delaying for support necessary the to provide protocol, facility new the to implement training In-service “delaying waiting room admission” toa members staff more or one of deployment with staff of existing Reorganization Description indicate that that indicate in all settings. women for costs transport with higher associated be could labour, admission of delaying active apolicy to await home sent are labour in early women If (e.g. epidurals). no models hospital-based than care intrapartum less-medicalized to tend offer models (94) models hospital-based than cost-effective more are these as employed, often are models care primary settings, LMIC In care. of intrapartum model system health the on depend would Cost-effectiveness ward inLMICs. labour to the admission direct versus admission delaying of cost-effectiveness the on evidence is no There considerations Additional labour. until active to hospital admission delaying of with apolicy occur would deaths fewer maternal 9.6 and births, 67 232 fewer caesarean epidurals, fewer 672 000 that estimates modelled on based (100) inthis HIC annually of million US$ 694 savings in cost result could latent phase inthe with admission compared to hospital admission delaying that suggests USA from the analysis cost-effectiveness A 2015 Resources (55) level of support perceived their and environment of nature the the experienced, pain level the of of inter-related including variety factors, a on likely is more to to dependent cope be ability (54) of labour phases time-bound defined, to recognize providers care likely health than less are women that suggests studies other from Evidence . These findings were findings . These . Primary care care . Primary . , and their their , and Equity discouraged, frustrated and embarrassed if, on No research evidence on the impact of delaying assessment, they are told to return home. admission on equity was found. A similar sub-analysis of providers’ experiences of admission practices suggests that health care Additional considerations professionals recognize women’s needs for clarity In HICs and among more advantaged women, and reassurance and they try to maintain a woman- unnecessary obstetric interventions to accelerate centred approach either on the phone or in person childbirth, including caesarean section and oxytocin (moderate confidence in the evidence). However, augmentation, are very prevalent. Therefore, if organizational pressures and time constraints often the effect of delaying admission reduces these lead to them acting as gatekeepers to the labour unnecessary and costly interventions as suggested ward, which can lead to an inconsistent approach to by the USA cost-effectiveness analysis (100), it labour ward admittance (moderate confidence in the might plausibly increase equity. evidence). In LMICs, disadvantaged women often present late Additional considerations at health care facilities, or give birth before arrival or end up having an unplanned , due to All of the above evidence was derived from studies transport and financial barriers (101–104); therefore, conducted in HICs. Some evidence from LMICs delaying admission in these settings might reduce suggests that women in these settings are more equity. likely to arrive at health care facilities in established labour (107). Transport costs to get to health care facilities are a major consideration for disadvantaged women in all Feasibility settings (102, 105, 106). If women were required to return home to await established labour, providing As part of a qualitative review of women’s disadvantaged women with transport funds would experiences of intrapartum care (26), the authors be necessary to ensure equity with this intervention. conducted a sub-analysis of women’s views of hospital admission practices. Findings, which were from HICs only, indicate that the “stay at home” Acceptability message is generally well recognized. However, for As part of a qualitative review of women’s reasons of safety and reassurance, many women experiences of intrapartum care (26), the authors would prefer to be at or near the labour ward conducted a sub-analysis of women’s views of when their embodied experience of labour begins, hospital admission practices. Findings, which were regardless of clinical assessment (high confidence in from HICs only, suggest that women recognize and the evidence). In situations where women are asked generally accept the message to stay at home for as to return home by health care professionals, they long as possible but their experience of early labour would like clear advice and instructions about what is often more intense than expected (especially for signs and symptoms to expect and when to return to nulliparous women), which prompts them to contact the labour ward (high confidence in the evidence). health care professionals, either by phone or visit, in search of clarity and reassurance (high confidence A similar sub-analysis of providers’ experiences of in the evidence). Women find it hard to accept that admission practices suggests that staff would tend staying at home is the best thing to do when they to support the approach of delaying labour ward have been led to believe that medical support is admission because it gives them the flexibility to important for their safety (high confidence in the manage organizational pressures relating to bed evidence). Women tend to view the hospital as a space and staff resources (moderate confidence place of safety and are acutely aware that they might in the evidence). However, findings also indicate be sent home if they are not in “active” labour. The that health care professionals may struggle to offer pressure of having to “get the timing right” places the kind of woman-centred care they wish to offer an additional strain on women and can leave them (and that women value) if this approach is adopted feeling anxious and vulnerable (high confidence (moderate confidence in the evidence). in the evidence). The decision to go to a hospital or birthing facility is usually determined by their Additional considerations embodied experience of labour (often associated All of the above evidence was derived from studies with level of pain) rather than a clinical assessment, conducted in HICs. and they can be left feeling disappointed, 3. EVIDENCE AND RECOMMENDATIONS

59 60 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.21 Feasibility effectiveness Cost- Acceptability Equity resources required of evidence of Certainty effects of Balance effects Desirable Values required Resources effects Undesirable the evidence of Certainty labour ward admission direct with compared admission ward labour delaying of Policy judgements: of Summary No included included No No included included No Don’t know Don’t know Don’t know Don’t know Don’t know know Don’t Don’t know Don’t know Don’t know studies studies ✓ – – – – – – – – – Varies Varies Varies Varies Varies Varies Varies Varies ✓ ✓ ✓ – – – – – Favours direct direct Favours Favours direct direct Favours Large costs Large admission admission Reduced – – – – uncertainty or or uncertainty favours direct direct favours favours direct direct favours admission admission admission admission Important Important Moderate variability Probably Probably Probably Very low Very Very low Very reduced Trivial Large costs No No ✓ – – – – – – – – – – uncertainty or or uncertainty favour direct direct favour favour direct direct favour Probably No Probably No Probably no no Probably or delaying delaying or or delaying delaying or admission admission admission admission admission admission Negligible important important Moderate variability Does not not Does Does not not Does Possibly costs or or costs savings impact Small Low Low ✓ – – – – – – – – – – uncertainty or or uncertainty Probably Yes Probably Yes Probably no no Probably admission admission important important Moderate Moderate Moderate Moderate variability increased Probably Probably Probably delaying delaying savings favours favours favours favours Small ✓ ✓ ✓ ✓ ✓ – – – – – - uncertainty or or uncertainty Large savings Large No important important No admission admission variability Increased delaying delaying Favours Favours Favours Favours Trivial Large High High Yes Yes – – – – – – – – – – - 3.2.5 Clinical pelvimetry on admission

RECOMMENDATION 11

Routine clinical pelvimetry on admission in labour is not recommended for healthy pregnant women. (Not recommended)

Remarks

 Indirect evidence derived from studies of X-ray pelvimetry suggests that routine clinical pelvimetry in healthy pregnant women on admission in labour may increase caesarean section without a clear benefit for birth outcomes.  Clinical pelvimetry is the assessment of the adequacy of the shape and size of the maternal (inlet, mid-pelvis and outlet) for vaginal birth through internal and should not be confused with a standard pelvic examination, which is required for the clinical assessment of cervical status, amniotic fluid, and fetal station and position at labour admission.  Clinical pelvimetry might have a role in triaging women at high risk of cephalo-pelvic disproportion who reside in rural and remote areas; however, there is currently no evidence that this practice improves outcomes.  In settings where clinical pelvimetry is routinely performed among healthy pregnant women on admission in labour, health care providers should be made aware that there is insufficient evidence to support this practice.  All women presenting to a facility in labour should be clinically assessed by the maternity-care provider according to recommended clinical practice, which includes performing a digital vaginal examination, with the woman’s consent, to assess the status (onset and extent) of labour.

Summary of evidence and considerations Maternal outcomes Effects of the intervention (EB Table 3.2.5) Mode of birth: Low-certainty evidence suggests that caesarean section may be more frequent with The evidence was derived from a Cochrane pelvimetry than without pelvimetry (3 trials, 769 systematic review that included five RCTs (108). women, RR 1.34, 95% CI 1.19–1.52). The absolute The review authors did not find any trials evaluating effect of pelvimetry may be 73 more caesarean clinical pelvimetry, therefore indirect evidence on sections per 1000 (from 6 to 157 more). the effects of X-ray pelvimetry on birth outcomes informed this recommendation. Three trials in the Maternal morbidity: The three included trials review were conducted in South Africa, Spain and provided no evidence on maternal morbidity. the USA, and involved 769 women with cephalic Duration of labour: This outcome was not reported singleton pregnancies at term. One was a trial from in the review. 1962 involving 305 labouring women; the other two involved 464 nulliparous women undergoing Birth experience: Maternal satisfaction and induction or augmentation of labour. All three trials other experiential aspects of pelvimetry were not evaluated radiological pelvimetry (specifically X-ray) evaluated in the review. compared with no pelvimetry. The remaining two trials were conducted in women with a previous Fetal and neonatal outcomes caesarean section; evidence from these is not Perinatal hypoxia-ischaemia: Evidence on the included in this guideline. effect of pelvimetry on “perinatal asphyxia” is very uncertain as it was derived from one trial with few Comparison: Routine clinical pelvimetry events, which also had limitations in study design compared with no pelvimetry and indirectness. Other fetal and neonatal morbidity Evidence was downgraded for indirectness, as data outcomes (Apgar scores < 7 at 5 minutes) were not were derived from studies of X-ray pelvimetry. reported in the relevant studies. 3. EVIDENCE AND RECOMMENDATIONS

61 62 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.22 outcomes. birth improving without section of caesarean chance the if increases it intervention unlikely to be this medical might appreciate women above, reviewof the presented findings the on Based considerations Additional confidence in the evidence). (high sensitive are to needs who their providers care health competent technically from information like would women to receive relevant introduced, are interventions Where interventions. of certain and in evidence)the (high confidence childbirth about apprehensive are time, first the for birth giving those sometimes be necessary. Most women, especially may intervention medical that acknowledge but baby, and mother for outcomes with good childbirth (23) care intrapartum during to women matters what at looking areview from of qualitative studies Findings Values to ahigher-level referral timely for (109, facility 110) aneed and section to caesarean with limited access settings low-resource insome women nulliparous to predict cephalo-pelvic disproportion among help might it that suggest studies observational however, some from is uncertain; findings pelvimetry of clinical accuracy diagnostic The section. with caesarean associated costs care health increased and morbidity inview potential additional of the undesirable is outcomes on other of benefits of evidence rate absence inthe section caesarean A higher with this procedure. associated experiences However, review the evaluate not did any maternal (108) pains labour is experiencing she when particularly woman, the for uncomfortable very be may which pelvis, bony of the aspect internal the of involves examination adigital Clinical pelvimetry considerations Additional indirectness. and limitations study to few due events, low certainty is of very Perinatal mortality: monitoring and Supervision Staff time Equipment Supplies Training Resource indicate that most women want a normal anormal want women most that indicate Main resource requirements for clinical pelvimetry clinical for requirements resource Main Evidence for this outcome this outcome for Evidence review audit/ of care quality of regular part as lead ward/clinic/facility labour by the Monitoring procedure the perform and consent their obtain women, to counsel Time None examination pelvic digital standard for Supplies pelvimetry clinical to how perform on training Practice-based Description . . and providers’ experiences of intrapartum care. care. of intrapartum experiences providers’ and review qualitative systematic the women’sfrom on pelvimetry clinical on evidence specific is no There Acceptability indicated. medically when to even able receive similar levels be may of not care, with similar findings women disadvantaged pelvis, having acontracted as assessed women privileged in section of caesarean use the increase might pelvimetry that given addition, equity. In reduce further and inafacility birth giving from women of labour, disadvantaged of deter progress could assessment for examination pelvic astandard than uncomfortable more be can which pelvimetry, clinical above, evidence indirect the on Based considerations Additional evidence) in the (high confidence inLMICs women by marginalized birth uptake ofthe facility-based to barrier important an are dehumanizing, and to uncomfortable by be women perceived are which infacilities, workers by health examinations vaginal digital that indicates birth to facility-based facilitators and areview from of barriers evidence However, found. was equity indirect on pelvimetry of clinical impact the on evidence direct No Equity itis unlikely to cost-effective. be outcomes, perinatal substantive improving without section caesarean of risk to increased lead could intervention the As afterwards. to findings the and explain consent, to her obtain examination, digital for reason the on woman the to counsel required istime also take may only minutes, itself procedure the while and, time is staff of this cost intervention main The considerations Additional found. was cost-effectiveness or requirements resource review on No evidence Resources (8) . However, general findings on women’s experiences and providers’ experiences of intrapartum care (26). suggest that women would rather avoid medical However, general findings on providers’ experiences interventions unless their baby is at risk (high suggest that providers in certain contexts confidence in the evidence) (26). In addition, where (particularly LMICs) may lack the time, training and/ an intervention is required, women would like to or resources to routinely perform clinical pelvimetry be informed about the procedure and treated by for all women presenting in labour (high confidence sensitive, kind and technically competent staff (high in the evidence). confidence in the evidence). Additional considerations Additional considerations Clinical pelvimetry requires specific experience and Women may welcome a pelvic examination by the expertise to examine with high certainty the internal care provider, which provides reassurance about diameters of the maternal pelvis in correlation with their chances of given birth vaginally. However, they the size of the fetal head, to assess the likelihood may not readily accept clinical pelvimetry if the of cephalo-pelvic disproportion during labour. findings are likely to preclude them from undergoing This expertise is generally limited to higher-level a trial of labour, or heighten their fears of adverse hospitals, experienced midwives and obstetricians, events during labour. and may not be readily available in lower-level hospitals and resource-limited settings. Feasibility There is no specific evidence on clinical pelvimetry from the qualitative systematic review on women’s

Table 3.23 Summary of judgements: Clinical pelvimetry compared with no clinical pelvimetry

Desirable ✓ – – – – – effects Don’t know Varies Trivial Small Moderate Large Undesirable – – – – ✓ – effects Don’t know Varies Large Moderate Small Trivial Certainty of – ✓ – – – the evidence No included Very low Low Moderate High studies Values – ✓ – – Important Possibly Probably no No important uncertainty or important important uncertainty or variability uncertainty or uncertainty or variability variability variability Balance of – – – ✓ – – – effects Don’t know Varies Favours no Probably Does not Probably Favours pelvimetry favours no favour favours pelvimetry pelvimetry pelvimetry or pelvimetry no pelvimetry Resources – – – – ✓ – – required Don’t know Varies Large costs Moderate Negligible Moderate Large savings costs costs or savings savings Certainty ✓ – – – – of evidence No included Very low Low Moderate High of required studies resources Cost- – – – ✓ – – – effectiveness Don’t know Varies Favours no Probably Does not Probably Favours pelvimetry favours no favour favours pelvimetry pelvimetry pelvimetry or pelvimetry no pelvimetry Equity – – – ✓ – – – Don’t know Varies Reduced Probably Probably no Probably Increased reduced impact increased Acceptability – ✓ – – – – Don’t know Varies No Probably No Probably Yes Yes Feasibility – ✓ – – - – Don’t know Varies No Probably No Probably Yes Yes 3. EVIDENCE AND RECOMMENDATIONS

63 64 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE four trials (11 338 women) CTG that shows on trials (11 338 four of birth: Mode Maternal outcomes admission compared with auscultation labour on Comparison: Cardiotocography (CTG) low of risk bias. to at be All trials were considered trials. two other the for stated clearly not was auscultation for used technique the and trial, device inanother ultrasound aDoppler or stethoscope fetal aPinard either trial, device inone ultrasound Doppler a handheld using performed was latter The with auscultation. trials]) [3 trial] 20 minutes or [1 monitoring usual or to CTG were (lasting randomized minutes 15 labour during low to at of risk complications be considered trials) (3 Kingdom (111) United the trial) (1 and in Ireland conducted RCTs four reviewsystematic included that aCochrane from derived was evidence The intervention (EB the of 3.2.6) Effects Table ofSummary evidence and considerations    Remarks assessment of fetal well-being on labour admission. (Recommended) the for recommended is stethoscope fetal Pinard or device ultrasound aDoppler using Auscultation RECOMMENDATION 13 admission in healthy pregnant women presenting in spontaneous labour. (Not recommended) Routine cardiotocography is not recommended for the assessment of fetal well-being on labour RECOMMENDATION 12    tracings in defence of clinical practice. of clinical indefence tracings CTG admission on by than relying auscultation, of findings indicate clearly which records, and notes medical litigation by good from keeping protected better be clinicians might that view, agreed and this support to no evidence is there However,that confident was complications. GDG the labour for factors risk apparent without even in women justified, is therefore use its that and auscultation than at-risk babies identifying at CTG clinicians that is better views of of the some CTG because admission an performing not about community legal and clinical inthe aware was concern of the GDG The 5minutes. every performed itis usually stage second inthe whereas minutes, 15–30 every performed of usually labour,stage is auscultation first active the In care. intrapartum of providing quality part integral and is avital rate, labour, heart fetal the by auscultating throughout regularly and admission at condition of fetal assessment aware the that be must All stakeholders experience. awoman’s childbirth impact negatively might and costs to childbirth adds which sampling, blood fetal CTG and continuous including interventions, of other acascade receiving baby her and woman of a likelihood the increases it addition, In outcomes. birth improving without section of caesarean risk the (CTG) cardiotocography increases that shows Evidence probably inlabour admission on Moderate-certainty evidence from from evidence Moderate-certainty . More than 13 000 women women 13 000 than . More 3.2.6 blood sampling (3 trials, 10 757 women, RR 1.28, 1.28, RR women, 10 757 trials, (3 sampling blood fetal increases admission CTG on with auscultation, compared that, shows evidence High-certainty 1.19, RR CI 2367 babies, 955 trial, 0.37–3.90).(1 difference to hypoxic-ischaemicencephalopathy no or itmay that make little suggests evidence 95% CI 0.72, 0.32–1.61),RR low-certainty and babies, 8056 trial, (1 seizures neonatal or 0.54–1.85) 5 minutes) 95% (4 CI 1.00, RR 11 324 trials, babies, scores rate to lowthe Apgar of difference no at (< 7 or little makes itprobably that suggests evidence Perinatal hypoxia-ischaemia: Fetal and neonatal outcomes experience. of childbirth measures any other or intervention with the satisfaction experience: Birth (from 0towith admission CTG on more). 16 1000 per 7more at is estimated section caesarean in 1.10, 95% difference CI absolute 0.95–1.27). The (RR birth vaginal instrumental increased not but 95% CI 1.00–1.44) 1.20, (RR section in caesarean increase with an associated is probably admission labour admission on well-being fetal of assessment Routine Trials women’s on report not did Moderate-certainty 95% CI 1.13–1.45). The absolute difference in effect Resources is estimated at 21 more babies having fetal blood No research evidence on relative costs or cost- sampling per 1000 (from 10 to 34 more). effectiveness of CTG compared with auscultation Fetal distress: The review did not report this was found. outcome. Additional considerations Perinatal mortality: Moderate-certainty evidence suggests that CTG on admission probably makes In the absence of additional health benefits little or no difference to perinatal mortality (4 trials, with CTG on admission, it is plausibly less cost- 11 339 babies, RR 1.01, 95% CI 0.30–3.47). effective than auscultation with a Pinard fetal stethoscope or a Doppler ultrasound device, due Long-term infant outcomes: None of the studies to higher equipment and supply costs, as well as reported data on severe neurodevelopmental excessive use of caesarean section, and a cascade disabilities. of other interventions. Some interventions, such as caesarean section, have significant resource Additional considerations implications for both the facilities and for the women The review also reported on effects of admission undergoing them. There is a clear health cost saving CTG on the rates of other medical interventions. in recommending that CTG is not used on labour High-certainty evidence shows that CTG on admission. admission has little or no effect on amniotomy (2 trials, 2694 women, RR 1.04, 95% CI 0.97–1.12), Equity oxytocin augmentation of labour (2 trials, 11 324 No direct evidence on the impact of admission CTG women, RR 1.05, 95% CI 0.95–1.17) or use of (or CTG, in general) on equity was found. epidural analgesia (3 trials, 10 757 women, RR 1.11, 95% CI 0.87 to 1.41). However, moderate- Additional considerations certainty evidence shows that CTG on admission probably increases the likelihood of continuous CTG The moderate-certainty evidence that CTG on monitoring during labour (3 trials, 10 753 women, RR admission does not improve childbirth outcomes 1.30, 95% CI 1.14 to 1.48). The absolute difference was derived from HICs only and may not be in effect is estimated at 125 more women receiving applicable to settings where marginalized women continuous CTG per 1000 (from 58 to 200 more). can only receive poor-quality antenatal care and where baseline risk of fetal mortality at labour Evidence from this review may not be applicable to admission may be higher. LMICs as all trials were conducted in HICs. Introduction of routine admission CTG might reduce equity if it leads to a cascade of unnecessary Values interventions that can only be accessed by more Findings from a qualitative review of what matters advantaged women and those in well resourced to women during intrapartum care (23) indicate settings. In settings with high perinatal mortality that most women want a normal childbirth, but rates, CTG interventions aimed at improving acknowledge that medical intervention may detection of the hypoxic fetus, with an appropriate sometimes be necessary to facilitate the birth of increase in caesarean section, might increase equity a healthy baby (high confidence in the evidence). by conferring greater benefit to the disadvantaged Most women, especially those giving birth for women. the first time, are apprehensive about childbirth (high confidence in the evidence) and of particular Acceptability interventions, although in certain contexts and/ or situations women welcome interventions to In a review of qualitative studies exploring women’s shorten labour or provide relief from pain (low and providers’ experiences of labour and childbirth, confidence in the evidence). Where interventions results suggest that some women find the use of are introduced, women would like to receive CTG reassuring but feel restricted by the equipment relevant information from technically competent and would prefer a more hands-on, woman-centred health care professionals who are sensitive to their approach to care (low confidence in the evidence) needs. Findings also showed that women want to (26). be in control of their birth process and would like to Findings from a sub-study of the review (26) showed be involved in decision-making around the use of that staff felt that CTG is overused, that it leads to interventions (high confidence in the evidence). unnecessary interventions and, from a midwifery 3. EVIDENCE AND RECOMMENDATIONS

65 66 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE a Table 3.24 only. settings HIC from are reviewQualitative findings considerations Additional confidence in the evidence). (compared outcomes toto CTG) better (low leads and flexibility more they believe offers it to IAbecause prefer would use professionals care health possible, where that, suggest also Findings inconsistent (high confidence in the evidence). be can interpretation and understanding that acknowledge and to CTG tracings interpret trained sufficiently feel not do professionals care health confidence in the evidence). In addition, some of litigation (high fears organizational to temper to manner inadefensive it use pressured feel and technology the trust not do many reassurance, CTG of offers use believe the that staff some While in evidence).the skills (high confidence focused perspective, undermines traditional, woman-

monitoring and Supervision Staff time Infrastructure Equipment Supplies trainingStaff Resource varies but might plausibly be similar to this estimate for a 15–30 cm length (assuming a paper speed of 1 cm/minute). of speed apaper (assuming length cm a15–30 for estimate to this similar be plausibly might but varies (112) use per US$ 0.03 at estimated been has (ECG) paper electrocardiograph of cost The cardiotocography (CTG), Doppler ultrasound device and Pinard fetal stethoscope admission: on well-being fetal of assessment for requirements resource Main                  Description                  CTG trace of anon-reassuring parameters the all identify to accurately is needed supervision CTG: experience provider on depending variable, Pinard: Doppler: minimum of 60 seconds personnel CTG by trained the to time interpret set-up plus test CTG: time required none Pinard: replacing) or charging need either (batteries operated battery Doppler: power for plug awall requires CTG: US$ 0.94 (112) Pinard: costs maintenance Doppler: CTG and 112) (32, to US$ 350 US$ 95 cost can device Doppler: US$ 1457.16 costs (112) machine CTG: Pinard: none (112) AA) (1.5V batteries replaceable require some gel, ultrasound Doppler: CTG: ultrasound gel, thermal paper, thermal gel, ultrasound CTG: (113) proficient to become take experience can training; practice-based Pinard: (32) training additional without to use easy Doppler: (112) findings the interpret and to how apply on training practice-based CTG: staff to use them. them. use to staff care health training and CTG machines in procuring investment will discourage needs resource health priority higher other only. settings, low-resource In settings HIC from are reviewQualitative findings considerations Additional accessories (low confidence in the evidence). of limited availability and maintenance to poor lead alternatives), often constraints financial but to (compared use with itisbelieve cheaper that also Staff settings. low-resource in findings the to of responding feasibility reduce would which evidence). is likely This to have implications, cost in the (high confidence interventions to unnecessary may lead totend and CTG believe that is overused staff that showed monitoring fetal CTGviews and on views (26) professionals’ care health review aqualitative systematic In exploring Feasibility a fuses (112) fuses . The cost of cardiotocography (CTG) paper (CTG) paper cardiotocography of cost . The , a sub-analysis on on , asub-analysis Table 3.25 Summary of judgements: Routine cardiotocography (CTG) on admission compared with auscultation of the fetal heart with Doppler ultrasound device or Pinard fetal stethoscope on admission

Desirable – – ✓ – – – effects Don’t know Varies Trivial Small Moderate Large Undesirable – – – – ✓ – effects Don’t know Varies Large Moderate Small Trivial Certainty of – – – ✓ – the evidence No included Very low Low Moderate High studies Values – ✓ – – Important Possibly Probably no No important uncertainty or important important uncertainty or variability uncertainty or uncertainty or variability variability variability Balance of – – – ✓ – – – effects Don’t know Varies Favours Probably Does not Probably Favours Pinard/ favours favour either favours admission Doppler Pinard/ admission admission CTG Doppler CTG or CTG Pinard/ Doppler Resources – – – ✓ – – – required Don’t know Varies Large costs Moderate Negligible Moderate Large savings costs costs or savings savings Certainty ✓ – – – – of evidence No included Very low Low Moderate High of required studies resources Cost- – – – ✓ – – – effectiveness Don’t know Varies Favours Probably Does not Probably Favours Pinard/ favours favour either favours admission Doppler Pinard/ admission admission CTG Doppler CTG or CTG Pinard/ Doppler Equity – ✓ – – – – – Don’t know Varies Reduced Probably Probably no Probably Increased reduced impact increased Acceptability – ✓ – – – – Don’t know Varies No Probably No Probably Yes Yes Feasibility – ✓ – – – – Don’t know Varies No Probably No Probably Yes Yes 3. EVIDENCE AND RECOMMENDATIONS

67 68 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE 3.2.8 3.2.7     Remarks (Not recommended) Administration of an enema for reducing the use of labour augmentation is not recommended. RECOMMENDATION 15     Remarks (Not perineal/pubicRoutine recommended) shaving is not recommended. to prior giving vaginal birth RECOMMENDATION 14        

be a conditional recommendation based on very low-quality evidence. evidence. low-quality very on based recommendation aconditional be available at: http://apps.who.int/iris/bitstream/10665/112825/1/9789241507363_eng.pdf document, guideline source inthe found be can this recommendation supporting evidence The this intervention. against recommendation strong a made therefore and women, and caregivers among acceptability and use resource care in health reduction the this recommendation, of implementing feasibility the on emphasis its placed GDG The for women. withdiscomfort invasiveassociated and It is considered benefits. clinical any other confer nor labour of duration the to shown reduce been neither has of enema use routine the that noted GDG The evidence. low-quality (46) WHO the from recommendations integrated been has for augmentation recommendation This of labour available at: http://apps.who.int/iris/bitstream/10665/186171/1/9789241549363_eng.pdf document, guideline source inthe found be can this recommendation supporting evidence The childbirth). and of time labour the before shortly (e.g. home at with comfortable is most she by whomever and to shaved wherever to be arrange advised be should she to to birth, shaving prior have perineal/pubic provider. chooses awoman where situations In care health the not and to woman the left be shaving should perineal/pubic regarding decision The section. caesarean for prepared being to women apply not does It birth. of vaginal context within the area genital external female the around to shavings all hair applies recommendation This treatment of maternal peripartum infections WHO the from recommendations integrated been has for prevention recommendation This and Enema onEnema admission Perineal/pubic shaving , in which the GDG for that guideline determined it to be a strong recommendation based on very very on based recommendation itto astrong be determined guideline that for GDG the , inwhich (114) , in which the GDG for that guideline determined it to it determined guideline that for GDG the , inwhich

3.2.9 Digital vaginal examination

RECOMMENDATION 16

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

Remarks

 This recommendation has been integrated from the WHO recommendations for prevention and treatment of maternal peripartum infections (114), in which the GDG for that guideline determined it to be a strong recommendation based on very low-quality evidence.  There is currently no direct evidence on the most appropriate frequency of vaginal examinations to prevent infectious morbidity in the mother and baby, and therefore this recommendation was based on consensus reached by the GDG, and it is in agreement with a similar recommendation in the 2014 WHO recommendations for augmentation of labour (46).  Priority must be given to restricting the frequency and total number of vaginal examinations. This is particularly crucial in situations when there are other risk factors for infection (e.g. prolonged rupture of amniotic membranes and long duration of labour).  The GDG acknowledged that the frequency of vaginal examinations is dependent on the context of care and the progress of labour. The group agreed that vaginal examinations at intervals more frequent than specified in this recommendation may be warranted by the condition of the mother or the baby.  Vaginal examinations of the same woman by multiple caregivers around the same time or at different time points should be avoided. The group noted that this practice is common in teaching settings where multiple cadres of staff (or students) perform vaginal examinations for learning purposes.  The evidence supporting this recommendation can be found in the source guideline document, available at: http://apps.who.int/iris/bitstream/10665/186171/1/9789241549363_eng.pdf 3. EVIDENCE AND RECOMMENDATIONS

69 70 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE ultrasound device. device. ultrasound and/or stethoscope fetal aPinard using Doppler auscultation trials to across include of IAvaried method The of risk bias. ahigh at being as assessed was study latter The trial. of the month each for (the study), USA interventions alternated which RCTstrials were individual aquasi-RCT was one and Three this analysis. from were excluded data these but pregnancies, with high-risk women included also inIreland conducted study The 1978 1986. and between findings their women), reported which (14 618 USA the women) and (504 Kingdom (989 women), women), (10 053 United the Ireland inAustralia trials conducted four from derived were data low-risk subgroup These included. review of the was low-risk the subgroup from derived evidence only of this guideline, purposes (115) labour during well-being of fetal (IA) assessment for auscultation intermittent versus CTG continuous reviewsystematic comparing aCochrane from derived was evidence The intervention (EB the of 3.2.10) Effects Table ofSummary evidence and considerations 3.2.10      Remarks pregnant women undergoing spontaneous labour. (Not recommended) Continuous cardiotocography is not recommended for assessment of fetal well-being in healthy RECOMMENDATION 17      defence of clinical practice. of clinical defence in CTG tracings on continuous by than relying of IA, findings indicate clearly which records, and notes medical litigation by good from keeping protected better Cliniciansbe might outcomes. birth improve not does and evidence-based is not aware this that practice made be should stakeholders all litigation, toagainst defensively protect CTG is used continuous where settings and countries In improved. (IA)be could auscultation of intermittent documentation coverage and how the consider should mortality perinatal with high incountries Stakeholders unknown. is newerof this technology effects the on evidence the that itagreed CTG is available, continuous mobile that acknowledged GDG the While women. for stressful be freely, to can able walk around and being and positions, birth and of labour labour, during havingchoice as a such interventions beneficial other restrict CTG can Continuous care. intrapartum woman-centred providing supportive, asubstitute as for used be not CTG should Continuous consequences. health 1000), fewer (1 per have seizures may may not or which further inneonatal reduction absolute small on the emphasis less placed GDG feasibility.and The acceptability with varying and effective, cost- being without interventions, medical other and section caesarean CTG increases continuous that suggests that evidence on emphasis its placed GDG the this recommendation, making In

Continuous cardiotocography (CTG) during labour . For the the . For control during labour, was not reported in the review. inthe labour, during control reported not was of loss perceived and with care, dissatisfaction position, birth preferred to adopt inability including experience: Birth 0.92, 95% CI 0.79–1.07). RR women, 504 trial, (1 methods monitoring fetal these between requirements analgesic in maternal difference no or little is probably there that suggests Moderate-certainty relief: pain evidence for Need low certainty. trials is of very these from birth vaginal more). instrumental on Evidence (from women 7to 70 1000 per sections caesarean more 30 at estimated is effect in difference absolute 95% CI The 1.24–3.45). 2.06, with IA(RR compared CTG with continuous increased may be section caesarean that women) suggests trials (1431 of birth: Mode Maternal outcomes (IA) (CTG) compared with intermittent auscultation Comparison: Continuous cardiotocography Low-certainty evidence from two two from evidence Low-certainty Evidence on birth experience, experience, birth on Evidence Fetal and neonatal outcomes Continuous CTG compared with intermittent Perinatal hypoxia-ischaemia: Moderate-certainty CTG was evaluated in an RCT conducted in evidence suggests that continuous CTG probably Sweden among 4044 participants at low risk of reduces neonatal seizures compared with IA (3 complications (116). In the intermittent group, trials, 25 175 babies, RR 0.36, 95% CI 0.16–0.79). CTG was performed for 10–30 minutes every The absolute difference in effect was estimated at 2.0–2.5 hours during the first stage of labour, and 1 event fewer per 1000 babies (from 0 to 2 fewer). stethoscope auscultation was performed every There were no data in the review on cord blood 15–20 minutes in the periods between CTG. All acidosis or cerebral palsy for the low-risk subgroup. women were monitored continuously in the second stage of labour. The review authors found no Perinatal mortality: This evidence is of very low significant differences in caesarean section for fetal certainty, due to study design limitations and very distress (1.2% vs 1.0%, respectively) or other birth few events. outcomes, and concluded that intermittent CTG was Long-term infant outcomes: Studies of women with as safe as continuous CTG for monitoring low-risk low-risk pregnancies did not report cerebral palsy or labour. other long-term infant outcomes. Values Additional considerations Findings from a qualitative review of what matters The evidence for the low-risk subgroup was to women during intrapartum care (23) indicate consistent with the evidence for high-risk and that most women want a normal childbirth, but mixed-risk subgroups. In the overall review analyses acknowledge that medical intervention may that included high-, low- and mixed-risk subgroups, sometimes be necessary to facilitate the birth of a the summary estimates suggest a difference healthy baby (high confidence in the evidence). between interventions in the effect on: Where interventions are introduced, women would  neonatal seizures – reduced with continuous like to receive relevant information from technically CTG (9 trials, 32 386 babies, RR 0.50, 95% CI competent health care professionals who are 0.31–0.80); sensitive to their needs.  caesarean section – increased with continuous The findings also showed that women want to be CTG (11 trials, 18 861 women, RR 1.63, 95% CI in control of their birth process and would like to 1.29–2.07); be involved in decision-making around the use of interventions (high confidence in the evidence).  instrumental vaginal birth – increased with continuous CTG (10 trials, 18 615 women, RR 1.15, 95% CI 1.01–1.33); and Additional considerations Evidence from the same qualitative review suggests  fetal blood sampling – increased with continuous that women might place a higher value on avoiding CTG (2 trials, 13 929 babies, RR 1.24, 95% CI the risk of additional interventions (e.g. caesarean 1.05–1.47). section, instrumental birth and fetal blood sampling) Summary estimates suggest little or no difference that make birth abnormal and which override their in effect on perinatal mortality, cerebral palsy, cord control of the birth process, without necessarily blood acidosis, hypoxic-ischaemic encephalopathy improving outcomes for them and their babies (23). (HIE), oxytocin augmentation and epidural In addition, continuous CTG during labour could analgesia, among others. negatively impact on a woman’s sense of autonomy Very few clinically relevant neonatal outcomes were during the birth process, by increasing her discom- reported consistently in the trials (115). In addition, fort and reducing her choices with regard to mobility as long-term follow-up was not performed, the long- and pain relief options. term effects of the reported neonatal seizures are not known. Resources The trials did not distinguish between nulliparous No research evidence on relative costs or cost- and parous women, or between women in effectiveness of CTG compared with IA was found. spontaneous and induced labour. In addition, trials were relatively old and clinical practices used in Additional considerations them might differ from current practice; for example, Auscultation with the Pinard fetal stethoscope is in one trial, routine amniotomy was performed the least expensive method of fetal monitoring. within an hour of admission in all women. 3. EVIDENCE AND RECOMMENDATIONS

71 72 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.26 with IA were conducted in HICs and the effect effect the and inHICs with IAwere conducted CTG compared Trials of continuous effects the on considerations Additional found. was of equity CTG on impact the on evidence No Equity (117) birth per €1316 was study inaDutch estimated as monitoring CTG of internal cost the instance, For facilities. to basic other to access ensure used be instead can monitoring, pH as such resources of ancillary use or costs, maintenance associated with the ward, labour the for CTG equipment related to procuring costs care Health savings. cost to substantial lead baby, the and could mother avoiding use the for its of morbidities risks with additional associated are which sampling, fetal and birth vaginal instrumental section, caesarean as such interventions, labour incostly increases to moderate lead also could CTGareunclear. of use Giventhe that effects term (with 1000), arate of 1fewer long- the per and seizures inneonatal reduction is absolute asmall benefit clear only the with IAsince compared when cost-effective be not might it that CTG suggests continuous of effects beneficial on evidence The a

Supplies trainingStaff Resource Staff time Infrastructure Equipment estimate, paper might cost US$ 0.48 for a labour lasting 8 hours (US$ 0.03 x16). (US$ 0.03 8hours lasting alabour for US$ 0.48 cost might paper estimate, this on Based 1cm/minute). of speed apaper (assuming length cm to 30 a15 for estimate to this similar be plausibly might but varies (112) use per US$ 0.03 at estimated been has (ECG) paper electrocardiograph of cost The cardiotocography (CTG), Doppler ultrasound device and Pinard fetal stethoscope labour: during well-being fetal of assessment for requirements resource Main .                 Description                 CTG: ultrasound gel, thermal paper, thermal gel, ultrasound CTG: (113) proficient to become take experience can training; practice-based Pinard: (32) training additional without to use easy Doppler: findings (112) the to how interpret and equipment the to how apply on training practice-based CTG: Pinard: variable, depending on provider experience provider on depending variable, Pinard: minutes 15 every seconds of 60 minimum Doppler: personnel by trained interpretation and monitoring regular needs tracing CTG: required none Pinard: replacing) or charging need either (batteries battery-operated Doppler: supply electricity astable and power for plug awall requires CTG: Pinard for none CTG; for highest costs: Maintenance US$ 0.94 (112) Pinard: 112) (32, to US$ 350 US$ 95 cost can device Doppler: duration of monitoring US$ 1457.16 costs (112) amachine CTG: Pinard: none (112) AA) (1.5V batteries replaceable require some gel, ultrasound Doppler: a fuses (112) fuses addition, findings from a qualitative review looking qualitative a from review looking findings addition, approach (low confidence in the evidence) (26) woman-centred hands-on, amore prefer would and by equipment the restricted feel but CTG reassuring of use the find women some that suggest results childbirth, and of labour experiences providers’ and women’s exploring areviewIn of qualitative studies Acceptability equity. on negatively impact further only could settings CTG into these of continuous (118–120) auscultated be rarely may only FHR the that and settings, insuch lacking is often progress of labour monitoring adequate that report Studies of resources. basic alack and care of quality to variable due inequitable, is highly sort of any monitoring rate (FHR) heart fetal electronic women (33) advantaged more coverage than intervention health have to remote areas lower and access in rural residing and poor, are educated who least women that indicates WHO’s State report 2015 of inequality interventions. of unnecessary to acascade if leads it equity reduce it could that CTG suggest of continuous effects However, rates. these mortality perinatal with high to LMICs applicable directly be may not estimates ; one machine and one bed per woman for the the for woman per bed one and machine ; one . In these settings, itis likely that settings, these . In . The cost of cardiotocography (CTG) paper (CTG) paper cardiotocography of cost . The . The introduction introduction . The . In . In at what matters to women during intrapartum care In spite of the evidence indicating no clear clinical suggest that women do not like to be left alone benefits, the views of some clinicians are that CTG during labour and would prefer the presence of a is better at identifying at-risk babies than IA and sensitive and competent health care professional that this justifies the additional risk of interventions, (high confidence in the evidence) (23). even in women without apparent risk factors for labour complications. However, CTG is likely to The findings of the qualitative review of experiences be particularly unacceptable for women and other of labour and childbirth also showed that some health care professionals who believe that childbirth health care professionals feel CTG is overused, that should be a natural, non-medicalized experience. it leads to unnecessary interventions and, from a midwifery perspective, undermines traditional, woman-focused skills (high confidence in the Feasibility evidence) (26). While some staff believe that the Findings from a qualitative systematic review of use of CTG offers reassurance, many do not trust women’s and health care providers’ experiences of the technology and feel pressured to use it in a labour and childbirth suggest that women may find defensive manner to temper organizational fears CTG irritating because it restricts their movement of litigation (high confidence in the evidence). (low confidence in the evidence) (26). In addition, some health care professionals do The review findings also indicate that staff believe not feel sufficiently trained to interpret CTG CTG tends to be overused and may lead to tracings and acknowledge that understanding and unnecessary interventions (high confidence in the interpretation can be inconsistent (high confidence evidence). They also believe that it is cheaper to use in the evidence). Findings also suggest that, where (compared to fetal monitoring techniques) but that possible, health care professionals would prefer to financial constraints may lead to poor maintenance use IA because they believe it offers more flexibility and limited availability of accessories. In addition, and leads to better outcomes (compared with CTG) some health care professionals believe that (low confidence in the evidence). workload pressures combined with poor staffing levels lead to CTG being used (continuously) as a Additional considerations “babysitter” and as an inadequate substitute for The qualitative findings were derived from HIC woman-centred care. settings only (26). Findings from a USA-based study exploring midwives’ attitudes towards the use of Additional considerations intermittent fetal monitoring found that among Qualitative findings are from HIC settings only. 145 midwives, 72.4% agreed that intermittent However, they suggest that women’s views might monitoring should be the standard of care and impede the use of CTG in labour care settings 87.0% stated that they would be willing to provide it. whereas health care professionals’ mixed views However, 53.9% indicated that nurse–patient ratios would impact its implementation differently were a problem in providing this service (121). depending on the context (26).

Table 3.27 Summary of judgements: Continuous cardiotocography (CTG) compared with intermittent auscultation (IA) for fetal monitoring during labour

Desirable – – – ✓ – – effects Don’t know Varies Trivial Small Moderate Large Undesirable ✓ – – – – – effects Don’t know Varies Large Moderate Small Trivial Certainty of – – ✓ – – the evidence No included Very low Low Moderate High studies Values – – ✓ – Important Possibly important Probably no No important uncertainty or uncertainty or important uncertainty or variability variability uncertainty or variability variability Balance of – – – ✓ – – – effects Don’t know Varies Favours IA Probably favours Does not favour Probably favours Favours IA Continuous CTG Continuous CTG Continuous or IA CTG Resources – – ✓ – – – – required Don’t know Varies Large Moderate costs Negligible costs or Moderate savings Large savings costs savings 3. EVIDENCE AND RECOMMENDATIONS

73 74 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE 3.2.11 effectiveness Cost- resources required of evidence of Certainty Equity Acceptability Feasibility      Remarks fetal stethoscope is recommended for healthy pregnant women in labour. (Recommended) aPinard or device ultrasound aDoppler either with rate heart fetal the of auscultation Intermittent RECOMMENDATION 18      appropriate resources are available to sustain implementation. available are to sustain resources appropriate to the ensure itis important device, to Doppler stethoscope fetal Pinard switching from before Therefore, settings. country inlow-income by cuts power impacted negatively be can electricity requires that of equipment Use supplies. other and of batteries countries) shortages and nearby from procurement or partners, development (due different from of equipment to donation types multiple equipment, faulty to see is it common settings low-resource insome that noted GDG The clear, decision-making. made shared to of action enable course subsequent the and to the woman explained be should auscultation of the findings The to woman. provided the be should purpose its and technique of the explanation aclear used, method of the Regardless " " " following protocol (113) the adopted therefore, and, purposes medico-legal and planning care health for protocol is important of However, standardization that agreed settings. group the care health inprotocols across variations and protocols IA different of benefits of comparative of evidence lack the acknowledged GDG The settings. initiatives inthese improvement quality through addressed to strongly be needs problem this and settings, (LMIC) country middle-income low- inmany and is inadequate labour during FHR of the monitoring that noted group The to protocols. clinical adherence with strict device used, the if irrespective care, intrapartum for is essential labour during FHR IAof that the stressed GDG The is unclear. long-term outcomes infant and early However, substantive other on outcomes. impact the ischaemia hypoxia- reduce may inturn which abnormalities, rate (FHR) heart of fetal detection the increase (CTG), cardiotocography device, could ultrasound stethoscope with fetal Pinard monitoring strict or Doppler (IA) with ahandheld auscultation intermittent that to suggest evidence is some There

" " " Intermittent fetal rate heart auscultation during labour presence or absence of accelerations and decelerations. and of accelerations absence or presence minute) the per and inbeats (as FHR number counted baseline asingle the Record Recording: contraction. the after seconds 30 least at for continue and contraction auterine during Auscultate Timing: contractions. uterine to three cover least at prolonged be bpm), 110–160 should (i.e. auscultation range normal always is not inthe FHR if the 1minute; least at for last should auscultation Each Duration: of labour. stage second in the minutes 5 of labour,stage and every first inactive minutes 15–30 every Auscultate Interval: No included included No Don’t know Don’t know Don’t know Don’t know studies ✓ – – – – Varies Varies Varies Varies . ✓ ✓ – – Favours IA Favours Reduced – – Probably reduced Probably Probably favours favours Probably Very low Very No No IA ✓ ✓ – – – Continuous CTG Does not favour favour not Does Probably No Probably No Probably no no Probably impact or IA or Low – – – – – Probably increased Probably favours favours Probably Continuous CTG Probably Yes Probably Yes Moderate – – – – – Continuous Increased Favours Favours High CTG Yes Yes – – – – – Summary of evidence and considerations indication) is of very low certainty. Moderate- certainty evidence, derived from the study that Effects of the intervention (EB Table 3.2.11) included women with risk factors for complications, Evidence was derived from a Cochrane systematic suggests that intermittent Doppler probably review that included three RCTs conducted in increases caesarean section for fetal distress Uganda, the United Republic of Tanzania and (1 trial, 627 women, RR 2.71, 95% CI 1.64–4.48) Zimbabwe, involving 6241 women in labour, but but probably makes little or no difference to only two studies (excluding the one from the United instrumental vaginal birth (1 trial, 627 women, RR Republic of Tanzania) were included in the meta- 1.35, 95% CI 0.78–2.32). analysis (122). Birth experience: There was no evidence on The trial in Uganda (1987 women without risk maternal childbirth experience from these trials, factors) compared intermittent use of a Doppler including satisfaction, inability to adopt preferred ultrasound device with intermittent monitoring position during labour, or perceived loss of control using a Pinard fetal stethoscope. Both methods during labour. were performed for 1 minute immediately after a contraction, and this was done every 30 minutes in Fetal and neonatal outcomes the first stage, every 15 minutes in the second stage Perinatal hypoxia-ischaemia: Low-certainty before bearing down, and every 5 minutes in second evidence suggests that intermittent Doppler may stage when bearing down. reduce hypoxic-ischaemic encephalopathy (HIE) (1 The Zimbabwe trial (633 women) was a four-arm trial, 627 babies, RR 0.10, 95% CI 0.01–0.78) and trial that compared intermittent cardiotocography neonatal seizures (RR 0.05, 95% CI 0.00–0.91). The (CTG), Doppler and two methods of Pinard FHR absolute difference in HIE is estimated at 29 fewer monitoring (strict and routine practice). In the per 1000 (from 7 to 31 fewer). Evidence on Apgar CTG arm, an external transducer was applied for scores is of very low certainty. 10 minutes every half hour to monitor the FHR; Fetal distress: Low-certainty evidence suggests that it is unclear how consistently the transducer a FHR abnormality may be detected more frequently for contractions was applied. The Doppler and with Doppler than with Pinard auscultation (2 trials, “strict” Pinard methods involved a research 2598 babies, RR 2.40, 95% CI 1.09–5.29) and that midwife auscultating the FHR for 1 minute during early and late decelerations are probably identified the last 10 minutes of every half hour, during and more frequently with Doppler (1 trial, 627 babies, immediately after a contraction, whereas the RR 2.72, 95% CI 1.73–4.28) (moderate-certainty midwives on duty performed auscultation in the evidence). “routine practice” arm. Women in this trial had obstetric or medical risk factors (excluding women Perinatal mortality: The evidence for this outcome with placental abruption or eclampsia) and were is of very low certainty. booked at or transferred to a referral hospital for Long-term infant outcomes: These were not childbirth. Where data from this trial were included reported in the trials. in meta-analyses, the evidence was downgraded for indirectness. Additional considerations Participants in both trials had term singleton The evidence for most outcomes was based on data pregnancies with , and on from a study among women described as having admission they had cervical dilatation less than “high-risk” pregnancies. From the evidence, it is or equal to 7 cm and a FHR of 120–160 beats per uncertain whether increased identification of early minute. and late decelerations and increased caesarean section for fetal distress translate to improved early Comparison 1: Intermittent monitoring with and long-term infant outcomes. Doppler ultrasound device compared with routine Pinard fetal stethoscope Values Two trials (Uganda and Zimbabwe) contributed data Findings from a review of qualitative studies looking to this comparison. at what matters to women during intrapartum care (23) indicate that most women want a normal Maternal outcomes childbirth with good outcomes for mother and baby, Mode of birth: The evidence on the effect of but acknowledge that interventions may sometimes these methods on overall caesarean section (any be necessary. When interventions are being 3. EVIDENCE AND RECOMMENDATIONS

75 76 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.28 advantaged more coverage than intervention health less have and remote areas lower and access rural in residing and poor, are educated who least women that indicates WHO’s State report 2015 of inequality considerations Additional found. was equity on monitoring of fetal types of different impact the on evidence No Equity IA available. of method cheapest is the stethoscope fetal Pinard considerations Additional found. with Pinard was compared Doppler of effectiveness cost- or relative on costs evidence research No Resources morbidity. section caesarean of increased expense willing to be would have and the at baby ahealthy hypoxia-ischaemiaperinatal seizures neonatal and as such morbidity avoiding on severevalue newborn ahigh Globally, place women hypoxia-ischaemia. perinatal itmay reduce and distress, fetal for section caesarean subsequent increases probably it abnormalities, of FHR detection may increase LMICs in Doppler that suggests effects on evidence The considerations Additional evidence). in the (high confidence sensitiveare to needs their who providers care health competent technically from attention and care receiving value also They in evidence).the (high confidence achoice given possible, where and, interventions of nature the the about like would women to informed be considered, Staff time Infrastructure Equipment Supplies trainingStaff Resource Pinard fetal stethoscope (comparison 1) and device ultrasound Doppler auscultation: intermittent for requirements resource Main Description                     Pinard: variable (minutes), depending on provider experience provider (minutes), on variable Pinard: depending experience provider (minutes), on variable depending Doppler: required none Pinard: replacing) or charging need either (batteries battery-operated Doppler: US$ 0.94 (112) Pinard: 112) (32, to US$ 350 US$ 95 cost can device Doppler: Pinard: none (112) AA) (1.5V batteries replaceable require some gel; ultrasound Doppler: (113) proficient to become experience take some can training; practice-based Pinard: (32) training additional without to use easy fairly Doppler: add to its appeal over monitoring. fetal Pinard to appeal its add could and reassurance provides which heartbeat, fetal the to allows also awoman hear Doppler only. settings high-income from were derived professionals care health from findings Qualitative considerations Additional evidence). in the to (low care confidence approach centred woman- amore facilitates it because stethoscope to fetal aPinard prefer use professionals care health settings, in evidence).the In certain confidence (compared women for with CTG)outcomes (low better potentiallyto leads and reassurance offers it because device likeDoppler staff show that a use to review (26) same the from childbirth and of labour experiences professionals’ care health on Findings evidence) (26) in the allows this that (high for confidence technique likely are to and to care favour any approach centred woman- hands-on, amore prefer would women that suggest results childbirth, and of labour experiences women’s exploring areviewIn of qualitative studies Acceptability women. advantaged more for care provide that in facilities likely is more use its therefore and costs additional may attract into practice clinical monitoring of Doppler introduction The needs. resource health of competing aresult as facilities care remote health to and apply, easier are inrural they scarce are (118–120)auscultated be rarely may only FHR the that and settings, such in lacking is often progress of labour monitoring women (33) . Studies report that adequate adequate that report . Studies . . While Doppler fetal monitors monitors fetal Doppler . While , Feasibility the resources associated with using Doppler – in A qualitative systematic review of women’s terms of initial purchase costs, training and ongoing experiences of labour and childbirth found no maintenance – may be restrictive (low confidence in feasibility concerns relating to the use of Doppler the evidence). (26). Additional considerations The same review also explored health care professionals’ views and found that staff believed A Pinard fetal stethoscope is the least expensive that Doppler offers a more flexible approach to fetal option; however, Doppler is probably easier to use monitoring and is less expensive to use compared and therefore might be more feasible in settings with other similar monitoring equipment (low with few midwives if the device is available and if confidence in the evidence) (26). However, findings equipment maintenance and a continuous supply of also suggest that in certain low-income settings batteries is assured.

Table 3.29 Summary of judgements: Intermittent auscultation using Doppler ultrasound device compared with Pinard fetal stethoscope (comparison 1)

Desirable – – – ✓ – – effects Don’t know Varies Trivial Small Moderate Large Undesirable – – – – – ✓ effects Don’t know Varies Large Moderate Small Trivial Certainty of – – ✓ – – the evidence No included Very low Low Moderate High studies Values – – ✓ – Important Possibly Probably no No important uncertainty or important important uncertainty or variability uncertainty or uncertainty or variability variability variability Balance of – – – – – ✓ – effects Don’t know Varies Favours Probably Does not Probably Favours Pinard favours Pinard favour favours Doppler Doppler or Doppler Pinard Resources – – – ✓ – – – required Don’t know Varies Large costs Moderate Negligible Moderate Large savings costs costs or savings savings Certainty ✓ – – – – of evidence No included Very low Low Moderate High of required studies resources Cost- – – – ✓ – – – effectiveness Don’t know Varies Favours Probably Does not Probably Favours Pinard favours Pinard favour favours Doppler Doppler or Doppler PInard Equity – – – ✓ – – – Don’t know Varies Reduced Probably Probably no Probably Increased reduced impact increased Acceptability – ✓ – – – – Don’t know Varies No Probably No Probably Yes Yes Feasibility – ✓ – – – – Don’t know Varies No Probably No Probably Yes Yes 3. EVIDENCE AND RECOMMENDATIONS

77 78 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE reported inthis trial. reported Long-term infant outcomes: low certainty. very Perinatal mortality: more). (from to 60 252 1000 per more 134 at estimated is set this limited data on based decelerations lateand early detecting in difference absolute 95% The CI 1.82–4.45). 2.84, (RR decelerations late FHR and early 95% including CI 4.21–8.79), 6.08, (RR abnormality of aFHR diagnosis the increases CTG probably intermittent that suggests Fetal distress: in this trial. reported not was acidosis Cord blood low certainty. is of very 5minutes 7at than of less scores Apgar (from 3tofewer). 30 1000 fewer per 25 on Evidence at is estimated set this limited data on based in HIE difference absolute The 95% CI 0.00–0.89). 0.05, (RR seizures 95% CI neonatal 0.04–0.90) and 0.20, (RR (HIE) hypoxic-ischaemic encephalopathy reduce CTG may intermittent that suggests evidence Perinatal hypoxia-ischaemia: Fetal and neonatal outcomes labour.during of control labour, loss during perceived position or preferred to adopt inability satisfaction, including this trial, from experience birth of maternal element experience: Birth 95% CI 0.86–2.49). 1.46, (RR birth vaginal to instrumental difference no or little makes probably it that suggests evidence certainty 2.92, (RR distress 95% fetal for CI 1.78–4.80). Low- 1.92, (RR 95%monitoring CI 1.39–2.64), particularly Pinard with routine compared section caesarean increases CTG probably intermittent that suggests of birth: Mode Maternal outcomes indirectness. for downgraded been has factors for complications; therefore, this evidence with risk were women inthis study participants above, mentioned duty. on As midwives the from care” “usual received group Pinard practice” “routine The babies. and women involved 633 this comparison for which inZimbabwe, conducted four-arm the from derived was Evidence trial stethoscope (CTG) compared with routine Pinard fetal cardiotocography Intermittent 2: Comparison Moderate-certainty evidence Moderate-certainty evidence There was no evidence on any on evidence no was There Evidence on this outcome is of this outcome on Evidence These were not were not These Low-certainty Low-certainty is more likely in facilities that provide care for more more for likely care provide that is more in facilities use its therefore and facilities the for and women the for costs additional in CTG will likely attract investment An needs. resource health competing of other aresult as facilities care remote health and 120) (118– auscultated be rarely may only FHR the that and settings, insuch lacking is often progress labour (33) women advantaged more coverage than intervention have to remote areas lowerhealth and access rural in residing and poor, are educated who least women that indicates WHO’s State report 2015 of inequality considerations Additional found. was equity on impact the on evidence No Equity found. was ofIA types different of effectiveness cost- or relative on costs evidence research No Resources morbidity. section caesarean of willing to have expense the at baby ahealthy may be and hypoxia-ischaemia perinatal as such morbidity avoiding on severe value newborn high a Globally, place women distress. fetal for section caesarean of subsequent expense the at ischaemia hypoxia- perinatal may reduce and abnormalities, of FHR detection may increase CTG inLMICs intermittent that suggests effects on evidence The considerations Additional in evidence).the (high confidence achoice given possible, where and, interventions of nature the the about like would women to informed be considered, being are interventions When necessary. be may sometimes interventions that acknowledge but baby, and mother for outcomes with good childbirth (23) care intrapartum during to women matters what at looking areview from of qualitative studies Findings Values outcomes. long-term infant to and translated improved early distress, fetal for section caesarean increased and latedecelerations, and early of identification increased whether is it uncertain evidence, the be could over-estimated. From effects beneficial the therefore, pregnancies; having “high-risk” as described women among study asingle from data on is based this comparison for evidence The considerations Additional . Studies report that adequate monitoring of monitoring adequate that report . Studies . Electronic fetal monitors are scarce in rural inrural scarce are monitors fetal . Electronic indicate that most women want a normal anormal want women most that indicate Table 3.30 Main resource requirements for intermittent auscultation: cardiotocography (CTG) and Pinard fetal stethoscope (comparison 2)

Resource Description  CTG: practice-based training on how to apply the equipment and how to interpret the Staff training findings (112)  Pinard: practice-based training; takes less experience to become proficient (113)  CTG: ultrasound gel, thermal paper,a fuses (112) Supplies  Pinard: none  CTG: a machine costs US$ 1457.16 (112); one machine and one bed per woman for the duration of monitoring Equipment  Pinard: US$ 0.94 (112)  Maintenance costs: CTG (none for Pinard)  CTG: requires a wall plug for power Infrastructure  Pinard: none required  CTG: tracing needs regular monitoring and interpretation by trained personnel Staff time  Pinard: variable, depending on provider experience a The cost of electrocardiograph (ECG) paper has been estimated at US$ 0.03 per use (112). The cost of cardiotocography (CTG) paper varies but might plausibly be similar to this estimate for a 15 to 30 cm length (assuming a paper speed of 1 cm/minute). Based on this estimate, paper might cost US$ 0.48 for a labour lasting 8 hours (US$ 0.03 x 16). advantaged women. CTG might also reduce equity Additional considerations if it leads to a cascade of interventions that can only Qualitative findings were derived from HIC settings be afforded by more advantaged women and those only. New wireless methods of CTG may be more in well resourced settings. acceptable to women than existing CTG as they allow women to remain mobile during labour; these Acceptability methods are undergoing evaluation for use in LMIC In a review of qualitative studies exploring women’s settings (123). and health care providers’ experiences of labour and childbirth, results suggest that some women Feasibility find the use of CTG reassuring but feel restricted by Findings from a qualitative systematic review of the equipment and would prefer a more hands-on, women’s views and experiences of labour and woman-centred approach (low confidence in the childbirth suggest that CTG may restrict women’s evidence) (26). movement (low confidence in the evidence) (26). From the same review (26), findings show that staff The same review explored health care professionals’ feel CTG is overused and may lead to unnecessary views and experiences of labour and childbirth; the interventions (moderate confidence in the evidence). findings indicate that many health care professionals From a midwifery perspective, staff believe that believe CTG tends to be overused and might lead to CTG undermines traditional, woman-focused skills unnecessary interventions (moderate confidence in (moderate confidence in the evidence) and may the evidence). This is likely to have cost implications. be used to “babysit” when staffing levels are low Findings also suggest that, where possible, health (low confidence in the evidence). While some staff care professionals prefer to use a Doppler device believe that the use of CTG offers reassurance, many because of the greater flexibility it allows and do not trust the technology and feel pressured to use because they believe it leads to better outcomes it in a defensive manner to temper organizational (compared with CTG). In addition, although health fears of litigation (high confidence in the evidence). care professionals believe that CTG is cheaper to In addition, some health care professionals do not use (compared with other high-tech alternatives), feel sufficiently trained to interpret CTG tracings and they recognize that financial constraints may lead acknowledge that understanding and interpretation to poor maintenance and limited availability of can be inconsistent (high confidence in the accessories in certain contexts. evidence). 3. EVIDENCE AND RECOMMENDATIONS

79 80 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.31 is only. likely to stethoscope fetal APinard settings HIC from derived were qualitative findings These considerations Additional fetal distress (RR 0.70, 95% CI 0.35–1.38) and and 0.70, (RR distress fetal 95% CI 0.35–1.38) to due 95% section CI 0.46–1.08), caesarean 0.71, (RR any indication for section of caesarean interms monitoring Pinard intensive routine and between difference no or little may be there that of birth: Mode Maternal outcomes indirectness. for downgraded been has it babies); therefore, and women 625 trial, (1 complications for factors with risk women included Zimbabwe trial that the Evidence for this comparison was derived from stethoscope fetal compared with “routine” monitoring with Pinard (or “Strict” 3: intensive)Comparison monitoring Feasibility Acceptability Equity effectiveness Cost- resources required of evidence of Certainty required Resources effects of Balance Values effects Desirable the evidence of Certainty effects Undesirable stethoscope (comparison 2) fetal (CTG) Pinard versus cardiotocography Intermittent judgements: of Summary Low-certainty evidence suggests suggests evidence Low-certainty No included included No No included included No Don’t know Don’t know Don’t know Don’t know Don’t know know Don’t Don’t know Don’t know studies studies ✓ – – – – – – – – – Varies Varies Varies Varies Varies Varies Varies Varies ✓ ✓ – – – – – – Large costs Large Reduced Favours Favours Favours Favours Pinard Pinard ✓ ✓ – – favours Pinard favours favours Pinard favours uncertainty or or uncertainty CTG reduces its feasibility inLMICs. feasibility its CTG reduces with supplies and maintenance ongoing for need The settings. inlow-resource option cheapest the be suggests that intensive Pinard monitoring probably probably intensive that monitoring Pinard suggests Fetal distress: low certainty. very is of (HIE) hypoxic-ischaemic encephalopathy and seizures neonatal 5minutes, 7at than less scores Perinatal hypoxia-ischaemia: Fetal and neonatal outcomes labour. during of control labour, loss during perceived or position preferred to adopt inability satisfaction, this including trial, from experience birth maternal experience: Birth 2.11). 95% CI 0.69– 1.21, (RR birth vaginal instrumental Important Important Moderate variability Probably Probably Probably Very low Very Very low Very reduced Trivial Large costs No No ✓ – – – – – – – – – – uncertainty or or uncertainty CTG or Pinard or CTG CTG or Pinard or CTG Probably No Probably No intermittent intermittent Probably no no Probably Negligible important important Moderate variability Moderate-certainty evidence Does not not Does Does not not Does Possibly costs or or costs savings impact favour favour favour favour Small Low Low There was no evidence on on evidence no was There ✓ ✓ ✓ – – – – – – – – uncertainty or or uncertainty Probably Yes Probably Yes intermittent intermittent Probably no no Probably important important Moderate Moderate Moderate Moderate variability increased Probably Probably Probably savings favours favours favours favours Evidence on Apgar Apgar on Evidence Small CTG CTG ✓ ✓ – – – – – – – – – uncertainty or or uncertainty Large savings Large No important important No intermittent intermittent variability Increased Favours Favours Favours Favours Trivial Large High High CTG CTG Yes Yes – – – – – – – – – – – increases the diagnosis of a FHR abnormality (RR monitoring of labour progress is often lacking in 1.71, 95% CI 1.10–2.65), but may not do so for such settings, and that the FHR may only rarely be early and late FHR decelerations (RR 1.33, 95% CI auscultated (118–120). Addressing this fundamental 0.79–2.23) (low-certainty evidence). quality of care issue with appropriate training, supervision and monitoring could have an impact Perinatal mortality: Evidence on this outcome is of on equity, irrespective of the method of intermittent very low certainty. auscultation. Long-term infant outcomes: These were not reported in this trial. Acceptability Findings from a qualitative systematic review of Additional considerations women’s and providers’ experiences of labour and From the evidence, it is uncertain whether increased childbirth (26) indicate that women are likely to identification of a FHR abnormality leads to appreciate the more intimate connection with a improved birth and long-term infant outcomes. health care professional that this strict or intensive monitoring approach enables, provided the practice Values is conducted by kind, competent staff who are Findings from a review of qualitative studies looking sensitive to their needs (high confidence in the at what matters to women during intrapartum evidence). care (23) indicate that most women want a normal The review’s findings also suggest that health care childbirth with good outcomes for mother and professionals like to deliver this kind of woman- baby, but acknowledge that medical intervention or centred care provided there are enough resources assessment may sometimes be necessary. Where (staff) to cover the more labour-intensive nature of this is the case, they would like to receive relevant this approach (high confidence in the evidence). information from technically competent health care providers who are sensitive to their needs (high Additional considerations confidence in the evidence). The qualitative evidence above suggests that if fetal monitoring were to be performed, women would Resources prefer that competent staff perform it in such a way No research evidence on resources was found. such that it detects fetal hypoxia in time to avert poor outcomes (26). Women may feel that they are Additional considerations better looked after if their health care providers are The two study arms in the Zimbabwe study appear providing strict monitoring of the well-being of their to reflect research-context (rigorous) practice baby. versus typical daily (less-rigorous) practice. It is plausible that more rigorous fetal monitoring is more Feasibility resource intensive in terms of staff time. A qualitative systematic review of women’s Main resource requirements: See resource experiences of labour and childbirth found no requirements in comparison 2 (Table 3.30). feasibility concerns relating to the intensive use of Pinard fetal stethoscope. Equity The same review also explored health care WHO’s 2015 State of inequality report indicates that professionals’ experiences of providing intrapartum women who are poor, least educated and residing in care and found that staff sometimes lacked the rural and remote areas have lower access to health time to conduct monitoring using this approach intervention coverage than more advantaged women and felt that accurate monitoring required skill and (33). In these settings, it is likely that FHR monitoring experience that was sometimes difficult to achieve is less rigorous due to a lack of resources and in time-pressured situations (low confidence in the poor quality of care. Studies report that adequate evidence) (26). 3. EVIDENCE AND RECOMMENDATIONS

81 82 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.32 effectiveness Cost- Equity Feasibility Acceptability resources required of evidence of Certainty effects of Balance Values required Resources the evidence of Certainty effects Desirable effects Undesirable stethoscope (comparison 3) fetal Pinard with monitoring routine with compared Strict judgements: of Summary No included included No No included included No Don’t know Don’t know Don’t know Don’t know know Don’t Don’t know Don’t know Don’t know studies studies ✓ – – – – – – – – – Varies Varies Varies Varies Varies Varies Varies Varies – – – – – – – – Large costs Large monitoring monitoring Reduced Favours Favours Favours Favours routine routine routine routine – – – – uncertainty or or uncertainty monitoring monitoring Important Important Moderate variability Probably Probably Probably Very low Very Very low Very reduced favours favours favours favours routine routine routine routine Trivial Large costs No No ✓ ✓ – – – – – – – – – uncertainty or or uncertainty Probably No Probably No favour strict strict favour favour strict strict favour Probably no no Probably monitoring monitoring Negligible important important Moderate variability or routine or routine Does not not Does Does not not Does Possibly costs or or costs savings impact Small Low Low ✓ ✓ ✓ – – – – – – – – uncertainty or or uncertainty favours strict strict favours favours strict strict favours Probably Yes Probably Yes Probably no no Probably monitoring monitoring important important Moderate Moderate Moderate Moderate variability increased Probably Probably Probably savings Small ✓ ✓ ✓ ✓ – – – – – – – uncertainty or or uncertainty Large savings Large Favours strict strict Favours No important important No Favours strict strict Favours monitoring monitoring variability Increased Trivial Large High High Yes Yes ✓ – – – – – – – – – – 3.2.12 Epidural analgesia for pain relief

RECOMMENDATION 19

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

Remarks

 The GDG agreed that while there is limited evidence on the impact of epidural analgesia compared with no epidural analgesia for pain relief during labour, epidural analgesia is a proven method for relieving pain related to surgery, including abdominal surgery, and chose to recommend it as a pain relief option.  Health care professionals should be aware that women’s desire for epidural analgesia might be moderated by the clinical context in which they receive antenatal and intrapartum care, whether labour is spontaneous or not, and their access to and knowledge of a range of other forms of pain relief measures.  It is likely that the care context and the type of care provision and care provider have a strong effect on the need for labour pain relief, and on the kinds of choices women make in relation to this need.  Both commonly used pharmacological options for pain relief during labour – epidural and opioid analgesic options – have advantages and disadvantages. Epidural analgesia appears to be the more effective pain relief option but compared with opioid analgesia it also requires more resources to implement and to manage its adverse effects, which are more common with epidural analgesia.  To avoid complications and preserve as much motor function as possible, the lowest possible effective concentration of local anaesthetic should be used when administering epidural analgesia (124).  For women with epidural analgesia in the second stage of labour, it is recommended that a birth position of the individual woman’s choice be facilitated, including an upright birth position. 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.

Summary of evidence and considerations the combined spinal–epidural technique. Control groups included: no analgesia (4 trials, 637 Effects of the intervention (EB Table 3.2.12) women); no epidural analgesia but other analgesia This evidence is derived from a Cochrane systematic (not specified) offered (2 trials, 190 women); and review, to which 43 trials contributed data (125). continuous support with non-pharmacological analgesia offered to both groups (1 trial, 70 women). Comparison 1: Any epidural analgesia compared with placebo or no epidural analgesia Maternal outcomes Seven trials involving 897 women compared epidural Pain relief: It is uncertain whether epidural analgesia analgesia with no analgesia. Trials were conducted compared with no analgesia reduces pain scores, in hospital settings in China (3 trials) and in Brazil, pain intensity or the need for additional analgesia India, Mexico and Turkey (1 trial each). Sample sizes during labour because the certainty of the evidence of individual trials ranged from under 100 to just for all of these outcomes is very low. over 300 women. One trial took place between 1990 and 2000, three from 2010 onwards, and dates Mode of birth: Moderate-certainty evidence were not stated in the other three trials. suggests that epidural analgesia probably leads to fewer women undergoing caesarean birth compared All trials used bupivacaine or ropivacaine for the with no analgesia (5 trials, 578 women, RR 0.46, epidural analgesia. Ropivacaine was supplemented 95% CI 0.23–0.90). It is uncertain whether epidural with sufentanil in one trial; bupivacaine was has an effect on instrumental births because the supplemented with fentanyl in one trial and with certainty of this evidence is very low. tramadol in another. Patient-controlled epidural analgesia was used in two trials. Three trials used Duration of labour: It is not clear whether epidural analgesia makes any difference to the length of 3. EVIDENCE AND RECOMMENDATIONS

83 84 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE evidence) (126) in the (moderate confidence overcontrol childbirth to retain them enables it that value they also and effectively, pain alleviates use labour its when analgesia epidural value and desire women that only) relief (from pain HICs they request highlights when analgesia of epidural use of the experiences women’s on A review of qualitative studies evidence). in the (high confidence achoice given possible, where and, interventions of nature the the about like would women to informed be considered, being are in evidence).the interventions When confidence (low pain relief from provide that interventions and/or contexts may situations welcome certain in evidence),the in and (high confidence childbirth about apprehensive are time, first the for birth giving those especially most women, that suggest findings (23) care intrapartum during to women matters what at looking areviewIn of qualitative studies Values trials. inany included of the reported were not Mother–baby interaction and breastfeeding: studies. included the Long-term outcomes: low. very is of this evidence certainty the because minutes 5 7at than of less scores with Apgar born babies of number on the effect an has analgesia epidural Perinatal hypoxia-ischaemia: Fetal and neonatal outcomes uncertain. retention is very urinary or drowsiness fever, vomiting, hypotension, on intervention no or placebo with compared epidural of effect Side-effects: low. very is of this evidence certainty the because in childbirth control poor of feelings perceived women’s affects epidural whether is it uncertain analgesia, with no 95% CI 1.05–1.65). Compared 1.32, RR (70 women, labour relief pain inwith satisfied or very satisfied they were reporting of women proportion the may increase epidural that trial suggests a single experience: Birth 0.89, 95% RR CI 0.63–1.24).women, 415 trials, (3 augmentation labour for oxytocin receive not or women whether to difference no or may make analgesia little epidural that suggests Augmentation of labour: low. is very evidence of the certainty the as placebo, with compared of labour stages second or first the Review evidence on the relative the Review on evidence . However, some women are fearful . However, fearful are women some Low-certainty evidence from from evidence Low-certainty These were not reported in reported were not These Low-certainty evidence evidence Low-certainty It is uncertain whether whether is uncertain It These These , of respiratory depression among women receiving receiving women among depression of respiratory incidence ahigher assumed costs analgesia Opioid complications. rate ofto less-common ahigher inaddition analgesia, stage) opioid than second the for hours 1.5 versus 1.75hours and stage, first the for 6hours versus hours (7 of labour duration a longer 0%) vs (30% and treatment requiring hypotension 0%), vs (1.5% headache puncture postural (45% 35%), vs retention (2.7% 0.13%), vs urinary 10%), fever (24% 6%), vs augmentation oxytocin (14% vs births vaginal instrumental more assumed analgesia epidural for US$ 120). modelled costs The (estimated with complications associated at costs (estimatedprofessionals increased and US$ 238) at care health for values), costs to higher due primarily (1998 US$ 338 at estimated was analgesia epidural of providing cost expected incremental the and US$ 3117, was birth vaginal of ahospital-based (127) analgesia opioid than more relief costs pain labour for analgesia providing epidural that suggests analgesia opioid with compared epidural of cost-effectiveness however,were found; review USA a2002 of the cost-effectiveness and reviews costs recent on No Resources childbirth. and labour during of control sense their impacts negatively that intervention an as analgesia of epidural use the view might women some addition, In weakness. of asign as discomfort ofor pain expression view physical and of childbirth part integral an pain labour consider might women cultures, some In ofrelief. pain with this form associated outcomes the how they valued have influenced may that of intervention forms other or of labour induction augmentation, had had women whether studies, to included identify, within the possible not was It USA. inthe Six were undertaken settings. inhigh-income were undertaken analgesia epidural of use the on qualitative studies included All the considerations Additional confidence in the evidence). (low pain-relief on decision their for members family and of professionals support the value and of relief pain this method to about make achoice evidence).in the opportunity the Women value (moderate confidence experience positive childbirth to have them a helped analgesia epidural that perceive in evidence).the women Some confidence (low experience their in or ineffective effective actually was relief provided pain the whether on were mixed views there and complications, and pain to potential due injection epidural an of receiving . In the review, the . In cost mean the Table 3.33 Main resource requirements for epidural analgesia

Resource Description  An anaesthetist or other specialized health care professional with training in epidural insertion and management Staff  An obstetrician or other specialized health care professional with training in performing instrumental birth Training  Specialist medical training is required  Infusion solution, sterile pack (including gloves, gown, hat, mask, sterile drapes), Supplies epidural insertion kit, intravenous catheter, appropriate medicines for resuscitation, oxygen Equipment and  Drip stand, infusion pump, full resuscitation equipment infrastructure  Time to administer the epidural analgesia Time  Time to monitor the woman and the baby during labour and after birth for side-effects  Specialist supervision and monitoring Supervision and monitoring  Complications associated with epidural require specialist supervision and management by an anaesthetist and obstetrician (if assisted instrumental birth is required)

opioids (14% vs 2%), a higher incidence of neonatal birthing units but, rather, are managed at a higher resuscitation due to respiratory depression (4.5% vs level of care (i.e. hospital obstetric units), such that 0.5%) and more pruritis (14% vs 12%). Caesarean bed costs are also likely to be higher. Labour ward section was assumed to occur at the same rate for stays are also likely to be longer with epidural, due epidural and opioid analgesia (20%). to the potential for longer duration of labour and postpartum monitoring. Additional considerations Findings from other studies suggest that costs Equity per birth are substantially higher with epidural No direct evidence was found on the impact of analgesia (128, 129). For example, in an Australian pain relief via epidural analgesia on equity. Indirect study, epidural analgesia use alone was shown to evidence from a review of facilitators and barriers increase the average cost of childbirth by up to to facility-based birth (8) indicates that “neglect 36% depending on the type of health care facility and delays in receiving care” probably acts as a (129). For nulliparous women giving birth in a public barrier to facility-based birth (moderate confidence health care facility, epidural analgesia increased in the evidence). Such neglect and delays might be birth costs by 20%, and when combined with applicable to labour pain management. labour augmentation it attracted an additional In addition, the review also highlights that many 24% increase in costs (i.e. 44% increase in total). women in LMICs fear “unfamiliar and undesirable” Findings from a Dutch study comparing routine birth practices, which are barriers to facility-based epidural analgesia with analgesia on request birth (high confidence in the evidence) (8). Some reported that birth costs were higher by €322 (€60 women could perceive epidural injections and other to €355) with routine epidural analgesia, due to types of injections as unfamiliar and undesirable higher medication costs, a longer stay in hospital, practices. and more caesarean sections and instrumental vaginal births (130). Additional considerations The health care professionals required to administer WHO’s 2015 State of inequality report concluded and monitor epidural analgesia, and to perform that there are still large gaps in skilled birth instrumental births, are probably the main cost attendance coverage (33). Epidural analgesia for component of this intervention. In the Dutch study, pain relief is commonly used in HICs and among costs attributed to the procedure itself were much more advantaged women in LMICs. Due to its high higher for epidural analgesia (€122) compared with resource implications, its availability within countries opioid analgesia (€15). often varies between facilities and, for example, it In many settings, women undergoing epidural is often not available in rural areas where women analgesia cannot be managed in midwife-led cannot afford it and the expertise is lacking (127). 3. EVIDENCE AND RECOMMENDATIONS

85 86 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE members) (low confidence in the in evidence).the (low members) confidence family from or education via antenatal received messages through professionals, (by care so health to do persuaded or pressurized felt others analgesia, to epidural use decision intheir professionals care by health supported felt women some although in evidence).the However, (moderate confidence of control have levels and asense energy their renew restore/ to relax, women by helping experience childbirth to and facilitatehelp apositive labour could analgesia epidural that evidence was There confidence in the evidence). (low unmanageable and overwhelming was labour levelthe of and/or pain over of control the sense when resort, alast as epidural an requested others in evidence),the while (moderate confidence labour of and/or pain a fear to during incontrol remain labour, with to apain-free analgesia help to alleviate epidural an for desire apriori an expressed women in evidence).the Some (moderate confidence others of by accounts and analgesia ofavailability epidural by the were Views influenced were mixed views. (126) usage analgesia of epidural experiences women’s review aqualitative systematic In exploring Acceptability settings. inhigh-resource use analgesia epidural by reducing equity positively impact might which (132) capabilities innate birthing rediscover their to women empower could discomfort labour of medicalization the reducing and pain labour surrounding women and professionals care health of attitudes the changing that argued been has It management. to pain approach atraditional prefer would who those and intervention, need not do that processes natural are childbirth and labour believe that who women for particularly birth, to facility-based abarrier as act could and practice undesirable and unfamiliar an as women by some perceived be might analgesia epidural settings, inLMIC particularly However, care. facility-based to access women disadvantaged more indirectly, by encouraging equity impact also might it above, evidence the on directly. care Based inintrapartum inequalities to reduce help might women to disadvantaged pain relief labour timely and Providing effective epidural use (131) to inrelation indecision-making of participation and/orlevel analgesia to adifferent epidural access level of receive adifferent might characteristics sociodemographic with different women that suggest study USA one from findings Limited . there there , relief method. this pain inimplementing issues logistical be might there in that evidence),the suggesting confidence to (low late administration attributed partly was review qualitative systematic (126) in another studies insome by women reported use analgesia epidural of of effectiveness lack A perceived in (veryevidence).the low confidence options of to time alack supportive provide and workload of aheavy because analgesia epidural use to women may encourage inHICs professionals care (26) childbirth and labour of experiences providers’ women’s and exploring review aqualitative systematic from Findings Feasibility is common. usage epidural where settings 126) (26, analgesia epidural on qualitative reviewThe findings considerations Additional labour. abnormal with an those for or women nulliparous for appropriate more may it be used, if is it believe that, professionals care health some that suggests also Evidence intervention. further potential for the and baby the from disconnection philosophy, with it side-effects, associate and midwifery with the is incongruous analgesia epidural that feel midwives some that suggests evidence The low confidence. of was very evidence (26) analgesia epidural views on professionals’ care health included childbirth and of labour experiences professionals’ care health and review qualitative systematic women’s on Another effect). too late to it for (e.g. administered was it take when and/or pain timing of administration breakthrough pain, to continuing attributed was effectiveness in evidence).the of lack Perceived confidence all not for (lowbut some, for effective considered was analgesia epidural by Pain relief afforded in evidence).the (low analgesia confidence epidural of following administration mobility restricted confidence in the evidence).Some women reported of (low failure asense and disappointment guilt, conflict, including of emotions negative range a experienced and baby the from disconnected felt also in evidence).the Some (low confidence insertion with needle associated complications other and pain including effects physiological negative in evidence).the experienced They (low confidence and/or babies themselves their for potential risks and over procedure the fears had analgesia epidural to receive adecision an made who women Some are all from studies conducted in HIC inHIC conducted studies all are from indicate that some health health some that indicate ; however, the however, the ;

Additional considerations used, there are likely to be financial implications as All of the findings on epidural analgesia in the well as additional training considerations, which may qualitative reviews (26, 126) came from HIC settings negatively impact on the feasibility of implementing where epidural analgesia is widely available. In this intervention. lower-resource settings, where it is not so widely

Table 3.34 Summary of judgements: Epidural analgesia compared with placebo or no epidural analgesia

Desirable – – – ✓ – – effects Don’t know Varies Trivial Small Moderate Large Undesirable ✓ – – – – – effects Don’t know Varies Large Moderate Small Trivial Certainty of – ✓ – – – the evidence No included Very low Low Moderate High studies Values – ✓ – – Important Possibly Probably no No important uncertainty or important important uncertainty or variability uncertainty or uncertainty or variability variability variability Balance of – – – – – ✓ – effects Don’t know Varies Favours Probably Does not Probably Favours opioids or no favours favour favours epidural epidural opioids or epidural epidural analgesia no epidural analgesia or analgesia analgesia no analgesia Resources – – ✓ – – – – required Don’t know Varies Large costs Moderate Negligible Moderate Large savings costs costs or savings savings Certainty – – ✓ – – of evidence No included Very low Low Moderate High of required studies resources Cost- – – – ✓ – – – effectiveness Don’t know Varies Favours no Probably Does not Probably Favours epidural favours no favour favours epidural analgesia epidural epidural epidural analgesia analgesia analgesia or analgesia no analgesia Equity – – – ✓ – – – Don’t know Varies Reduced Probably Probably no Probably Increased reduced impact increased Acceptability – ✓ – – – – Don’t know Varies No Probably No Probably Yes Yes Feasibility – ✓ – – – – Don’t know Varies No Probably No Probably Yes Yes

Comparison 2: Epidural analgesia compared Bupivacaine or levobupivacaine was used for the with parenteral opioid analgesia epidural analgesia in most of the studies when Thirty-five trials involving 10 835 women compared reported. Bupivacaine was supplemented with epidural analgesia with opioids (125). Trials were fentanyl in 10 of the studies and with tramadol in conducted in hospital settings in Canada (3 trials), one study. Levobupivacaine was supplemented China (2), Egypt (2), Finland (2), India (2), Israel (2), with fentanyl in one study. Only four of the studies the Netherlands (3), the United Kingdom (2) and used the combined spinal–epidural technique. the USA (10), and one trial each in Denmark, France, Epidural use was discontinued in the second stage of Iran, Kuwait, Malaysia, Norway and Sweden. Sample labour in three studies. Opioids compared included sizes in individual trials varied considerably, ranging pethidine (17 trials, 6889 women), butorphanol from less than 50 to more than 1000 women. Eleven (1 trial, 100 women), fentanyl (3 trials, 447 women) trials were conducted between 1990 and 2000, six and remifentanil (9 trials, 3462 women), while other between 2000 and 2010, three between 2010 and opioids were used in the remaining trials. Opioids were administered as patient-controlled intravenous 2013, and the dates were not stated in 14 trials. 3. EVIDENCE AND RECOMMENDATIONS

87 88 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE of hypotension, although there was considerable considerable was there although of hypotension, likelihood the may increase analgesia epidural that Side-effects: 0.87–1.03). 0.95, 95% RR CI women, (332 experience childbirth their with satisfied or very they were satisfied reporting CI of 0.62–2.21) women to or number the 1.17, RR women, (334 95% inchildbirth control poor of to perception women’s difference no or make little may analgesia epidural that trial suggests single experience: Birth 95%1.11, CI 1.01–1.22). 8746 (20 trials, opioids RR with parenteral women, compared analgesia with epidural increased may be with oxytocin of labour augmentation that suggests Augmentation of labour: (MD 95%minutes 14.96, CI 8.96–20.96). by approximately 15 increased may be stage second of the length the that suggests evidence certainty 29.79 95%MD CI low- 12.79–46.79) and minutes, women, 2654 trials, (10 opioids with parenteral compared analgesia epidural receiving women for minutes by approximately 30 increased is probably of labour stage first of the length the that suggests Duration of labour: 10 745trials, 1.07, RR women, 95% CI 0.97–1.19). (34 birth caesarean undergoing of women numbers in the difference no or to little leads probably analgesia epidural that suggests evidence certainty 95% CI 1.29–1.59). Moderate- 1.43, RR women, 10 343 trials, (31 group opioids parenteral in the with 9.6% compared birth vaginal instrumental an having group analgesia epidural inthe with 13.2% birth, vaginal instrumental may increase epidural of birth: Mode 0.10, 95% CI 0.04–0.25). RR women, 5099 trials, (16 analgesia any additional for need the may reduce epidural suggests evidence 1.47, RR women, 95% CI 1.03–2.08). Low-certainty 1911 trials, (7 good very or excellent relief as pain to rate opioids receiving likely those more than be may receive epidural who women that suggests evidence scale). Low-certainty a10-point lower on points approximately of 3 to adifference equates this -0.73; [SMD]to difference 95%-4.56 CI -2.64, mean standardized women, (5 1133 analgesia trials, opioid with parenteral compared labour during inwomen scores pain may reduce analgesia epidural Pain relief: Maternal outcomes in1trial). unclear was route of administration in5trials (the injection intramuscular and trials, in10 injection intravenous in19 trials, analgesia Low-certainty evidence suggests that that suggests evidence Low-certainty Low-certainty evidence suggests suggests evidence Low-certainty Low-certainty evidence suggests that that suggests evidence Low-certainty Low-certainty evidence from a from evidence Low-certainty Moderate-certainty evidence Low-certainty evidence evidence Low-certainty evidence). in the (high confidence achoice given possible, where and, interventions of nature the the about like would women to informed be considered, being are in evidence).the interventions When confidence (low pain relief from provide that interventions and/or contexts may situations welcome certain in evidence),the in and (high confidence childbirth about apprehensive are time, first the for birth giving those especially most women, that suggest findings (23) care intrapartum during to women matters what at looking areviewIn of qualitative studies Values trials. inany included of the reported were not Mother–baby interaction and breastfeeding: trials. inany included of the reported Long-term neonatal outcomes: CI 0.10–0.23). 0.15, 95% RR babies, 2645 trials, (10 administration naloxone likely to less need probably are opioids parenteral than rather analgesia epidural received mothers whose babies that suggests evidence 1.17,RR 95% CI 0.64–2.14). Moderate-certainty 7.15 than less pH babies, cord arterial 480 trials, (3 for groups between difference no or little was there that suggests however, evidence low-certainty 95% CI 0.69–0.94); 0.81, (8 RR 4783 trials, babies, analgesia opioid than analgesia fewer with epidural 7.2 than less pH is probably with acord arterial of babies number the suggests evidence certainty 95% CI 0.58–1.10). 0.80, RR Moderate- 9147 babies, trials, (23 5minutes 7at than less scores in Apgar difference no or is little there that suggests evidence Perinatal hypoxia-ischaemia: Fetal and neonatal outcomes 95% 9.20, CI RR 2.28–37.11). women, 343 (4 analgesia with epidural trials, increased probably retention is of risk urinary the opioids, parenteral with compared that, suggests evidence certainty 95% CI 1.82–3.73). 2.60, RR women, Moderate- 4671 trials, (10 analgesia with epidural increased be °C) may fever (temperature > 38 suggests evidence low. is very Low-certainty evidence of the certainty the as drowsiness, maternal or vomiting, and nausea reduces analgesia epidural analgesia, with opioid whether,CI clear 0.05–0.97). is not It compared 95% 0.23, RR babies, (5 2031 trials, with opioids compared oxygen requiring depression respiratory of risk with areduced associated is probably analgesia epidural that suggests evidence certainty 95% CI 1.89–67.95). 11.34, RR Moderate- women, to 4212 trials, have (10 hypotension reported of women numbers trials inthe across inconsistency Low-certainty Low-certainty These were not were not These These These , Findings from a review of qualitative studies on In some cultures, women might consider labour women’s experiences during labour and childbirth pain as an integral part of childbirth and view (evidence derived from HICs only) highlights that physical expression of pain or discomfort as a sign women desire and value epidural analgesia when of weakness. In addition, some women might view its use alleviates labour pain effectively, and they the use of epidural analgesia as an intervention that also value that it enables them to retain control negatively impacts their sense of control during over childbirth (moderate confidence in the labour and childbirth. evidence) (26). However, some women are fearful of receiving an epidural injection due to potential Resources pain and complications, and expressed mixed views No recent reviews on costs and cost-effectiveness on whether the pain relief provided was actually were found; however, a 2002 USA review of the effective or ineffective in their experience (low cost-effectiveness of epidural compared with confidence in the evidence). Some women perceive opioid analgesia suggests that providing epidural that epidural analgesia helped them to have a analgesia for labour pain relief costs more than positive childbirth experience (moderate confidence opioid analgesia (127). In the review, the mean cost in the evidence). of a hospital-based vaginal birth was US$ 3117, Women value the opportunity to make a choice and the incremental expected cost of providing about this method of pain relief and value the epidural analgesia was estimated at US$ 338 (1998 support of professionals and family members for values), primarily due to higher costs for health care their decision on pain-relief (low confidence in the professionals (estimated at US$ 238) and increased evidence). costs associated with complications (estimated at US$ 120). Costs modelled for epidural analgesia Additional considerations assumed more instrumental vaginal births (14% vs 10%), fever (24% vs 6%), oxytocin augmentation All the included qualitative studies on the use of (45% vs 35%), urinary retention (2.7% vs 0.13%), epidural analgesia were undertaken in high-income postural puncture headache (1.5% vs 0.0%), settings. Six were undertaken in the USA. It was hypotension requiring treatment (30% vs 0%), and not possible to identify, within the included studies, a longer duration of labour (7 vs 6 hours for the first whether women had had augmentation, induction stage, and 1.75 vs 1.50 hours for the second stage) of labour or other forms of intervention that may than opioid analgesia, in addition to a higher rate have influenced how they valued the outcomes of less-common complications. Opioid analgesia associated with this form of pain relief.

Table 3.35 Main resource requirements for epidural and opioid analgesia

Resource Description  Epidural analgesia: an anaesthetist or other specialized health care professional with training in epidural insertion and management; other trained staff, e.g. nurse trained in Staff monitoring women with epidural analgesia  Opioid: a physician is usually needed to prescribe opioids (this varies between countries and settings); however, other staff, such as a midwife or nurse, can administer opioids  Epidural analgesia: specialist medical training is required Training  Opioid: fairly easy to administer  Epidural analgesia: infusion solution, sterile pack (including gloves, gown, hat, mask, sterile drapes), epidural insertion kit, skin cleaning solution, intravenous catheter, appropriate Supplies medicines for resuscitation, oxygen  Opioid: medicine (e.g. pethidine), needle, syringe, intravenous catheter (optional), skin cleaning solution, oxygen, appropriate medicines for resuscitation Equipment and  Epidural analgesia: drip stand, infusion pump, oxygen and full resuscitation equipment infrastructure  Opioid: oxygen and full resuscitation equipment  Staff time to administer and monitor epidural analgesia is substantially longer than the Time time to administer and monitor opioid use  Both epidural analgesia and opioids need supervision and monitoring Supervision and monitoring  Complications associated with epidural usually require specialist supervision and management by an anaesthetist and obstetrician (if assisted instrumental birth is required) 3. EVIDENCE AND RECOMMENDATIONS

89 90 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE women in LMICs fear “unfamiliar and undesirable” undesirable” and “unfamiliar fear inLMICs women many that review the highlights also addition, In management. pain to labour applicable be might delays and in evidence).the neglect Such confidence (moderate birth to facility-based a barrier as acts probably care” in receiving delays and “neglect (8) birth to facility-based barrier areview and from of facilitators evidence Indirect equity. on analgesia relief via epidural of pain impact the on found was evidence direct No Equity monitoring. postpartum and of labour duration to longer potential for the due with epidural, likely also are stays to longer be likely ward also are to higher. costs be Labour bed units), obstetric hospital that level (i.e. of such care ahigher rather, at but, managed are units birthing inmidwife-led managed be cannot analgesia epidural undergoing women settings, many In (€15). analgesia opioid (€122) with analgesia compared epidural for higher were much itself to procedure the attributed costs study, Dutch the In of this intervention. component cost main the probably are births, instrumental to and perform analgesia, epidural monitor and to administer required professionals care health The (130) births vaginal instrumental and sections caesarean more and inhospital, stay alonger costs, medication to higher due analgesia, (€60 epidural with routine by €322 tohigher €355) were costs birth that reported request on analgesia with analgesia epidural routine comparing study aDutch from intotal). increase 44% Findings (i.e. 24% additional an incosts increase attracted it augmentation with labour combined when and 20%, by costs birth increased analgesia facility, epidural health inapublic birth giving women primiparous (129) of facility type the on 36% depending by to up of childbirth average cost the increase to shown was alone use analgesia study, epidural 129) (128, analgesia with epidural higher substantially are birth per costs that suggest studies other from Findings considerations Additional (20%). analgesia opioid and rate epidural for same the to at occur assumed (14% was pruritis more vs12%). section Caesarean (4.5% 0.5%) vs depression and to respiratory due resuscitation 2%),vs of neonatal incidence ahigher (14% opioids receiving women among depression of respiratory incidence ahigher assumed costs . For example, in an Australian Australian inan example, . For indicates that that indicates . . For . For or to remain in control during labour (moderate labour to during incontrol or remain labour,a pain-free to alleviate ofand/ pain afear with to analgesia help epidural an for desire priori a an expressed evidence).in the women Some (moderate confidence of others by accounts and analgesia, epidural of by the availability influenced were Views usage. analgesia mixed views of epidural (126) experiences care intrapartum women’s review aqualitative systematic In exploring Acceptability settings. inhigh-resource use analgesia epidural by reducing equity positively impact might which (132) capabilities innate birthing rediscover their to women empower could discomfort) labour of (and pain medicalization the labour reducing surrounding women and professionals care health of attitudes the changing that argued been has It management. to pain approach atraditional prefer would who those and intervention, need not do that processes natural are childbirth and labour believe that who women for particularly birth, to facility-based abarrier as act could and practice undesirable and unfamiliar an as women by some perceived be might analgesia epidural settings, inLMIC particularly However, care. facility-based to access women disadvantaged more indirectly, by encouraging equity impact also might it above, evidence the on directly. care Based inintrapartum inequalities to reduce help might women to disadvantaged pain relief labour timely and Providing effective epidural use (131) related to indecision-making level of participation and/or analgesia to adifferent epidural access level of receive adifferent might characteristics sociodemographic with different women that (127) is lacking expertise the and it afford cannot women where areas available inrural not is it often example, for and, facilities between varies often countries within availability its implications, resource high to its Due inLMICs. women advantaged more among and inHICs used relief ispain commonly coverage (33) attendance birth inskilled gaps still are large there that concludedWHO’s State report 2015 of inequality considerations Additional practices. undesirable and unfamiliar as of injections types other and injections epidural perceive could women in evidence)the (8) (high confidence birth to facility-based barriers are which practices, birth . Limited findings from one USA study suggest suggest study USA one from findings . Limited . . Epidural analgesia for for analgesia . Epidural , there were , there . Some . Some , confidence in the evidence), while others requested was of very low confidence. The evidence suggests an epidural as a last resort, when the level of that some midwives feel that epidural analgesia is pain and/or sense of control over the labour was incongruous with the midwifery philosophy, and overwhelming and unmanageable (low confidence in associate it with side-effects, disconnection from the evidence). the baby and the potential for further intervention. Evidence also suggests that some health care There was evidence that an epidural could help to professionals believe that, if it is used, it may be facilitate a positive labour and childbirth experience more appropriate for nulliparous women or for those by helping women to relax, to restore/renew with an abnormal labour. their energy levels, and to have a sense of control (moderate confidence in the evidence). However, although some women felt supported by health Additional considerations care professionals in their decision to use epidural The qualitative review findings (26, 126) are all from analgesia, others felt pressurized or persuaded to do studies conducted in HIC settings where epidural so (by health care professionals, through messages usage is common. received via antenatal education of from family members) (low confidence in the evidence). Feasibility Some women who made a decision to receive an Findings from a qualitative systematic review epidural analgesia had fears over the procedure and of intrapartum care experiences (26) indicate potential risks for themselves and/or their babies that some health care professionals in HICs may (low confidence in the evidence). They experienced encourage women to use epidural analgesia because negative physiological effects including pain and of a heavy workload and a lack of time (very low other complications associated with needle insertion confidence in the evidence). (low confidence in the evidence). Some also felt A perceived lack of effectiveness of epidural disconnected from the baby and experienced a analgesia use reported by women in some studies range of negative emotions including conflict, included in another systematic review (126) guilt, disappointment and a sense of failure (low was partly attributed to late administration (low confidence in the evidence). Some women reported confidence in the evidence), suggesting that there restricted mobility following administration of might be logistical issues in implementing this pain epidural analgesia (low confidence in the evidence). relief method. Pain relief afforded by epidural analgesia was considered effective for some, but not for all (low Additional considerations confidence in the evidence). Perceived lack of All of the findings on epidural use in the qualitative effectiveness was attributed to continuing pain, reviews (26, 126) came from HIC settings where breakthrough pain and/or timing of administration epidural analgesia is widely available. In lower- (e.g. when it was administered too late for it to take resource settings, where it is not so widely used, effect). there are likely to be financial implications as well Another qualitative systematic review on women’s as additional training considerations, which may and health care providers’ experiences of labour and negatively impact on the feasibility of implementing childbirth included health care professionals’ views this intervention. on epidural analgesia (26); however, the evidence 3. EVIDENCE AND RECOMMENDATIONS

91 92 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.36 effects Desirable Values effects Undesirable effects of Balance the evidence of Certainty effectiveness Cost- resources required of evidence of Certainty Feasibility required Resources Acceptability Equity Summary of judgements: Epidural analgesia compared with opioid analgesia opioid with compared analgesia Epidural judgements: of Summary No included included No No included included No Don’t know Don’t know Don’t know know Don’t Don’t know Don’t know Don’t know Don’t know Don’t know studies studies – – – – – – – – – Varies Varies Varies Varies Varies Varies Varies Varies ✓ ✓ – – – – – – Favours opioid opioid Favours Favours opioid opioid Favours Large costs Large analgesia analgesia Reduced ✓ – – – uncertainty or or uncertainty favours opioid opioid favours favours opioid opioid favours Important Important Moderate variability analgesia analgesia Probably Probably Very low Very Very low Very Probably reduced Trivial Large costs No No ✓ ✓ – – – – – – – – – uncertainty or or uncertainty Probably No Probably No Probably no no Probably important important Negligible Moderate variability analgesia analgesia analgesia analgesia Does not not Does Does not not Does or opioid opioid or or opioid opioid or Possibly epidural epidural epidural epidural costs or or costs savings impact favour favour favour favour Small Low Low ✓ ✓ ✓ ✓ ✓ – – – – – – uncertainty or or uncertainty Probably Yes Probably Yes Probably no no Probably important important Moderate Moderate Moderate Moderate variability increased analgesia analgesia Probably Probably Probably epidural epidural epidural epidural savings favours favours favours favours Small ✓ – – – – – – – – – – uncertainty or or uncertainty Large savings Large No important important No variability Increased analgesia analgesia epidural epidural epidural epidural Favours Favours Favours Favours Trivial Large High High Yes Yes – – – – – – – – – – – 3.2.13 Opioid analgesia for pain relief

RECOMMENDATION 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. (Recommended)

Remarks

 Many women appreciate some form of pain relief in labour and would like a choice of options. The evidence suggests that opioids probably provide some relief from pain during labour, despite having some undesirable side-effects, such as drowsiness, nausea and vomiting.  Despite being widely available and used, pethidine is not the preferred opioid option, as shorter-acting opioids tend to have fewer undesirable side-effects.  Before use, health care providers should counsel women about the potential side-effects of opioids, including maternal drowsiness, nausea and vomiting, and neonatal respiratory depression, and about the alternative pain relief options available.  It is important that health care providers take care to ensure that the correct dosage is administered, as opioid overdose can have serious consequences.  Stakeholders should be aware that the care context and the type of care provision and care provider might have a strong effect on the need for labour pain relief, and on the kinds of choices women make in relation to this need.  The GDG agreed that for women who suffer from current or previous opioid addiction, non-opioid methods of pain relief are preferred.  Health care providers need to be trained to manage side-effects if they arise and must be aware that opioid medication should be securely stored with a register kept of its dispensing, to reduce the risk of abuse.

Summary of evidence and considerations Comparison 1.a. Pethidine (intramuscular [IM]) compared with placebo Effects of the intervention (EB Table 3.2.13) Four trials involving 406 women compared IM This evidence is derived from an updated Cochrane pethidine with a saline placebo. The trials were systematic review, with 61 trials involving over conducted in hospital settings in Hong Kong Special 8000 women contributing data (133). The trials Administrative Region, Iran (2 trials) and South were conducted in hospital settings in 21 countries: Africa. Sample sizes in the individual trials ranged Argentina, Austria, Canada, China, Denmark, Egypt, from 50 to 150. The trials were published between Germany, Hong Kong Special Administrative Region, 1970 and 2014. Two trials used IM pethidine doses India, Iran, the Netherlands, Nigeria, Norway, of 50 mg and two used doses of 100 mg. Use of Pakistan, Singapore, South Africa, Sweden, Thailand, subsequent doses was not well described. All used Turkey, the United Kingdom and the USA. The trials IM saline as placebo. were published between 1958 and 2017. Duration of labour was not reported in the review. Maternal outcomes Comparison 1: Parenteral opioids compared Pain relief: Low-certainty evidence suggests that with placebo or no opioids IM pethidine may reduce pain scores 30 minutes after administration (reduction of 40 mm on a Opioids that have been compared with placebo or 100-mm scale) (1 trial, 50 women, RR 25.00, 95% no analgesia in RCTs include pethidine, pentazocine, CI 1.56–400.54). Likewise, low-certainty evidence tramadol and fentanyl. suggests that women receiving pethidine compared with placebo may be more likely to rate pain relief as “good” or “fair” 1 hour after administration (1 study, 116 women, RR 1.75, 95% CI 1.24–2.47). While 3. EVIDENCE AND RECOMMENDATIONS

93 94 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE included trial. included breastfeeding: interaction, mother–baby experience, Birth reported. were side-effects other No 95% CI 1.05–5.64). 2.43, RR 240 trial, (1 women, IVpethidine receiving women for increased vomiting may be and nausea Side-effects: low certainty. of very is section caesarean and birth vaginal instrumental of birth: Mode to 95% -4.56). CI -4.1, -3.64 MD women, 240 trial, (1 scores pain may reduce IV pethidine Pain relief: Maternal outcomes with placebo. IVpethidine compared inEgypt conducted trial with 240 women One compared with placebo PethidineComparison 1.b. (intravenous [IV]) not reported in any of the included trials. inany included of the reported not were These outcomes: infant adverse Long-term low certainty. is of very evidence The <7): scores (Apgar hypoxia-ischaemia Perinatal Fetal and neonatal outcomes trials. included the breastfeeding: interaction, mother–baby experience, Birth 95% CI 1.06–3.40). 1.90, RR women, 406 trials, (3 to placebo compared vomiting and nausea increases pethidine IM suggests evidence 2.43–8.95). Moderate-certainty 4.67, RR women, 166 (2 trials, 95% labour CIduring drowsiness maternal may increase pethidine IM Side-effects: low certainty. is of very birth vaginal instrumental on 0.79, any effect 95% on Evidence CI 0.50–1.26). RR women, 380 (2 rates trials, section to caesarean difference no or may make little pethidine IM that of birth: Mode low. is very evidence of the certainty the as pethidine, improved with IM relief is with pain satisfaction whether is unclear It low certainty. is use of very epidural on effect its on 95% CI evidence the 0.54–0.94), 0.71, RR women, 50 trial, (1 analgesia of other use the may reduce pethidine IM that suggests evidence low-certainty Low-certainty evidence suggests that that suggests evidence Low-certainty Low-certainty evidence suggests that that suggests evidence Low-certainty Low-certainty evidence suggests that that suggests evidence Low-certainty Evidence of any effect on of any Evidence effect Low-certainty evidence suggests suggests evidence Low-certainty These were not reported in the inthe reported were not These These were not reported inany of reported were not These trial. inthis were reported outcomes neonatal or fetal No Fetal and neonatal outcomes breastfeeding: interaction, mother–baby experience, Birth reported. not were side-effects Other vomiting. reported Side-effects: 95% respectively). CI 0.10–3.39, 0.60, RR and 0.89, 95% RR CI 0.24–3.25 women, 89 trial, (1 birth vaginal instrumental or caesarean to difference no or may make little pentazocine IM of birth: Mode 95% CI -3.6, -9.91MD to 2.71). women, 89 trial, (1 with placebo compared scores pain to difference no or may make little pentazocine Pain relief: Maternal outcomes in2016. trial published was The placebo. a saline with 30 mg) (IM, pentazocine compared women 150 involving inPakistan trial conducted three-arm One with placebo Pentazocine (IM) 1.c. Comparison compared uncertain. is very outcomes other relief and pain labour on of fentanyl effects of the evidence The in 2016. published and inIran, setting inahospital conducted trial was The analgesia. no receiving group control with a apart) (IV, hour an of 25 mcg, 2doses fentanyl trial involving 70 compared One women analgesia no FentanylComparison 1.e. (IV) compared with uncertain. is very outcomes other relief and pain on labour of tramadol effects of the evidence The in1994. published and inChina, setting hospital ina trial conducted was The analgesia. no receiving with agroup 100 mg) (IM, tramadol receiving women compared trial women involving 60 One analgesia no TramadolComparison 1.d. (IM) compared with reported in the included trial. included inthe reported Long-term neonatal outcomes: trial. included in the Perinatal hypoxia-ischaemia: Fetal and neonatal outcomes Low-certainty evidence suggests that IM IM that suggests evidence Low-certainty None of the women inthis trial women of the None Low-certainty evidence suggests suggests evidence Low-certainty These were not reported inthis trial. reported were not These This was not reported reported not was This These were not were not These Summary of the main findings for comparison 1 findings suggest that most women, especially those The evidence suggests that pethidine may provide giving birth for the first time, are apprehensive about labour pain relief but may also be associated childbirth (high confidence in the evidence), and in with more side-effects (nausea, vomiting and certain contexts and/or situations may welcome drowsiness) compared with placebo. Pentazocine interventions that provide relief from pain (low may make little difference to pain scores. Evidence confidence in the evidence). When interventions are on the effects of tramadol and fentanyl on pain being considered, women would like to be informed relief in labour and other outcomes is of very low about the nature of the interventions and, where certainty. possible, given a choice (high confidence in the evidence). Additional considerations A qualitative systematic review exploring women’s The Cochrane systematic review (133) also experiences of opioid use during labour could only included other comparisons – between different identify very low-confidence evidence (126). The opioids, and between opioids and other analgesia findings suggest that some women value opioids (inhaled analgesia, transcutaneous electrical nerve to help them cope with intense and unmanageable stimulation [TENS] and complementary methods) labour pains. Mixed responses were identified in – which were not presented in this framework; terms of whether the pain relief was effective or evidence on these options was predominantly from ineffective and whether it had a positive or negative single studies and assessed in the review to be of impact on their labour and childbirth experience. low or very low certainty. The data available for this qualitative review were Evidence from another Cochrane systematic very limited: only three studies, including two in review (125) of epidural analgesia included a HICs and one in an upper-middle-income country. comparison of epidural analgesia with opioids One study contained minimal data to inform the (35 trials, 10 835 women). Findings suggest that review, and one involved qualitative interviews with epidural may be more effective in reducing pain women involved in an RCT evaluating different during labour compared to parenteral opioids. With opioid regimens. All participants were women who epidural analgesia, pain scores in women during had requested pain relief. labour may be reduced compared with parenteral It was not possible to identify, within the included opioid analgesia, women may be more likely to studies, whether women had had augmentation, rate pain relief as excellent or very good, and the induction of labour or other forms of intervention need for any additional analgesia may be reduced that may have influenced their valuation of the (all low-certainty evidence). However, epidural outcomes associated with this form of pain relief. analgesia probably increases labour duration (moderate-certainty evidence) and may increase Resources the need for interventions during labour (e.g. labour augmentation, instrumental vaginal birth) (low- No evidence on the relative cost or cost- certainty evidence). There is probably little or no effectiveness of the different opioid analgesics difference between the two pain relief options was found. However, a USA review of the cost- in relation to low Apgar scores (low-certainty effectiveness of epidural analgesia compared with evidence). opioid analgesia found opioid analgesia to be more cost-effective than epidural analgesia, due to the Repeated use of opioid analgesics is associated higher costs of health care professionals associated with the development of psychological and physical with administering epidural, as well as higher costs dependence. In view of worldwide drug addiction associated with managing complications (127). problems and associated adverse events, there have been recent concerns expressed about prescribing Opioid administration in a Dutch study published in opioids for the relief of acute and chronic pain (134). 2016 was associated with an estimated unit cost of These concerns are probably less applicable to use €15 (about US$ 18) per procedure (including staff of opioids for pain relief in labour (135, 136); however, costs) (130). the long-term effects of opioid analgesia on women and their offspring are not known. Additional considerations While in some high-resource settings parenteral Values opioid medicines are considered relatively In a review of qualitative studies looking at what inexpensive, these medicines may not be accessible matters to women during intrapartum care (23), in all settings, and in some LMICs they may not be

affordable (136, 137). 3. EVIDENCE AND RECOMMENDATIONS

95 96 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.37 1 indirectly, by encouraging equity impact also might it above, limited evidence the on directly. Based care inintrapartum inequalities reduce to help might women relief topain disadvantaged coverage (33) attendance birth inskilled gaps still are large there concludedWHO’s State 2015 report that of inequality considerations Additional unfamiliar undesirable and practices. to be injections perceive might women some that in evidence).the possible It is (high confidence birth to facility-based barriers are which practices, birth undesirable” and “unfamiliar fear LMICs in women many that review highlights also The management. pain to labour applicable be might delays and evidence).the neglect Such in (moderate confidence birth to facility-based abarrier as acts probably care” inreceiving delays (8) birth facility-based to barrier areview and from of facilitators evidence equity. Indirect on opioids relief with parenteral of pain impact the on found was evidence direct No Equity depression) costs about US$ 6 per dose. per US$ 6 about costs depression) Naloxone (to dose. respiratory reverse per US$ 6.50 around cost can remifentanil and dose; per US$ 3 around cost can meptazinol and diamorphine US$ 1.30; about cost can tramadol US$ 1; than less cost can fentanyl or of pethidine A dose monitoring and Supervision Time infrastructure Equipment and Supplies Training Staff Resource https://bnf.nice.org.uk/ website: Formulary National British Main resource requirements for opioid analgesia opioid for requirements resource Main . Providing effective and timely labour labour timely and . Providing effective            Description            indicates that “neglect and and “neglect that indicates Secure method of storing opioids and recording opioid use to avoid use abuse opioid recording and opioids of storing method Secure Supervision of administration and monitoring for side-effects administer and 2–10 prepare to estimated obtain, An minutes Oxygen saturation monitor Naloxone for reversing respiratory depression if necessary Anti-emetics for preventing or treating associated nausea/vomiting solution (optional), catheter cleansing skin intravenous syringe, (e.g. pethidine),Opioid needle, Training to monitor and manage side-effects and complications (IM) injection intramuscular or (IV) intravenous an as administer to easy fairly are opioids medications; to administer training provider care health Usual opioids administer can nurse, or midwife as a such staff, Other opioids) prescribe also can midwives settings some in countries; all in (this case the is not opioids to prescribe needed is usually A physician 1 labour, were mixed views there (126) relief during pain for use of opioid experiences women’s review aqualitative systematic In exploring Acceptability women. advantaged more among of childbirth medicalization the by reducing equity positively impact might which (132) capabilities innate birthing rediscover their to women empower could discomfort) labour of (and pain medicalization the labour reducing surrounding women and professionals care health of attitudes the changing that argued been has It management. pain including childbirth, and relating to labour processes decision-making inthe to participate empowered be and options pharmacological respective the of undesirable) and effects of the (desirable informed be relief should pain Women requesting care. intrapartum in inequalities to address help might it options, preferences) cultural and traditional (including non-pharmacological of and pharmacological choice a reliefoffered are pain requesting women If to management. pain approach atraditional prefer would who those and intervention, need not do that processes natural are childbirth and lieve labour that be who women for particularly birth, facility-based to abarrier as act could which undesirable, and unfamiliar as relief options pain medical perceive may women some However,care. settings, inLMIC facility-based to access women disadvantaged more . , - Some women requested opioids due to intense and quality qualitative evidence. While confidence unmanageable labour pains (very low confidence in the evidence is very low, the majority of in the evidence). Opioids were reported to be an negative comments were expressed towards IM effective (very low confidence in the evidence) or pethidine use, whereas opinions on intranasal and ineffective form of pain relief (very low confidence in subcutaneous fentanyl were generally far more the evidence). Women continued to experience pain positive. due to the pain relief method being ineffective, being It was not possible to identify, within the included provided too late or wearing off too early (very low studies, whether women valued the outcomes confidence in the evidence). associated with opioids differently if they had had Some women experienced negative physiological augmentation, induction of labour or other forms of (e.g. sickness, distorted cognitive processes, intervention. inability to achieve a physiological birth) and It has been suggested in other studies that the care psychological (e.g. disappointment) impacts (very context and the type of care provision and care low confidence in the evidence). However, other provider have a strong effect on the need for labour review findings highlight that opioids increased pain relief, and on the kinds of choices women make women’s enjoyment, shortened and reduced the in relation to this need (138, 139). intensity of the contractions, and aided them to achieve a physiological birth (very low confidence in Feasibility the evidence). In a qualitative systematic review exploring women’s Following opioid use, some women were experiences of opioid use during labour (126), the disappointed due to an over-reliance on staff to lack of effectiveness of opioids to relieve pain was administer the medication for them, and a lack sometimes attributed to late administration (very of caregiver support (very low confidence in the low confidence in the evidence), which suggests the evidence). Women were also not always fully aware need for more timely and sensitive use of this pain of the route of administration or the risks of opioid relief method. use (very low confidence in the evidence). In another review that included health care provider Additional considerations experiences (26), no qualitative accounts of health In low-resource settings, where opioids are not care professionals’ views of opioid use in women so widely available and used, there are likely to be during labour and childbirth were identified. financial implications as well as additional training requirements for their administration and for the Additional considerations management of potential maternal and neonatal Overall, the review on women’s experiences of side-effects. pain relief options (126) highlights the lack of high-

Table 3.38 Summary of judgements: Opioid analgesia compared with no opioid analgesia

Desirable – – – – ✓ – effects Don’t know Varies Trivial Small Moderate Large Undesirable – – – ✓ – – effects Don’t know Varies Large Moderate Small Trivial Certainty of – ✓ – – – the evidence No included Very low Low Moderate High studies Values – ✓ – – Important Possibly Probably no No important uncertainty or important important uncertainty or variability uncertainty or uncertainty or variability variability variability Balance of – – – – ✓ – – effects Don’t know Varies Favours no Probably Does not Probably Favours opioid opioid favours no favour opioid or favours opioid opioid no opioid Resources – – – ✓ – – – required Don’t know Varies Large costs Moderate costs Negligible costs Moderate Large savings or savings savings 3. EVIDENCE AND RECOMMENDATIONS

97 98 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE included trials. trials. included inthe reported were not outcomes maternal Other low. is very evidence of the certainty as the breastfeeding, affects Breastfeeding: 95% CI 0.28–1.07). 0.55, RR 1590 women, trials, (3 drowsiness maternal for groups between difference no or is little there suggests evidence low-certainty 95% CI 1.06–1.47), while 1.25, RR women, 1589 trials, (3 with meptazinol vomiting is increased Side-effects: low. very is evidence of the certainty the as birth, caesarean for pethidine and meptazinol between a difference is there whether clear is it not while CI 0.81–1.22), 95% 1.00, RR 1266 women, trials, (3 birth vaginal assisted in difference no or little may be there of birth: Mode 95% CI 0.91–1.12). 1.01, RR women, 801 groups) inboth (more trial, 60% (1 than “poor” as pain rating relief for groups between difference no or little may be there suggests evidence Low-certainty low. is very evidence of the certainty the as epidural, or analgesia of to additional or use the scores, pain to any makes difference meptazinol IM whether Pain relief: Maternal outcomes 1988. and 1981 between trials were published The 1100. to 46 from trials ranged sizes inindividual Sample (6 (2Africa trials) Kingdom United the trials). and (2 trials), inDenmark settings South in hospital Trials pethidine. with IM weremeptazinol conducted IM compared women trials involvingEight 2222 (IM)with pethidine Meptazinol (IM)Comparison 2.a. compared with pethidine types) compared Parenteral 2: (various opioids Comparison Acceptability effectiveness Cost- Equity Feasibility resources required of evidence of Certainty Compared with pethidine, it is not clear clear is it not with pethidine, Compared Moderate-certainty evidence suggests suggests evidence Moderate-certainty Low-certainty evidence suggests suggests evidence Low-certainty It is not clear whether meptazinol meptazinol whether clear is not It No included included No Don’t know Don’t know know Don’t Don’t know Don’t know studies – – – – – Varies Varies Varies Varies ✓ ✓ ✓ – Favours no no Favours Reduced opioid – – favours no no favours Probably Probably Very low Very reduced opioid No No (5 trials, 409 women, RR 0.57, RR 95% women, CI 0.33–0.97), (5 409 trials, with tramadol reduced may be sleepiness maternal Side-effects: low certainty. is of very birth vaginal assisted or birth caesarean on with pethidine compared tramadol of birth: Mode low. is very evidence of the certainty the as analgesia, additional for to women’s need any makes difference tramadol IM whether clear not is it 95% with pethidine, CI 1.10–2.21). Compared 25.4%) vs (4 1.56, (38.8% RR 243 trials, women, relief pain poor reporting of women number the may increase tramadol with pethidine, compared Pain relief: Maternal outcomes 2009. and 1980 between trials were published The to 45 from 160. trials ranged sizes inindividual Turkey Sample Thailand, Kingdom. United the and Germany, Iran, inAustria, settings in hospital Trials pethidine. IM versus were conducted tramadol IM compared women Six trials involving 483 (IM)pethidine Comparison Tramadol 2.b. (IM) compared with not reported in the included trials. included inthe reported not were These outcomes: infant adverse Long-term later. or of weeks 36 at born 95% CI 1.0, 0.95–1.05) RR inbabies babies, 1333 95% CI 0.77–1.02) (2 trials, resuscitation neonatal or 0.89, RR 975 trial, (1 babies, naloxone administration to difference no or may make little meptazinol that Side-effects: low. is very evidence of the certainty the as 5minutes, 7at than more scores Apgar or changes FHR to any makes difference meptazinol Perinatal hypoxia-ischaemia: Fetal and neonatal outcomes ✓ – – – – favour opioid or or opioid favour Probably No Probably No Probably no no Probably Low-certainty evidence suggests that that suggests evidence Low-certainty no opioid Does not not Does impact Low-certainty evidence suggests that that suggests evidence Low-certainty Low-certainty evidence suggests suggests evidence Low-certainty Low The evidence on the effect of effect the on evidence The ✓ – – – – favours opioid favours Probably Yes Probably Yes Moderate increased Probably Probably It is not clear whether whether clear is not It – – – – – Favours opioid Favours Increased High Yes Yes – – – – – but it is unclear if the opioids are any different in with pain relief (RR 1.13, 95% CI 1.02–1.26). From terms of vomiting, as the certainty of the evidence is another trial published in 1986 involving 135 women very low. in Thailand, it is unclear whether IM morphine makes any difference to pain relief when compared Other maternal outcomes were not reported in the with pethidine. trials. Moderate-certainty evidence suggests there is little Fetal and neonatal outcomes or no difference in the need for additional analgesia Perinatal hypoxia-ischaemia: When compared with between morphine or diamorphine compared with pethidine, it is not clear whether tramadol makes pethidine (2 trials, 574 women, RR 1.00, 95% CI any difference to low Apgar scores at 5 minutes, as 0.92–1.10). no events were reported in either group. Side-effects: Evidence on vomiting and sleepiness Side-effects: It is unclear whether tramadol makes from the trial in Thailand with 135 women comparing any difference to neonatal respiratory distress, as IM morphine with pethidine is of very low certainty. the certainty of the evidence is very low. There were Another trial in the United Kingdom with 161 no neonatal resuscitation events in trials where women (133 analysed), published in 1999, examined tramadol was compared with pethidine. diamorphine versus pethidine, with both groups receiving the anti-emetic prochlorperazine. Low- Long-term adverse infant outcomes: These were certainty evidence suggests that IM diamorphine not reported in the trials. plus prochlorperazine may reduce vomiting compared with pethidine plus prochlorperazine (RR Comparison 2.c. Tramadol (IM) with 0.39, 95% CI 0.17–0.86). triflupromazine compared with pethidine (IM) Mode of birth: Moderate-certainty evidence with triflupromazine suggests there is little or no difference between A single trial with 40 women conducted in Germany the groups for caesarean birth (RR 0.94, 95% CI which was published in 1992 compared IM tramadol 0.66–1.35) or assisted vaginal birth (RR 1.28, 95% CI with IM pethidine; both groups also received 0.91–1.80). triflupromazine (an antipsychotic sometimes used as an anti-emetic). Other maternal outcomes were not reported in these trials. Maternal outcomes Fetal and neonatal outcomes Side-effects: It is not clear whether there is any difference between groups for vomiting or Perinatal hypoxia-ischaemia: Moderate-certainty sleepiness, as the certainty of the evidence is very evidence suggests there is little or no difference low. between diamorphine or morphine compared with pethidine in neonatal resuscitation (2 trials, 574 Other maternal outcomes were not reported in the babies, RR 0.96, 95% CI 0.66–1.41). trial Long-term adverse neonatal outcomes: These were not reported. Fetal and neonatal outcomes Fetal/neonatal outcomes were not reported in the trial. Comparison 2.e. Dihydrocodeine (IM) compared with pethidine (IM) One trial conducted in South Africa with 196 Comparison 2.d. Morphine or diamorphine (IM) compared with pethidine (IM) women, which was published in 1970, is included in this comparison. Maternal outcomes Pain relief: One trial involving 484 women in the Maternal outcomes United Kingdom which was published in 2014 compared IM diamorphine with pethidine. High- Pain relief: The certainty of this evidence is very low. quality evidence suggests diamorphine probably Side-effects: The certainty of evidence on vomiting slightly lowers maternal pain scores at 30 and 60 and sleepiness is very low. minutes compared with pethidine (MD -0.8, 95% CI Other maternal outcomes were not reported in the -1.24 to -0.36 and MD -0.8, 95% CI -1.26 to 0.34, trial. respectively, measured on a 10-point scale) and slightly increases the number of women satisfied 3. EVIDENCE AND RECOMMENDATIONS

99 100 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE trial. inthe reported were not outcomes Fetal/neonatal Fetal and neonatal outcomes 2–4 hours after birth and low-certainty evidence evidence low-certainty and birth after 2–4 hours at scores behavioural infant compared babies 72 Perinatal hypoxia-ischaemia: Fetal and neonatal outcomes 95% CI 0.12–1.69). 0.45, RR women, 310 trial, (1 birth caesarean for groups between difference no or little may be there of birth: Mode 0.18–0.94). 95% 0.41, CI RR women, 72 trial, (1 nalbuphine with frequent vomiting is less and nausea suggests Side-effects: 0.55–4.94) 95% CI 1.65, RR 307 trial, (1 women, analgesia additional as epidural of use to the difference no or little makes nalbuphine that suggests evidence 95% CI Low-certainty 0.55–0.96). 0.73, (RR with nalbuphine reduced relief maywith pain be satisfaction maternal suggests women trial with 72 Pain relief: Maternal outcomes reported. outcomes of the most low for very is evidence of the certainty The this comparison. in 1999, included and are 1986 between published and Kingdom, United the and Germany Argentina, in conducted women trials with 430 Three (IM)with pethidine Comparison Nalbuphine (IM) 2.g. compared trials. inthe reported were not outcomes Fetal/neonatal Fetal and neonatal outcomes trials. inthe reported were not outcomes maternal Other 95% CI 0.24–0.90). 0.46, RR women, 391 trials, (3 lower with may pentazocine be nausea Side-effects: Maternal outcomes low. is very reported outcomes of the one all but for evidence of the certainty The in1980. published was recent most –the old years (IM); 40 than more are trials all except the one with pethidine pentazocine Six trials compared (IM)with pethidine Comparison 2.f. Pentazocine (IM) compared Low-certainty evidence from a single asingle from evidence Low-certainty Moderate-certainty evidence suggests evidence Low-certainty Low-certainty evidence suggests suggests evidence Low-certainty One study with study One trial. inthe reported were not outcomes Fetal/neonatal Fetal and neonatal outcomes trial. inthe reported were not outcomes maternal Other 95% CI0.39, 0.20–0.78). (RR with phenazocine frequent less vomiting may be Side-effects: intervention. additional as analgesia of epidural use low for Pain relief: Maternal outcomes pethidine. versus phenazocine in1970 IM published compared and Kingdom United inthe conducted women trial with 212 A single (IM)with pethidine PhenazocineComparison 2.h. (IM) compared (RR 0.05, 95% CI 0.00–0.82). 0.05, (RR with fentanyl slightly less may be sedation maternal Side-effects: lower). lower, (MD 0.20 with pethidine 95% CI 0.34–0.06 compared administration after 1hour scores pain maternal higher), slightly reduced may report but (MD higher, 0.4 medication 95%the CI 0.14–0.66 of doses slightly more may need fentanyl receiving Pain relief: Maternal outcomes low. is very reported outcomes most for evidence of the certainty The inthis comparison. is in1989 included published and USA inthe conducted women trial with 105 A single (IV) pethidine Comparison Fentanyl 2.j. (IV) compared with reported. all low outcomes for is very evidence the of certainty the as outcomes, on effect differential have any medications the whether clear is not It inthis in1978 comparison. is published included and inGermany conducted women trial with 80 A single (IM)with pethidine Comparison Butorphanol (IM) 2.i. compared not reported in the trials. inthe reported not Long-term adverse neonatal outcomes: CI -1.26 to -6.14). (MD -3.7, nalbuphine received mothers whose 95% slightly lower (worse) suggests ininfants scores The certainty of the evidence is very is very evidence of the certainty The Low-certainty evidence suggests women women suggests evidence Low-certainty Low-certainty evidence suggests suggests evidence Low-certainty Low-certainty evidence suggests suggests evidence Low-certainty These were These Fetal and neonatal outcomes Mode of birth: The certainty of the evidence is very Perinatal hypoxia-ischaemia: Low-certainty low for assisted vaginal birth and caesarean section. evidence suggests that infant neurobehavioural Side-effects: Low-certainty evidence suggests scores at 1–2 hours after birth may be higher if vomiting may be reduced with butorphanol (1 trial, mothers received fentanyl rather than pethidine 200 women, RR 0.04, 95% CI 0.00–0.67). (MD 1.30, 95% CI 0.15–2.45 higher). No other relevant maternal outcomes were reported Long-term adverse neonatal outcomes: These were in these trials. not reported in the trial. Fetal and neonatal outcomes Comparison 2.k. Nalbuphine (IV) compared Perinatal hypoxia-ischaemia: The evidence with pethidine (IV) regarding low infant Apgar scores at 5 minutes is of A single trial with 28 women conducted in the USA very low certainty. and published in 1995 examined this comparison. Long-term adverse neonatal outcomes: These were not reported in the trials. Maternal outcomes Mode of birth: The certainty of the evidence is very Comparison 2.n. Morphine (IV) compared with low for caesarean birth. pethidine (IV) No other relevant maternal outcomes were reported Two studies with 163 women conducted in Sweden in this trial. (1996) and the USA (1961) provided data for this comparison. Fetal and neonatal outcomes Perinatal hypoxia-ischaemia: There were no babies Maternal outcomes with low Apgar scores at 5 minutes. Pain relief: Low-certainty evidence suggests that Long-term adverse neonatal outcomes: These were women may be slightly less satisfied with pain relief not reported in the trial. with morphine (1 trial, 141 women, RR 0.87, 95% CI 0.78–0.98), and may be more likely to require additional doses of analgesia (1 trial, 143 women, RR Comparison 2.l. Phenazocine (IV) compared with pethidine (IV) 3.41, 95% CI 1.90–6.12). A single trial with 194 women conducted in the USA Mode of birth: In a study with 20 women, no women and published in 1964 examined this comparison. required caesarean section. The certainty of the evidence is very low for all No other guideline outcomes were reported in these outcomes reported or there are no events. Most trials. outcomes were not reported. Comparison 2.o. Alphaprodine (IV) compared Fetal and neonatal outcomes with pethidine (IV) Perinatal death: None were reported (low-certainty A single USA trial published in 1958 with data for evidence). 395 women compared IV alphaprodine with IV pethidine. Comparison 2.m. Butorphanol (IV) compared with pethidine (IV) Maternal outcomes Three studies with 330 women, all conducted in Side-effects: Moderate-certainty evidence suggests the USA and published between 1979 and 2005, vomiting is less frequent with alphaprodine (RR compared IV butorphanol with IV pethidine. 0.38, 95% CI 0.22–0.66). No other relevant maternal outcomes were reported Maternal outcomes in these trials. Pain relief: Low-certainty evidence suggests that pain scores may be slightly lower and pain relief Fetal and neonatal outcomes slightly higher for women in the butorphanol group (1 trial, 80 women, MD -0.6, 95% CI -1.02 to -0.18 Perinatal hypoxia-ischaemia: The evidence on and MD 0.67, 95% CI 0.25 to 1.09, respectively). neonatal resuscitation is of very low certainty. The certainty of the evidence is very low for use of Long-term adverse neonatal outcomes: These were epidural analgesia or the need for further analgesia.

not reported in the trial. 3. EVIDENCE AND RECOMMENDATIONS

101 102 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE not reported in the trials. inthe reported not Long-term adverse neonatal outcomes: to 1.86). 95% CI -0.66 0.6, MD infants, 56 trial, (1 2hours after in infants scores neurobehavioural in difference no or little may be there suggests evidence Low-certainty naloxone low administration. for is very evidence the 0.13, 95% RR CI 0.01–2.16).infants, of certainty The (1 17 trial, minutes at 5 scores Apgar in difference no or little may be there suggests evidence Perinatal hypoxia-ischaemia: Fetal and neonatal outcomes 0.95, 95% CI 0.61–1.49). RR 119 women, vomiting (2 and studies, nausea for groups between difference no or little may be there suggests evidence CI 0.14–0.66). Low-certainty 95% (MD 0.4, with remifentanil is slightly increased sleepiness that suggests women trial with 105 single Side-effects: 95% 1.1, CI MD 0.46–1.74).women, 68 trial, (1 with remifentanil slightlywas higher experience with childbirth satisfaction that suggests experience: Birth respectively). 0.60–5.46, 95% CI 1.81, RR and 0.96, 95%RR CI 0.46–2.00 97 (2 trials, women, births caesarean or vaginal assisted for difference no or little may be there that of birth: Mode 95% 0.42, CI RR 0.20–0.89). women, 122 (2 trials, is lower withanalgesia remifentanil of epidural use suggests evidence certainty 95% CI -8.59, -27.61MD to 10.44). Moderate- women, 122 (2 trials, inlabour scores pain maternal for groups between difference no or little may be Pain relief: Maternal outcomes inthis comparison. included are 2010 and 2001 between trial)(1 published (2 trials) Kingdom Netherlands United the and inthe conducted women trials with 237 Three pethidine with PCA remifentanil PCA Comparison 2.q. compared outcomes. all low reported for is very evidence the of certainty The this comparison. examined Africa inSouth conducted women trial with 29 A single pethidine (PCA) pentazocine compared with PCA Comparison Patient-controlled 2.p. analgesia Low-certainty evidence suggests there there suggests evidence Low-certainty Moderate-certainty evidence from a from evidence Moderate-certainty Low-certainty evidence suggests suggests evidence Low-certainty Moderate-certainty evidence Low-certainty Low-certainty These were These outcomes were not reported in the trial. inthe reported were not outcomes Long-term adverse neonatal outcomes: trial. inthe reported not Perinatal hypoxia-ischaemia: Fetal and neonatal outcomes in this trial. were reported outcomes maternal relevant other No reported. all low outcomes for is very evidence of the certainty areunclear, as the interventions of the effects 95% CI -1.02 to (MD 0). -0.51, pethidine relative The with PCA compared nalbuphine by PCA reduced slightly may be inlabour scores pain maternal Pain relief: Maternal outcomes in1987.published Kingdom United inthe conducted women with 60 study inasingle is examined comparison This pethidine PCA Comparison 2.r. nalbuphine compared PCA with 0.5, 95% CI -1.950.5, to 0.95). (MD birth after 2hours at scores neurobehavioral ininfant difference no or little suggests evidence Perinatal hypoxia-ischaemia: Fetal and neonatal outcomes 0.87,(RR 95% CI 0.55–1.37). to 0.13) 95% (MD CI vomiting -0.25 or -0.16, scores sleepiness maternal in difference no or little may be Side-effects: 0.03–2.34). CI 95% 0.25, (RR 95% CI 0.22–1.49) birth caesarean or 0.57, (RR birth vaginal assisted for interventions the between difference no or little may be there of birth: Mode 0.21–0.92). 95% CI 0.44, (RR fentanyl PCA receiving women is lower in analgesia of epidural use that suggests evidence to95% CI 0.26). -1.56 Moderate-quality (MD -0.65, scores pain maternal for interventions the between difference no or little may be there Pain relief: Maternal outcomes in2010. published and Netherlands inthe conducted was study The in this comparison. is included 120 for women trial with data A single pethidine PCA fentanyl PCA compared withComparison 2.s. Low-certainty evidence suggests that that suggests evidence Low-certainty Low-certainty evidence suggests suggests evidence Low-certainty Low-certainty evidence suggests there there suggests evidence Low-certainty Low-certainty evidence suggests suggests evidence Low-certainty These outcomes were Low-certainty Low-certainty These These Long-term adverse neonatal outcomes: These Additional considerations outcomes were not reported in the trial. The data available for the qualitative review on women’s experiences of opioid use during labour Comparison 2.t. PCA meptazinol compared with were very limited – they were obtained from just PCA pethidine three studies (2 in high-income countries and 1 in an This comparison is examined in a single study of upper-middle-income country) (126). One of these 10 women conducted in the United Kingdom. The studies contained minimal data to inform the review, certainty of all reported outcomes is very low. and one involved qualitative interviews with women involved in an RCT of different opioid regimens. All Summary of the main findings for participants were women who had requested pain comparison 2 relief. Diamorphine is associated with slightly better It was not possible to identify, within the included pain relief than pethidine and may be associated studies, whether women had had augmentation, with less nausea and vomiting. Fentanyl may be induction of labour or other forms of intervention associated with slightly better pain relief than that may have influenced their valuation of the pethidine, less maternal sedation, less epidural use outcomes associated with this form of pain relief. and slightly better infant neurobehavioural scores after birth. Remifentanyl is probably associated Resources with less frequent use of epidural analgesia but No evidence on the relative cost or cost- more drowsiness than pethidine; it may lead to effectiveness of the different opioid analgesics higher satisfaction with birth experience scores. was found. However, a USA review of the cost- Nalbuphine may lead to less maternal satisfaction effectiveness of epidural analgesia compared with with pain relief and lower infant behavioural scores opioid analgesia found opioid analgesia to be more after birth; however, it probably causes less nausea cost-effective than epidural analgesia, due to the and vomiting than pethidine. Most evidence on higher costs of health care professionals associated other opioids compared with pethidine is of very low with administering epidural, as well as higher costs certainty. associated with managing complications (127). Opioid administration in a Dutch study published in Values 2016 was associated with an estimated unit cost of Findings from a review of qualitative studies looking €15 (about US$ 18) per procedure (including staff at what matters to women during intrapartum care costs) (130). (23) suggest that most women, especially those giving birth for the first time, are apprehensive about Additional considerations childbirth (high confidence in the evidence), and in certain contexts and/or situations may welcome While in some high-resource settings parenteral interventions that provide relief from pain (low opioid medications are considered relatively confidence in the evidence). When interventions are inexpensive, these medications may not be being considered, women would like to be informed accessible in all settings and in some LMICs they about the nature of the interventions and, where may not be affordable (136, 137). possible, given a choice (high confidence in the A dose of pethidine or fentanyl can cost less evidence). than US$ 1; tramadol can cost about US$ 1.30; A qualitative systematic review exploring women’s diamorphine and meptazinol can cost around experiences of opioid use for pain relief during US$ 3 per dose; and remifentanil can cost around labour could only identify very low-confidence US$ 6.50 per dose. Naloxone (to reverse respiratory 1 evidence (126). The findings suggest that some depression) costs about US$ 6 per dose. women appear to value opioids to help them cope with intense and unmanageable labour pains. Mixed Equity responses were identified in terms of whether the No direct evidence was found on the impact of pain pain relief was effective or ineffective and whether it relief with any parenteral opioids on equity. had a positive or negative impact on their labour and Indirect evidence from a review of facilitators and childbirth experience. barrier to facility-based birth (8) indicates that

1 British National Formulary website:

https://bnf.nice.org.uk/ 3. EVIDENCE AND RECOMMENDATIONS

103 104 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.39 labour discomfort) could empower women to women empower could discomfort) labour of (and pain medicalization the labour reducing surrounding women and professionals care health of attitudes the changing that argued been has It populations. advantaged more and settings inhigh-resource used preferentially are if these equity on impact negative have might alternatives a opioid of expensive Use management. pain including childbirth, and relating to labour processes decision-making inthe to participate empowered be and options available pharmacological respective of undesirable) the and effects of the (desirable informed be relief should pain Women requesting experience. childbirth of their control more by women giving care, inintrapartum inequalities to address help itmight preferences) options, cultural and traditional (including pharmacological non- and pharmacological of choice a offered and about informed relief are pain requesting women If considerations Additional practices. undesirable and unfamiliar to be injections perceive might women some that in evidence).the possible It is (high confidence birth to facility-based barriers are which practices, birth undesirable” and “unfamiliar fear LMICs in women many that review highlights also The management. pain to labour applicable be might delays and in evidence).the neglect Such confidence (moderate birth to facility-based abarrier as acts probably care” inreceiving delays and “neglect and monitoring Supervision Time infrastructure Equipment and Supplies Training Staff Resource Main resource requirements for opioid analgesia opioid for requirements resource Main             Description             Secure method of storing opioids and recording opioid use to avoid use abuse opioid recording and opioids of storing method Secure Supervision of administration and monitoring for side-effects administer and 2–10 prepare to estimated obtain, An minutes equipment Resuscitation Oxygen Naloxone for reversing respiratory depression if necessary Anti-emetics for preventing or treating associated nausea/vomiting (optional) catheter intravenous syringe, (e.g. pethidine),Opioid needle, Training to monitor and manage side-effects and complications (IM) injection intramuscular or (IV) intravenous an as administer to easy fairly are opioids medications; to administer training provider care health Usual opioids administer can nurse, or midwife as a such staff, Other opioids) prescribe also can midwives settings some in countries; all in (this case the is not opioids to prescribe needed is usually A physician evidence). Women always not were aware fully also in (verythe low confidence support of caregiver alack and them, for medication the administer to over-reliance an due disappointed to staff on were women some use, Following opioid evidence).the in (very birth low confidence achieve aphysiological to them aided and contractions, of the intensity the reduced and shortened women’s enjoyment, increased opioids that highlight review findings in evidence).the However, low confidence other (very impacts (e.g. disappointment) psychological and birth) to achieve aphysiological inability cognitive processes, distorted (e.g. sickness, physiological negative experienced women Some confidence in the evidence). early too off latetoo wearing provided or low (very being ineffective, being to relief method pain the due pain evidence).the to experience Women continued in pain of relief form low ineffective confidence (very the in evidence) or effective low confidence (very to an be evidence).in the were reported Opioids (very pains labour low confidence unmanageable to and intense due opioids requested women Some labour, were mixed views there (126) relief during pain for use of opioid experiences women’s review aqualitative systematic In exploring Acceptability women. advantaged more among of childbirth medicalization the by reducing equity positively impact might which (132) capabilities innate birthing rediscover their . , of the route of administration or the risks of opioid Feasibility use (very low confidence in the evidence). In a qualitative systematic review exploring women’s In another review that included health care provider experiences of opioid use during labour (126), the experiences (26), no qualitative accounts of health lack of effectiveness of opioids to relieve pain was care professionals’ views of opioid use were sometimes attributed to late administration (very identified. low confidence in the evidence), which suggests the need for more timely and sensitive use of this pain Additional considerations relief method. Overall, the review on women’s experiences of Additional considerations pain relief options (126) highlights the lack of high- quality qualitative evidence. While confidence In lower-resource settings, where opioids are not in the evidence is very low, the majority of so widely available and used, there are likely to be negative comments were expressed towards IM financial implications as well as additional training pethidine use, whereas opinions on intranasal and requirements for their administration and for the subcutaneous fentanyl were generally far more management of potential maternal and neonatal positive. side-effects. It has been suggested in other studies that the care It is likely that the type of opioid used in different context and the type of care provision and care settings and countries would be influenced by the provider have a strong effect on the need for labour cost of the medication. pain relief, and on the kinds of choices women make in relation to this need (138, 139).

Table 3.40 Summary of judgements: Various opioid analgesia compared with pethidine

Desirable – ✓ – – – – effects Don’t know Varies Trivial Small Moderate Large Undesirable – ✓ – – – – effects Don’t know Varies Large Moderate Small Trivial Certainty of – ✓ – – – the evidence No included Very low Low Moderate High studies Values – ✓ – – Important Possibly Probably no No important uncertainty or important important uncertainty or variability uncertainty or uncertainty or variability variability variability Balance of – ✓ – – – – – effects Don’t know Varies Favours Probably Does not Probably Favours other pethidine favours favour other favours other opioid pethidine opioid or opioid pethidine Resources – ✓ – – – – – required Don’t know Varies Large costs Moderate Negligible Moderate Large savings costs costs or savings savings Certainty – – ✓ – – of evidence No included Very low Low Moderate High of required studies resources Cost- – ✓ – – – – – effectiveness Don’t know Varies Favours no Probably Does not Probably Favours opioid opioid favours no favour opioid favours opioid opioid or no opioid Equity – ✓ – – – – – Don’t know Varies Reduced Probably Probably no Probably Increased reduced impact increased Acceptability – ✓ – – – – Don’t know Varies No Probably No Probably Yes Yes Feasibility – ✓ – – – – Don’t know Varies No Probably No Probably Yes Yes 3. EVIDENCE AND RECOMMENDATIONS

105 106 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE 3.2.14 mindfulness training. mindfulness labour) waves as during such and sounds (e.g. analgesia listening to audio calming yoga, techniques), breathing relaxation, music, muscle (e.g. progressive techniques relaxation general evaluated included techniques Relaxation USA. the (2 trials), Turkey (2 trials), and Kingdom United the trials), Taiwan Norway, Sweden, [China], Thailand (2 Brazil trials), countries: 10 (2 trials), Iran (2 Italy contributed data (140) review, to trials involving women 15 which 2248 systematic aCochrane from is derived in labour relief pain for techniques relaxation on evidence The intervention (EB the of 3.2.14)Effects Table ofSummary evidence and considerations most trials. most in defined clearly not was care Usual techniques. relaxation muscle and breathing combined and relaxation, muscle progressive techniques, breathing 2017. and included 2000 Interventions between to 1087. 40 from trials ranged Trials were published sizes trial each). (1 inindividual Sample Kingdom Turkey Sweden, inIran, each) and United the and (2 Italy trials and inBrazil settings in hospital Trials to data this comparison. were conducted contributed trials women involvingEight 1382 techniques) compared with usual care (no relaxation relaxationComparison 1:General techniques     Remarks (Recommended) awoman’s on preferences. depending other techniques, are recommended for healthy pregnant women requesting pain relief during labour, and mindfulness music, breathing, relaxation, muscle progressive including Relaxation techniques, RECOMMENDATION 21     beneficial effects have very certainty. low havevery effects beneficial the unlikely are to harmful, be techniques relaxation while that women inform should providers Care soothing. find might women that practices traditional and cultural and acupuncture hypnobirthing, immersion, water as such inthis guideline, considered not are that techniques favour other might which contexts, and settings across within and widely vary can relief options pain Non-pharmacological make to inrelation women thisthat need. choices of kinds on the pain relief,and labour for need on the have effect could astrong provider care provision of and care type the and context care aware the that be should professionals care Health experience. birth maternal the relieve enhance and pain discomfort, labour reduce can techniques relaxation that labour, indicates qualitative ofrelief during evidence pain form and some desire women Most Relaxation techniques for pain management pain for techniques Relaxation . Trials in were conducted relaxation makes any difference to labour to labour any makes difference relaxation Augmentation of labour: low certainty. is of very evidence the of labour, duration to the as anymakes difference Duration of labour: certainty. low is of very evidence the as birth, caesarean or on instrumental have any effect techniques of birth: Mode low.very is evidence of the relief,with pain certainty the as on satisfaction women’s any effect has relaxation 0.99,RR 95% CI 0.88–1.11). whether is unclear It women, 1036 relief (2 pain trials, pharmacological additional of use to the difference no or make little may relaxation that suggests evidence certainty to 0.23). Low- 95% 0.0, CI MD -0.23 women, 977 (1 pain trial, of to perceptions women’s difference no or little makes probably relaxation that suggests evidence labour, moderate-certainty throughout low (4 is very evidence women). 273 trials, pain For of the certainty the because techniques relaxation by is reduced of labour phase active inthe intensity pain scale). whether is unclear It a5-point on to -1.97; 95% CI -0.53 -1.25, measured was pain MD women, 40 trial, (1 of labour latent phase the during intensity pain may reduce relaxation Pain relief: Maternal outcomes Low-certainty evidence suggests that that suggests evidence Low-certainty It is unclear whether relaxation relaxation whether is unclear It It is unclear whether relaxation relaxation whether is unclear It It is unclear whether whether is unclear It augmentation, as this evidence is of very low Adverse effects, mother–baby interaction, certainty. breastfeeding: These were not reported in either of the included trials. Birth experience: Low-certainty evidence suggests that relaxation techniques may make little or no difference to women’s overall satisfaction with the Fetal and neonatal outcomes experience of giving birth (3 trials, 1176 women, Perinatal hypoxia-ischaemia: The evidence on this SMD 0.03, 95% CI -0.37 to 0.31) or their anxiety outcome is of very low certainty. scores (1 trial, 140 women, MD 0.3, 95% CI -4.15 Admission to special care and long-term adverse to 4.75). No studies reported on maternal sense of infant outcomes: These were not reported in the control. trials. Adverse effects, mother–baby interaction, breastfeeding: These were not reported in any of Comparison 3: Music compared with usual care the included trials. (no music) Three trials involving 241 women compared music Fetal and neonatal outcomes with a control group. Trials were conducted in Perinatal hypoxia-ischaemia and admission to hospital settings in Italy, Taiwan [China] and Turkey. special care: The evidence on these outcomes is of Sample sizes ranged from 58 to 161. The trials were very low certainty. published between 2010 and 2014. All three trials offered a selection of music for labour; one included Long-term infant outcomes: These were not a preparation booklet for the antenatal period. The reported in the trials. comparison groups received usual care.

Comparison 2: Yoga techniques compared with Maternal outcomes control (no yoga techniques) Pain relief, mode of birth, birth experience: The Two trials involving 149 women, both conducted in evidence on pain relief (pain intensity, use of Thailand, compared yoga techniques with a control epidural analgesia), mode of birth (instrumental group. The trials were published in 2007 and 2008. vaginal, caesarean) and birth experience (maternal One trial used breathing, chanting, education and anxiety) is of very low certainty. postures; the other used yoga postures only. Women in the control groups had usual care in one trial, and Maternal satisfaction and sense of control: These were encouraged to maintain a supine position in outcomes were not reported in the trials. labour in the other trial. Duration of labour, labour augmentation, adverse effects, mother–baby interaction, breastfeeding: Maternal outcomes These outcomes were not reported in the trials. Pain relief: Low-certainty evidence suggests that yoga may slightly reduce pain scores in labour Fetal and neonatal outcomes (1 trial, 66 women, MD -6.12, 95% CI -0.47 to -11.7) Admission to special care: The evidence on this and slightly increase satisfaction with pain relief outcome is of very low certainty. (1 trial, 66 women, MD 7.88, 95% CI 1.51–14.25). It is unclear whether yoga has any effect on the use of Perinatal hypoxia-ischaemia and long-term adverse pharmacological pain relief because the certainty of infant outcomes: These were not reported in the the evidence is very low. trials. Mode of birth: This was not reported in the trials. Comparison 4: Audio-analgesia compared with Duration of labour: Low-certainty evidence control suggests that yoga may reduce the duration of One trial involving 25 women compared audio labour (1 trial, 66 women, MD -139.91 minutes, 95% analgesia with a control group. The trial was CI -27.32 to -252.50). conducted in the United Kingdom in 1965. The Augmentation of labour: Evidence on this outcome intervention group listened to “sea noise” set at 120 is of very low certainty. decibels in labour; the control group listened to the same sound set at 90 decibels. Birth experience: Low-certainty evidence suggests that yoga may slightly improve women’s overall childbirth satisfaction scores (1 trial, 66 women, MD 6.34, 95% CI 0.26–12.42). 3. EVIDENCE AND RECOMMENDATIONS

107 108 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE trial. inthe were reported outcomes neonatal or fetal No Fetal and neonatal outcomes trial. inthe were reported outcomes maternal other No low. is very evidence the of certainty the relief because with pain satisfaction on any effect has labour of waves during sound Pain relief: Maternal outcomes certain contexts and/or contexts may situations welcome certain in evidence),the in and (high confidence childbirth about apprehensive are time, first the for birth giving (23) care intrapartum during to women matters what at looking areview from of qualitative studies Findings Values trial. inthis were reported outcomes neonatal or fetal No Fetal and neonatal outcomes trial. inthe reported were not outcomes These mother–baby effects, interaction, breastfeeding: Duration of labour, labour augmentation, adverse trial. inthe reported not was Anxiety certainty. low is of very scores satisfaction on evidence the 95% CI 1.61–60.99); however, 31.3, MD 26 women, trial, (1 training improved with mindfulness be may inlabour of control women’sthat sense experience: Birth low certainty. is of very birth caesarean and birth of birth: Mode trial. the in reported were not outcomes pain low.very Other is evidence of the certainty the relief because pain pharmacological of use on the effect an has training Pain relief: Maternal outcomes mindfulness component. the without course antenatal anine-week received group comparison The period. antenatal in the course parenting and labour mindfulness-based 2017. anine-week received group intervention The in published and USA, inthe trial conducted was The group. with acontrol training mindfulness compared trial women involving 30 One training) (no control with mindfulness Comparison 5: Mindfulness training compared suggest that most women, especially those those especially women, most that suggest It is unclear whether listening to the whether is unclear It It is unclear whether mindfulness mindfulness whether is unclear It The evidence on instrumental vaginal vaginal instrumental on evidence The Low-certainty evidence suggests suggests evidence Low-certainty

companion training. training. companion into or doula/labour available, are these where classes into integrated antenatal be this can training techniques), breathing and relaxation and muscle (e.g. techniques relaxation of some component cost interventions). Training main the be would costs music (e.g. effort and time staff little require others while companion, of alabour support with the or learned, once herself by woman the performed be can techniques of these most as interventions, cost likely are to relatively be low- techniques Relaxation considerations Additional was found. interventions of these effectiveness cost- or costs the on evidence research No Resources and/or companionship. professionals birth care health with attending formed relationships related to be positive could techniques relaxation 139) (138, make to inrelation women this need choices of kinds the relief, on pain and labour for need the on have effect provider astrong care provision and of care type the and is context likelyIt care the that of relief. pain with this form associated outcomes of the valuation their may that have influenced of intervention forms other or of labour induction augmentation, had had women whether studies, included identify, within the to possible not was It inLMICs. were undertaken of which none providers, for three review only and women’s the for qualitative were found studies qualitative reviewin the relief, pain eight on only studies the across consistent were findings While considerations Additional in evidence).the (moderate confidence well-being postnatal on apositive influence had also methods in evidence).the These (low confidence experience to childbirth able have and and apositive labour pains, labour with their to effectively able work labour, during incontrol relaxed and felt them using (moderate confidence in the evidence). Women by techniques relaxation relief provided the valued (126) techniques coping pain to labour reviewrelated of aseparate In qualitative studies evidence). in the (high confidence achoice given possible, where and, interventions of nature the the about like would women to informed be considered, being are in evidence).the interventions When confidence (low pain relief from provide that interventions . For example, some of the findings related to findings of the some example, . For , women , women Table 3.41 Main resource requirements for relaxation techniques for pain relief

Resource Description Staff  Midwife or other provider (as per usual care)  Training in relaxation techniques (e.g. included in provider training, labour companion Training training and/or antenatal classes) Supplies  None  Varies, depending on the intervention: music interventions require a method of playing Equipment and music (e.g. phone, CD player, MP3 player, speakers); for yoga, sufficient floor space to infrastructure spread a yoga mat, etc.  Time to train: varies, depending on the intervention  Time to perform: varies depending on the intervention Time  Some of these interventions can be performed by the woman herself or require little staff time/effort (e.g. music interventions), while others might require continuous support/ coaching before and throughout labour Supervision and  Not required monitoring

If non-pharmacological techniques reduce the use of The review findings suggest that women valued pharmacological techniques, they might be cost- having a range of taught techniques (during the effective; however, evidence of this effect is lacking. antenatal period) that could be adapted according to their changing needs during labour and childbirth Equity (low confidence in the evidence). Women also Within the qualitative review on women’s and valued the techniques as a means of enhancing providers’ experiences (26), providers in HICs the participation of partners and caregivers (low noted that equity in the delivery of complementary confidence in the evidence). therapies was compromised due to a lack of The evidence on health care provider views on resources (funds and midwives time) (very low providing pain relief, from another review (26), is confidence in the evidence). There is no evidence of very low confidence; however, it suggests that from this review on relaxation techniques and equity some health care providers believe that relaxation from LMICs. techniques increase women’s ability to trust their bodies and promote a positive childbirth experience. Additional considerations The evidence from midwife respondents suggests If women requesting pain relief are offered a choice that midwives may consider complementary of pharmacological and non-pharmacological therapies to be aligned with the woman-centred options, including traditional and cultural philosophy of midwifery. preferences, this might help to address inequalities in intrapartum care. Additional considerations Only eight studies were found for the qualitative Acceptability review of women’s experiences of pain relief options In a systematic review of qualitative studies (126) and three for the providers’ views (26), none of exploring women’s views of labour pain relief which were undertaken in LMICs. options (126), relaxation techniques were reported It is possible that of the findings on acceptability of to be an acceptable and effective method of pain relaxation techniques could be related to positive relief in HICs (moderate confidence in the evidence). relationships and labour companionship and not Relaxation techniques facilitated a peaceful birthing due to the relaxation techniques themselves. Two environment and enhanced feelings such as safety, studies have suggested that the care context and strength, control and connection, which contributed the type of care provision and care provider have a to a positive labour and childbirth experience strong effect on the need for labour pain relief, and (moderate confidence in the evidence). Some on the kinds of choices women make in relation to women also used them after the birth, to facilitate this need (138, 139). well-being (e.g. techniques to soothe the baby or to facilitate breastfeeding). 3. EVIDENCE AND RECOMMENDATIONS

109 110 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.42 in (veryevidence).the low confidence practitioners therapy of complementary training and regulation of lack and base, evidence of an lack professionals, among of consensus lack bureaucracy, including to provision techniques, the of relaxation barriers relief (26) pain providing views on professionals’ care health review qualitative systematic the In included that Feasibility effectiveness Cost- effects of Balance Values resources required of evidence of Certainty the evidence of Certainty required Resources Equity effects Desirable effects Undesirable Feasibility Acceptability techniques) (no relaxation care usual with compared techniques Relaxation judgements: of Summary , staff identified a number of number a identified , staff No included included No No included included No Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know studies studies ✓ ✓ – – – – – – – – Varies Varies Varies Varies Varies Varies Varies Varies – – – – – – – – Favours usual usual Favours Favours usual usual Favours Large costs Large Reduced care care – – – – uncertainty or or uncertainty favours usual usual favours usual favours preparation and labour companion training. companion labour and preparation to education/ inplace facilitate maternal already are classes antenatal where insettings implement to feasible more plausibly are herself woman the by performed be can that or companions labour by provided be can that techniques Relaxation considerations Additional Important Important Moderate variability Probably Probably Probably Very low Very Very low Very reduced Trivial Large costs care care No No ✓ – – – – – – – – – – uncertainty or or uncertainty techniques or or techniques or techniques Probably No Probably No Probably no no Probably usual care usual care usual important important Negligible relaxation relaxation Moderate variability Does not not Does not Does Possibly costs or or costs savings impact favour favour favour Small Low Low ✓ ✓ – – – – – – – – uncertainty or or uncertainty Probably Yes Probably Yes Probably no no Probably techniques techniques important important relaxation relaxation Moderate Moderate Moderate Moderate variability increased Probably Probably Probably savings favours favours favours favours Small ✓ ✓ ✓ ✓ ✓ – – – – – – uncertainty or or uncertainty Large savings Large No important important No techniques techniques relaxation relaxation variability Increased Favours Favours Favours Favours Trivial Large High High Yes Yes ✓ – – – – – – – – – – 3.2.15 Manual techniques for pain management

RECOMMENDATION 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. (Recommended)

Remarks

 Most women desire some form of pharmacological or non-pharmacological pain relief during labour, and qualitative evidence indicates that massage can reduce labour discomfort, relieve pain and enhance the maternal birth experience.  While the quantitative and qualitative evidence largely relates to massage, warm packs are unlikely to be harmful and some women might find these to be soothing.  Health care professionals should be aware that the care context and the type of care provision and care provider could have a strong effect on the need for labour pain relief, and on the kinds of choices women make in relation to this need.  Non-pharmacological pain relief options can vary widely across settings and contexts, which might favour other techniques not considered in this guideline, such as water immersion, hypnobirthing, acupuncture, and cultural and traditional practices that women might find soothing.  Health care professionals should communicate to women the options available for pain relief in their birth facility, and discuss the advantages and disadvantages of these options as part of antenatal care.  Care providers should inform women that while manual techniques for managing pain are unlikely to be harmful, evidence of the beneficial effects is of very low certainty.

Summary of evidence and considerations Maternal outcomes Effects of the intervention (EB Table 3.2.15) Pain relief: Moderate-certainty evidence suggests that pain scores in the first stage of labour are This evidence is derived from a Cochrane systematic probably reduced with massage compared with review (141), which included 12 studies involving usual care (6 trials, 362 women, SMD -0.81, 95% 1024 women. The trials were conducted in Australia, CI -1.06 to -0.56). Evidence on pain scores in the Brazil, Canada, Iran (6 trials), Taiwan [China], the second stage of labour and use of pharmacological United Kingdom and the USA. The trial reports were pain relief is of very low certainty. published between 2002 and 2016. Mode of birth: Low-certainty evidence suggests Comparison 1: Massage techniques compared that massage may make little or no difference to with usual care (no massage) instrumental vaginal birth (4 studies, 368 women, RR 0.71, 95% CI 0.44–1.13) and caesarean section (6 Eight trials involving 671 women compared massage studies, 514 women, RR 0.75, 95% CI 0.51–1.09). with usual care. Trials were conducted in antenatal clinics or hospitals in Australia, Brazil, Canada, Duration of labour: This evidence is of very low Iran (3 trials), Taiwan and the United Kingdom. certainty. Sample sizes of individual trials ranged from 46 Augmentation of labour: This evidence is of very to 176 women; seven trials involved 100 or fewer low certainty. women. Birth partners provided the massage in three trials (326 women); two of these provided Birth experience: Low-certainty evidence suggests antenatal training for the partners. Three trials used that more women may report satisfaction with professionals trained in massage (185 women), one their birth experience if they have massage (1 trial, used student midwives (100 women), and one did 60 women, RR 1.90, 95% CI 1.07–3.38). Evidence not clearly report who provided the massage (60 on satisfaction scores was of very low certainty. women). Usual care was not well reported. Sense of control was reported in two studies using different measures: moderate-certainty evidence from one trial suggests that sense of control scores 3. EVIDENCE AND RECOMMENDATIONS

111 112 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE reported in the trials. inthe reported not are These outcomes: infant adverse Long-term 95% CI 0.31–1.62). 0.71, RR infants, 231 intensive (2 unit trials, care neonatal to admission riskthe of to the difference no or may make little massage that suggests evidence 95% Low-certainty CI 0.23–0.79). 0.43, RR infants, 231 (2 trials, resuscitation may require receive massage mothers whose fewerthat infants Adverse effects: 95% CI 0.72, 0.17–3.14). RR infants, 215 (2 trials, scores lowApgar to difference no minutes at 5 (< 7) or may make little massage that suggests evidence Perinatal hypoxia-ischaemia: Fetal and neonatal outcomes Breastfeeding: -16.27, MD women, 95% CI -27.03 to -5.51). 60 trial, (1 massage receiving inwomen reduced may be scores anxiety that suggests evidence 95% Low-certainty CI -11.68 to -0.52). -6.10, MD women, 56 trial, (1 group massage the for better slightly may be scores of control sense that suggests trial also another from evidence low-certainty and 95% CI 3.77–24.33); 14.05, 124trial, MD women, (1 massage receiving women for were increased These outcomes were not reported in the trials. inthe reported were not outcomes These Fetal and neonatal outcomes trials. inthe reported were not outcomes maternal Other low certainty. is of very towels of warm use packs, or labour: of labour, duration during scores) (pain relief Pain Maternal outcomes applied. was intervention the stage what at clear not itwas minutes; 30 least at for areas perineal and to sacral the pack the trial applied other The stage. second inthe of labour,stage to perineum and the first inthe abdomens and women’s lower backs to the packs warm the trials (192 women) applied Two 2013. and 2009 between place took and inIran inhospitals trials were conducted All three care. with usual application pack warm compared trials involving women 252 Three usual care (no warm packs) Comparison 2: Warm compared with packs The evidence on these outcomes, with the with the outcomes, these on evidence The This was not reported in the trials. trials. inthe reported not was This Low-certainty evidence suggests suggests evidence Low-certainty Low-certainty Low-certainty Training cost main the be then would costs companion. by a labour if performed interventions Manual techniques could be relatively low-cost considerations Additional pain. of back treatment the for practices body-based of or to manipulative use the pertained (142) populations clinical and of therapies a number cost-savings possible across and cost-effectiveness of evidence emerging found conditions related) (non-pregnancy- of other arange for therapies of complementary review cost-effectiveness of the However, a from found. was evidence pain indirect labour for interventions of these effectiveness cost- or costs the on evidence research No Resources ofrelief. pain with this form associated outcomes of the valuation their maythat have influenced of intervention forms other or of labour induction augmentation, had had women whether studies, to included identify, within the possible not was It (126) inLMICs were of undertaken which none were found, qualitative review, studies four only but inthe studies the across were consistent Findings considerations Additional low confidence in the evidence). evidence),the to it ineffective be found (very others in pain (low confidence with labour work effectively to them enabled massage that found women some in evidence).the However,(low confidence while reported were also anxious, less and reassured safe, feeling as such women’s overall well-being, to in evidence).the Benefits (low confidence to over and retain control childbirth calm, feel to and relax them enabled techniques these when ofrelief pain aform as techniques massage valued (126) techniques coping pain to labour reviewrelated of aseparate In qualitative studies evidence). in the (high confidence achoice given possible, where and, interventions of nature the the about like would women to informed be considered, being are in evidence).the interventions When confidence (low pain relief from provide that interventions and/or contexts may situations welcome certain in evidence),the in and (high confidence childbirth about apprehensive are time, first the for birth giving (23) care intrapartum during to women matters what at looking areview from of qualitative studies Findings Values suggest that most women, especially those those especially women, most that suggest . The majority of studies included inthis review included of studies majority . The , women , women . Table 3.43 Main resource requirements for manual techniques for pain relief

Resource Description Staff  Midwife or other provider (as per usual care)  Health care provider or labour companion training in manual techniques (for Training the labour companion, this could be included in antenatal classes) Supplies  Lotion, massage oil, clean towels Equipment and  Access to warm water infrastructure  Time to train: varies, depending on the intervention Time  Time to perform: provided intermittently over the course of labour Supervision and monitoring  Not required

component, which could be integrated into antenatal some health care professionals believe that massage classes where these are available, or into doula/ techniques increase the potential for a positive labour companion training. However, the cost childbirth experience (very low confidence in the of massage provided by professional massage evidence) (26). Midwife respondents felt that therapists could be relatively high, depending on complementary therapies were a valued alternative location and setting. to pharmacological pain relief and that they were aligned with midwifery’s woman-centred philosophy, If non-pharmacological techniques reduce the use of which values and facilitates active participation pharmacological techniques, they might be cost- by each woman in her own labour and childbirth effective; however, evidence of this effect is lacking. process (very low confidence in the evidence).

Equity Additional considerations Within a qualitative systematic review that included The qualitative review findings on women and health care providers’ views on different pain relief providers’ views (26, 126) were all from studies options (26), providers in HICs noted that equity conducted in HICs. in the delivery of complementary therapies was compromised due to a lack of resources (funds It is possible that the findings on acceptability of and midwives’ time) (very low confidence in the massage could be related to positive relationships evidence). The review found no evidence on manual and labour companionship, and not due to the techniques and equity from LMICs. massage itself. Two studies have suggested that the care context and the type of care provision and care Additional considerations provider have a strong effect on the need for labour If women requesting pain relief are offered a choice pain relief, and on the kinds of choices women make of pharmacological and non-pharmacological in relation to this need (138, 139). options, including traditional and cultural preferences, it might help to address inequalities in Feasibility intrapartum care. In the qualitative systematic review that explored health care professionals’ views on providing Acceptability pain relief (26), staff indicated that barriers to the A systematic qualitative review of women’s provision of massage or other manual techniques experiences of pain relief in labour found that included bureaucracy, lack of consensus among training in massage techniques enhanced professionals, lack of an evidence base, and lack of participation of the women’s birth partners (low regulation and training for complementary therapy confidence in the evidence), whereas massage practitioners (very low confidence in the evidence). carried out by midwives enhanced the mother– midwife relationship and women’s sense of feeling Additional considerations cared for (low confidence in the evidence) (126). Manual techniques that can be provided by labour companions are plausibly more feasible to In another systematic qualitative review that implement in settings where antenatal classes are included health care professionals’ views on already in place to facilitate maternal education/ providing pain relief, the evidence suggests that

preparation and labour companion training. 3. EVIDENCE AND RECOMMENDATIONS

113 114 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE 1 3.2.16 Table 3.44 effectiveness Cost- Equity Feasibility Acceptability resources required of evidence of Certainty effects of Balance Values required Resources the evidence of Certainty effects Desirable effects Undesirable Warm packs were also evaluated but most of the quantitative and qualitative evidence relates to massage. relates evidence qualitative and quantitative the of most but evaluated also were Warm packs     Remarks (Not recommended) recommended. not is labour in augmentation of use the reducing and delay preventing for relief Pain RECOMMENDATION 23     available at: http://apps.who.int/iris/bitstream/10665/112825/1/9789241507363_eng.pdf document, guideline source inthe found be can this recommendation supporting evidence The care. intrapartum of good component essential make an that it benefits substantial other has it but augmentation labour for need the reduce relief necessarily may pain not that acknowledged GDG The augmentation. of labour frequency or duration inlabour with reductions of relief is pain associated any form that to suggest evidence clear is no there that noted GDG The evidence. low-quality very (46) WHO the from recommendations integrated been has for augmentation recommendation This of labour Pain relief for preventing labour delay labour preventing for relief Pain , in which the GDG for that guideline determined it to be a conditional recommendation based on on based recommendation itto aconditional be determined guideline that for GDG the , inwhich

Summary of judgements: Manual techniques techniques) No included included No No included included No Don’t know Don’t know Don’t know Don’t know Don’t know know Don’t Don’t know Don’t know Don’t know studies studies ✓ – – – – – – – – Varies Varies Varies Varies Varies Varies Varies Varies ✓ ✓ ✓ – – – – – Favours usual usual Favours Favours the the Favours Large costs Large usual care usual Reduced care – – – – uncertainty or or uncertainty favours usual usual favours favours the the favours usual care usual Important Important Moderate variability Probably Probably Probably Very low Very Very low Very reduced Trivial Large costs 1 care compared with usual care (no manual (no manual care usual with compared No No – – – – – – – – – – – favour manual manual favour favour manual manual favour uncertainty or or uncertainty the usual care usual the techniques or or techniques techniques or or techniques Probably No Probably No Probably no no Probably usual care usual Negligible important important Moderate variability Does not not Does Does not not Does Possibly costs or or costs savings impact Small Low Low ✓ ✓ – – – – – – – – – uncertainty or or uncertainty Probably Yes Probably Yes Probably no no Probably techniques techniques important important Moderate Moderate Moderate Moderate variability increased Probably Probably Probably savings favours favours favours favours manual manual manual manual Small ✓ ✓ ✓ ✓ – – – – – – – uncertainty or or uncertainty Large savings Large No important important No techniques techniques variability Increased Favours Favours Favours Favours manual manual manual manual Trivial Large High High Yes Yes ✓ – – – – – – – – – –

3.2.17 Oral fluid and food

RECOMMENDATION 24

For women at low risk, oral fluid and food intake during labour is recommended. (Recommended)

Remarks

 This recommendation has been integrated from the WHO recommendations for augmentation of labour (46), in which the GDG for that guideline determined it to be a conditional recommendation based on very low-quality evidence.  Given that restriction of oral fluid and food intake has no beneficial effects on important clinical outcomes, including the use of labour augmentation, the GDG puts its emphasis on respect for the wishes of the woman and therefore made a positive recommendation.  The GDG noted that no cases of Mendelson’s Syndrome (inhalation of food and drink from the stomach into the lungs during general anaesthesia – the most important safety concern limiting oral intake during labour – were reported in over 3000 women participating in the trials included in the systematic review.  The evidence supporting this recommendation can be found in the source guideline document, available at: http://apps.who.int/iris/bitstream/10665/112825/1/9789241507363_eng.pdf

3.2.18 Maternal mobility and position

RECOMMENDATION 25

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

Remarks

 This recommendation has been integrated from the WHO recommendations for augmentation of labour (46), in which the GDG for that guideline determined it to be a strong recommendation based on very low-quality evidence.  Although the evidence does not suggest that mobility and upright position in labour reduce the use of oxytocin augmentation, the GDG placed its emphasis on the clinical benefits in terms of reducing caesarean section.  The GDG noted that in many settings, traditional practices of enforcing bed rest for all women in labour are common, rather than allowing women’s choices to be informed by their knowledge of the benefits of mobility and upright position. The GDG puts its emphasis on providing women with the choice of an intervention that is beneficial, cheap and easy to implement, and therefore made a strong recommendation for this intervention.  This recommendation should inform and support women’s choices on what position to adopt during the first stage of labour.  The evidence supporting this recommendation can be found in the source guideline document, available at: http://apps.who.int/iris/bitstream/10665/112825/1/9789241507363_eng.pdf 3. EVIDENCE AND RECOMMENDATIONS

115 116 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE 3.2.20 3.2.19     Remarks recommended. (Not recommended) not is labour in delay of prevention for labour of management active for care of A package RECOMMENDATION 27     Remarks morbidities is not recommended. (Not recommended) Routine vaginal cleansing with chlorhexidine during labour for the purpose of preventing infectious RECOMMENDATION 26         be a strong recommendation based on moderate-quality evidence. evidence. moderate-quality on based recommendation astrong be at: http://apps.who.int/iris/bitstream/10665/112825/1/9789241507363_eng.pdf available document, guideline source inthe found be can this recommendation supporting Evidence WHO recommendations for augmentation of labour inthe is recommended intervention aseparate as labour during support Continuous to package. the attributed benefits the for responsible component the probably is and to beneficial, shown be been has that package of the component only is the care one-to-one continuous that noted also GDG The considerations. other these outweigh notclearly do benefits clinical reported the because package the to not recommend chose GDG The settings. inmany feasible be may not which resources, health on demands considerable exerts that package to acomplex be is considered intervention the addition, In of care. recipients as autonomy and choices women’s rights, undermine could that one and interventional and prescriptive to highly be approach the considered it as recommendation its However, rate. support not did section group the caesarean possible and of labour duration the of in reducing terms potential benefits has of interventions this that package agreed GDG The evidence. low-quality (46) WHO the from recommendations integrated been has for augmentation recommendation This of labour available at: http://apps.who.int/iris/bitstream/10665/186171/1/9789241549363_eng.pdf document, guideline source inthe found be can this recommendation supporting evidence The colonization. GBS for screening on guidance and policy of local context within the implemented be should this that recommendation agreed group the Therefore, women. inpregnant colonization GBS for screening the regarding inpolicies variations considerable the acknowledged GDG The morbidity. B Streptococcus group on infectious maternal (GBS)-related intervention of the potential effect on the not and neonate the for benefits of clinical lack the on based was recommendation This treatment of maternal peripartum infections WHO the from recommendations integrated been has for prevention recommendation This and

Active management of labour of management Active Vaginal cleansing , in which the GDG for that guideline determined it to be a conditional recommendation based on on based recommendation itto aconditional be determined guideline that for GDG the , inwhich (114) , in which the GDG for that guideline determined it to it determined guideline that for GDG the , inwhich .

3.2.21 Routine amniotomy

RECOMMENDATION 28

The use of amniotomy alone for prevention of delay in labour is not recommended. (Not recommended)

Remarks

 This recommendation has been integrated from the WHO recommendations for augmentation of labour (46), in which the GDG for that guideline determined it to be a conditional recommendation based on very low-quality evidence.  The GDG noted that in spite of the common use of amniotomy for prevention of labour delay in clinical practice, there is no clear evidence that the potential benefits outweigh the potential harms.  As early amniotomy may increase the risk of perinatal HIV transmission, this recommendation could be strengthened in settings where HIV infection is prevalent and women may present in labour with unknown HIV status.  The evidence supporting this recommendation can be found in the source guideline document, available at: http://apps.who.int/iris/bitstream/10665/112825/1/9789241507363_eng.pdf

3.2.22 Early amniotomy and oxytocin

RECOMMENDATION 29

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

Remarks

 This recommendation has been integrated from the WHO recommendations for augmentation of labour (46), in which the GDG for that guideline determined it to be a conditional recommendation based on very low-quality evidence.  The GDG noted that the variable reduction in the duration of the first stage of labour itself does not justify the intervention, given that no substantive differences were found in other important clinical outcomes.  The GDG noted the substantial overlap between this intervention and the other components of the active management of labour, and considered it as equally highly prescriptive and interventional. Like the package of active management of labour, the group placed much emphasis on its potential to undermine women’s rights, choices and autonomy as recipients of care, and therefore did not recommend the intervention. Additionally, the intervention is not considered feasible in many settings, as it requires considerable health care resources to implement.  The evidence supporting this recommendation can be found in the source guideline document, available at: http://apps.who.int/iris/bitstream/10665/112825/1/9789241507363_eng.pdf 3. EVIDENCE AND RECOMMENDATIONS

117 118 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE 3.2.24 3.2.23     Remarks (Not recommended) recommended. not is labour in delay of prevention for agents antispasmodic of use The RECOMMENDATION 31    Remarks recommended. (Not recommended) not is analgesia epidural receiving women in labour in delay of prevention for oxytocin of use The RECOMMENDATION 30        available at: http://apps.who.int/iris/bitstream/10665/112825/1/9789241507363_eng.pdf document, guideline source inthe found be can this recommendation supporting evidence The priority. aresearch as delay of labour treatment the for agents antispasmodic of use of the effectiveness the considers GDG The available. becomes risks minimal with benefits clinical demonstrating until information new practice the to not recommend chose and reported, were poorly which issues, safety on value high placed GDG The outcomes. infant or maternal critical other inthe improvement translate into not did it as inconsequential, clinically considered was hour by one of labour stage first of the length inthe shortening The results. of the applicability wide to permit interventions and to participants the with respect were too available heterogeneous data the that noted GDG The evidence. low-quality very (46) WHO the from recommendations integrated been has for augmentation recommendation This of labour available at: http://apps.who.int/iris/bitstream/10665/112825/1/9789241507363_eng.pdf document, guideline source inthe found be can this recommendation supporting evidence The analgesia. epidural receiving inwomen progress labour delay of of confirmed treatment as indicated when performed be should with oxytocin Augmentation evidence. low-quality (46) WHO the from recommendations integrated been has for augmentation recommendation This of labour

Antispasmodic agents Antispasmodic Oxytocin for women with epidural analgesia epidural with women for Oxytocin , in which the GDG for that guideline determined it to be a conditional recommendation based on on based recommendation itto aconditional be determined guideline that for GDG the , inwhich on based recommendation to it aconditional be determined guideline that for GDG the , inwhich

3.2.25 Intravenous fluids for preventing labour delay

RECOMMENDATION 32

The use of intravenous fluids with the aim of shortening the duration of labour is not recommended. (Not recommended)

Remarks

 This recommendation has been integrated from the WHO recommendations for augmentation of labour (46), in which the GDG for that guideline determined it to be a strong recommendation based on very low-quality evidence.  The GDG did not recommend this intervention on the basis of no clear evidence of benefits over harms. The group noted that the risk of maternal fluid overload, particularly when intravenous oxytocin infusion becomes indicated during the course of labour, might become accentuated.  The GDG agreed that low-risk women should be encouraged to drink fluids during labour.  The GDG acknowledged that intravenous (IV) fluid may become necessary for other indications and for supportive care in labour even for low-risk women.  The GDG placed its emphasis on the widespread and unnecessary use of routine administration of IV fluids for all women in labour and many health care facilities in low-, middle- and high-income settings that increases cost, has considerable impact on the resource use and reduces women’s mobility, and therefore made a strong recommendation against this intervention.  The evidence supporting this recommendation can be found in the source guideline document, available at: http://apps.who.int/iris/bitstream/10665/112825/1/9789241507363_eng.pdf 3. EVIDENCE AND RECOMMENDATIONS

119 120 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE stage, varied widely across studies. studies. across widely varied stage, second of the duration the impact could which birth, vaginal instrumental and analgesia epidural such interventions Labour women. parous for data 17 reported and nulliparous, for of labour stage second of the duration the on data reported studies Twenty-one 2016. included and of the 1960 between trials were published The status. socioeconomic and origins ethnic of different women over 200 000 Zambia), and USA the involving Kingdom, United Norway, TaiwanNigeria, [China], the Uganda, Myanmar, of Korea, Republic Japan, Germany, Israel, Finland, (China, Egypt, Croatia, countries Colombia, high-income in17 and low-, middle- conducted were studies of labour.stage included The first the of duration the for review evidence provided same (52) outcomes perinatal with normal women inlow-risk of labour duration evaluating the studies review asystematic from of 37 derived was Evidence of labour stage second of the Duration ofSummary evidence and considerations 3.3.1 3.3     Remarks — — practice. for recommended is labour of stage second the of duration and definition following the of use The RECOMMENDATION 33     — — and intervention to expedite childbirth should be considered. considered. be should tochildbirth expedite intervention and decreases, time within areasonable birth of spontaneous chance the durations, standard mentioned above- the beyond extended has However, stage second intervention. the for when grounds no are there head, fetal of the descent inthe of progress is evidence there and condition, isfetus ingood the of woman’s labour. is the satisfactory, condition progress the When on and condition, fetal and maternal of the surveillance on based be should of labour stage second the curtailing about A decision cm. 10 than earlier dilatation acervical at down to urge bear the feel can aware awoman that be should attendants Birth normally. is progressing labour when is unnecessary and to woman the unpleasant be could stage second of the beginning at the room delivery to room aspecific labour the Transportation from present. been has status this cervical how long for uncertain itremains examination, vaginal on is found dilatation complete If is diagnosed. dilatation complete when moment the at this urge yet may not she feel or dilatation complete before down tourge bear the may feel Awoman known. precisely not is often practice inclinical of labour stage second of the onset the and science inexact is an research on based stage second of the onset of the description The (Recommended) 2hours. within completed usually is birth another. In first isbirth labours, usually completed within 3 hours whereas in subsequent labours, to woman one from varies stage second the of duration the that informed be Women should contractions. (Recommended) uterine expulsive of aresult as down, to bear urge involuntary an has woman the which during baby, the of birth and dilatation cervical full between time of period the is stage second The Second stage of labour Definition and duration of the second stage of labour of stage second the of duration and Definition

. The . The with 95th percentile thresholds of 65–138 minutes of 65–138 minutes thresholds with 95th percentile (0.2–1.1 minutes 14–66 was stage hours),second of the duration median the that indicates studies four from evidence moderate-certainty 3.45, stage: second Nulliparous of labour. stage second of the onset of the definitions and interventions characteristics, inpopulation to heterogeneity due pooled were not studies These down. tourge bear the or dilatation of cervical cm 10 as point starting Two reference dilatation. the defined studies cm of 10 cervical from starting thisas defined others while stage second the for point reference starting the define clearly not did Eleven studies of the populations. study inthe use epidural 48.0% and 42.9% 4.1%, reported studies use) other three while epidural 100% and with 0% (groups use epidural to according population nulliparous the subdivided study One studies. infive reported not was use epidural used; was analgesia epidural no women, nulliparous for data reporting studies 13 ofIn the As shown inTable shown As (1.1–2.3 hours). The two studies with epidural use Additional considerations of 48% and 100% in this group reported longer Women generally place a high value on the total durations (median of 53–66 minutes [0.9–1.1 hours], duration of labour, although the relative importance and 95th percentiles of 138–216 minutes [2.3–3.6 of how long or how short labour is may be context hours]). dependent. Evidence from other studies suggests Low-certainty evidence from 17 studies presenting that women are less likely (than health care duration of the second stage as mean and standard providers) to recognize defined, time-bound phases deviations reported mean durations of 20–116 of labour (54), and their ability to cope is more likely minutes (0.3–1.9 hours), with estimated statistical to be dependent on a variety of inter-related factors, (“maximum”) limits of 78–216 minutes (1.3–3.6 including the level of pain experienced, the nature of hours). Two studies reported epidural use. One with the environment and their perceived level of support 42.9% epidural use reported a mean duration of (55). 20 minutes (0.3 hours) and a 95th percentile of 60 minutes (1 hour). The other trial, with 4.1% epidural Resources use, reported a mean duration of 40 minutes (0.7 No review evidence on resource requirements hours) with no statistical limits reported. relating to duration of the second stage of labour Parous second stage: Low-certainty evidence from was found. two studies presenting data for parity of 1 and parity of more than 1 separately reported median duration Additional considerations of the second stage of 6–12 minutes (0.1–0.2 hours), Application of limits for the duration of the second with 95th percentile thresholds of 58–76 minutes stage as informed by the respective 95th percentile (1.0–1.3 hours) (Table 3.45). The subpopulation thresholds as the benchmark for identifying unduly of women with 100% epidural use in one of these prolonged second stage of labour might be cost- studies had longer median durations (18–24 minutes effective as it has the potential to reduce the use [0.3–0.4 hours]) and 95th percentiles (96–120 of interventions to hasten birth, especially with minutes [1.6–2.0 hours]). instrumental vaginal birth and caesarean section. Low-certainty evidence from 15 studies reporting However, it might increase costs associated with data as a mean suggests that the mean duration of longer supportive care. the second stage ranged from 6 to 30 minutes (0.1– In certain middle- and high-income country settings 0.5 hours), and the statistical (“maximum”) limits where physicians attend to all women in labour, the were estimated as 16–78 minutes (0.3–1.3 hours). use of limits for the duration of the second stage There was no epidural use in eight of the studies, it of labour based on 95th percentile thresholds for was unreported in six studies, and epidural use was managing labour may likely result in an increase in reported in 2.4%, 4.3% and 9.5% of women in three health care resource use. studies. Only four of these studies clearly reported the starting reference point for the second stage. Equity Sensitivity analysis excluding second stage No evidence on the impact on equity was found. interventions also reveals a similar range of values. It shows that nulliparous women are able Additional considerations to successfully complete the second stage within An important indication for second stage caesarean 20–78 minutes, with statistical limits ranging from section is prolonged second stage based on the 60 to 174 minutes (1.0–2.5 hours). For parous expectation that the second stage should not last women, the duration of the second stage is shorter, longer than 1 hour. However, caesarean section is ranging from 6 to 30 minutes (0.1–0.5 hours), with a highly inequitable intervention (especially when upper estimates ranging from 16 to 78 minutes (0.3 used without a clear medical indication) as it is to 1.3 hours). unlikely to be promptly received by disadvantaged women in resource-poor settings. Application of Values safe upper limits to all women has the potential Findings from a review of qualitative studies looking to reduce inequity that is associated with over- at what matters to women during childbirth (23) medicalization of childbirth. indicate that most women want a normal childbirth with good outcomes for mother and baby, but Acceptability acknowledge that medical intervention may Findings from a review of qualitative studies looking sometimes be necessary. at what matters to women during labour and 3. EVIDENCE AND RECOMMENDATIONS

121 122 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.45 Studd 1975Studd (151) Studd 1973 (150) 1973 Studd Duignan 1975 (148) Duignan Shi 2016 (149) 2016 Shi Kilpatrick 1989 (67) 1989 Kilpatrick Jones 2003 (65) 2003 Jones (64) 1999 Albers (63) 1996 Albers Dior 2013 (147) 2013 Dior (146) women) Rican (Puerto- Diegmann 2000 (144) 1991 Abdel-Aleem (16) 2010 Zhang (16) 2010 Zhang (18) 2002 Zhang (62) 2018 Oladapo (143) 1992 Paterson Study NULLIPAROUS WOMEN Zhang 2010 (P =1) 2010 (16) Zhang (62) (P =2+) 2018 Oladapo (P =1) 2018 (62) Oladapo Study PAROUS WOMEN (152) Wusteman 2003 (69) 1993 Schorn (66) 1998 Schiff (68) 2007 Lee (58) 1994 Juntunen Zhang 2010 (P =2+) 2010 Zhang (16) (P =2+) 2010 Zhang (16) (P =1) 2010 (16) Zhang American women) (146) Diegmann (African- 2000 (145) 1986 Chen Duration of the second stage of labour in nulliparous and parous women parous and nulliparous in labour of stage second the of Duration

12 649 21 524 12 218 12 631 8 270 4 100 2 032 4 001 4 106 1 488 2 166 1 952 1 091 1 162 500 806 437 347 373 194 120 157 176 175 66 66 69 42 18 N N analgesia (%)analgesia analgesia (%)analgesia Epidural Epidural 42.9 100 100 100 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 NR NR NR NR NR 48 0.1 4.1 0 0 Reference points Reference Reference points Reference 10 cm to cm birth 10 to cm birth 10 10 cm to cm birth 10 10 cm to cm birth 10 10 cm to cm birth 10 to cm birth 10 10 cm to cm birth 10 10 cm to cm birth 10 10 cm to cm birth 10 to cm birth 10 to cm birth 10 10 cm to cm birth 10 10 cm to cm birth 10 10 cm to cm birth 10 10 cm to cm birth 10 10 cm to cm birth 10 10 cm or urge urge or cm 10 10 cm or urge urge or cm 10 to bear down to bear to bear down to bear Undefined Undefined Undefined Undefined Undefined Undefined Undefined Undefined Undefined Undefined Undefined (minutes) (minutes) (minutes) duration duration duration Median Median Median Median Mean Mean 116 40 44 46 36 66 66 54 20 54 66 54 54 45 43 43 42 36 24 78 53 53 32 14 18 12 11 11 6 percentile percentile (minutes) (minutes) (minutes) 3.0 NR NR NR NR NR NR NR NR NR NR NR NR 5th 5th 5th 5th 46 50 20 54 34 43 47 24 39 36 23 33 SD 18 5 2 2

percentile percentile (minutes) (minutes) (minutes) +2SD 60 140 138 138 122 132 95th 95th 95th 95th 110 146 168 120 216 216 147 174 78 91* NR NR NR NR NR NR 46 66 96 58 65 65 76 a a a * a a a a a

Mean SD +2SD duration (min) (min) (min) Abdel-Aleem 1991 (144) 372 0.0 Undefined 29 16 61a Albers 1996 (63) 602 NR 10 cm to birth 17 20 57a Albers 1999 (64) 1 705 0.0 10 cm to birth 18 23 64a Dior 2013 (P = 1 to 4) 27 252 NR Undefined 21 NR NR (147) Dior 2013 (P = 5+) (147) 4 112 NR Undefined 16 NR NR 10 cm or urge Duignan 1975 (148) 869 0.0 17 NR NR to bear down Gibb 1982 (153) 749 NR Undefined 17 NR NR Jones 2003 (65) 120 0.0 Undefined 22 28 78a Juntunen 1994 (P = 2/3) 42 2.4 Undefined 8.7 5.5 NR (58) Juntunen 1994 (GM) (58) 42 9.5 Undefined 6 5 16a Kilpatrick 1989 (67) 3 767 0.0 10 cm to birth 19 21 61a Paterson 1992 (143) 13 159 0.0 Undefined 19 21 61 Schiff 1998 (66) 94 NR Undefined 30 24 78a Schorn 1993 (69) 30 NR Undefined 24 24 72 Studd 1973 (150) 264 0.0 Undefined 22 NR NR Studd 1975 (151) 322 4.3 Undefined 19 NR NR Wusteman 2003 (152) 71 0.0 Undefined 16 21 58a GM: grand multiparity; NR: not reported; P: parity; SD: standard deviation; a Values estimated by systematic review authors Source: Abalos et al., 2018 (52).

Table 3.46 Main resource requirements for using 95th percentile thresholds as upper limits of duration of the second stage of labour

Resource Description Training  Practice-based training for health care providers  Revised training manuals and clinical protocols for health care providers and those in pre- service training Supplies  Educational materials for women on what comprises “normal” labour in terms of the duration of the second stage and when birth should be expected  Revised paper partograph to include second stage  Sufficient beds in the labour ward to support women whose second stage might be slower Infrastructure than the average for their population  Ongoing supervision and monitoring with regular audit and review of outcomes related to Supervision and extending the upper limits to diagnose prolonged second stage, when fetal and maternal monitoring conditions are reassuring 3. EVIDENCE AND RECOMMENDATIONS

123 124 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.47 intrapartum of delivering experiences providers’ at areviewIn looking of qualitative evidence Feasibility 91) (72, 73, terms in negative labour long very and short very both likely to report more are women that to is suggest evidence There considerations Additional (moderate confidence). limits time of standardized regardless individual to the tailored was of labour length optimal the where toif they were able “go flow” with the experience apositive labour likelymore to report are women However, childbirth, asked after when (low confidence). labour ashorter prefer would women pregnant most that indicate (23) childbirth effectiveness Cost- resources required of evidence of Certainty effects of Balance Values effects Desirable Equity required Resources the evidence of Certainty effects Undesirable Feasibility Acceptability duration of the second stage of labour of stage second the of duration the for limits upper as thresholds percentile 95th the of Use judgements: of Summary No included included No No included included No Don’t know know Don’t Don’t know know Don’t Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know studies studies ✓ ✓ ✓ – – – – – – – . Varies Varies Varies Varies Varies Varies Varies Varies ✓ – – – – – – – average limits existing limits Large costs Large Reduced Favours Favours Favours Favours – – – – uncertainty or or uncertainty average limits existing limits could lead to longer hospital stays), hospital to longer lead avoided. could be can (which section caesarean as such interventions, obstetric unnecessary if especially workload, staff increase significantly or stays hospital to increase is unlikely group parity their for boundary percentile 95th of the limits within the women Supporting considerations Additional (26) care personalized provide to staff care of health ability the limit may also rules evidence).the informal protocols and Local in (high confidence pressures time organizational and shortages by staff constrained may be labours (26) care Important Important Moderate variability Probably Probably Probably Very low Very Very low Very reduced favours favours favours favours Trivial Large costs No No – – – – – – – – – – – , the capacity to accommodate longer longer to accommodate capacity , the Favours neither neither Favours Favours neither neither Favours uncertainty or or uncertainty average limits limits average existing limits increased or or increased Probably No Probably No upper (95th (95th upper Probably no no Probably percentile) Negligible important important Moderate variability Possibly limits or or limits costs or or costs savings impact Small Low Low ✓ – – – – – – – – – – Probably Yes Probably Yes or variability or upper (95th (95th upper Probably no no Probably uncertainty uncertainty percentile) important important Moderate Moderate Moderate Moderate increased increased Probably Probably Probably savings favours favours favours favours . limits limits Small ✓ ✓ ✓ ✓ ✓ ✓ – – – – – uncertainty or or uncertainty Large savings Large No important important No upper (95th (95th upper percentile) variability Increased increased Favours Favours Favours Favours Trivial Large limits limits High High Yes Yes – – – – – – – – – – – 3.3.2 Birth position for women without epidural analgesia

RECOMMENDATION 34

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

Remarks

 The evidence suggests that upright birth positions during the second stage of labour might reduce episiotomy and instrumental vaginal births but might also be associated with increased risk of postpartum haemorrhage (PPH) and second-degree tears. However, most evidence is of low certainty and the GDG agreed that the difference in benefits and harms between upright and recumbent positions might not be clinically apparent.  It is important that any particular position is not forced on the woman and that she is encouraged and supported to adopt any position that she finds most comfortable.  The health care professional should ensure that the well-being of the baby is adequately monitored in the woman’s chosen position. Should a change in position be necessary to ensure adequate fetal monitoring, the reason should be clearly communicated to the woman.  A practical approach to positioning in the second stage for women desiring an upright birth position might be to adapt to a semi-recumbent or all-fours position just before expulsion of the fetus, to facilitate perineal techniques to reduce perineal tears and blood loss.

Summary of evidence and considerations Mode of birth: Low-certainty evidence suggests that an upright position may reduce instrumental Effects of the intervention (EB Table 3.3.2) vaginal birth (21 trials, 6481 women, RR 0.75, 95% The evidence is derived from a Cochrane systematic CI 0.66–0.86; absolute risk difference: 32 fewer per review that included 32 individual RCTs conducted 1000 [from 18 to 44 fewer]) but may make little or in low-, middle- and high-income countries (154). no difference to caesarean section (16 trials, 5439 Thirty trials involving 9015 women contributed data women, RR 1.22, 95% CI 0.81–1.81). On sensitivity on upright compared with recumbent positions. Trial analysis, whereby studies at high risk of bias were participants were nulliparous and/or parous women excluded, the certainty of evidence of a reduction with uncomplicated singleton pregnancies at more in instrumental vaginal birth became high (10 trials, than 36 weeks of gestation, except in two trials that 2534 women, RR 0.71, 95% CI 0.56–0.90) and included earlier . Ten trials compared a the certainty of evidence of no effect on caesarean birthing/squat stool, nine trials compared a birthing section became moderate (9 trials, 2544 women, chair, and three trials compared a birth cushion with RR 1.47, 95% CI 0.88–2.46). recumbent controls. Perineal/vaginal trauma: Low-certainty evidence suggests that an upright position may reduce Comparison: Upright position compared with episiotomy (17 trials, 6148 women, RR 0.75, 95% CI recumbent position in second stage of labour 0.61–0.92; absolute risk difference: 101 fewer [from Maternal outcomes 32 to 158 fewer]) and may increase second-degree Duration of labour: Evidence on the duration perineal tears (18 trials, 6715 women, RR 1.20, 95% of labour from 19 trials (5811 women) is of very CI 1.00–1.44; absolute risk difference: 25 more per low certainty due to design limitations and high 1000 [from 0 to 56 more]). On sensitivity analysis, inconsistency across studies in the meta-analysis. whereby studies at high risk of bias were excluded, However, on sensitivity analysis, whereby studies the certainty of evidence of an increase in second- at high risk of bias were excluded, low-certainty degree tears became high (9 trials, 2967 women, RR evidence suggests that an upright birth position may 1.35, 95% CI 1.10–1.67). Evidence on third- or fourth- make little or no difference to the duration of the degree perineal tears1 is of very low certainty overall, second stage in minutes (10 trials, 2499 women, MD 4.34 fewer minutes, 95% CI 9.00 fewer to 0.32 1 A third-degree tear involves injury to the anal sphincter more). complex and a fourth-degree tear extends through the

anal sphincter complex to involve the anal epithelium. 3. EVIDENCE AND RECOMMENDATIONS

125 126 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Overall, 57% of nulliparous women and 26% and women of of nulliparous 57% Overall, women. innulliparous not but women inparous risk OASI increased with an were associated seats birth (156) all-fours positions or standing kneeling, risk with in supine, difference clear no and women, innulliparous position birth a lateral OASI with risk adecreased women, parous and ofrisk OASI with lithotomy innulliparous position increased an (OASI) found position injury birth and sphincter of anal inSweden obstetric conducted women of 113 000 study A population-based considerations Additional 0.79, (155) RR 95%982 babies, CI 0.51–1.21) (4 positions with upright trials, mortality perinatal in difference no or little may be there that suggests Perinatal mortality: 95% CI 0.22–0.93). 0.46, RR 617(2 trials, babies, patterns FHR with fewer abnormal associated probably are positions upright that suggests Fetal distress: (HIE) outcomes. acidosis, or hypoxic-ischaemic encephalopathy 7, than less score Apgar 5-minute cord blood report Perinatal hypoxia-ischaemia: Fetal and neonatal outcomes experience outcomes. experience: Birth 0.97, RR women, 95% CI 0.93–1.02). 3093 trials, (7 stage second the during requirements analgesia in difference no or little may be there that suggests evidence Low-certainty low certainty. very trial (90 inone women) is of measured intensity higher). pain on lower to evidence 0.32 Further 1.28 lower, 0.48 MD 95% CI women, 155 trial, (1 pain 95% CI 0.16 higher), lower to 0.8 postpartum or higher, 0.32 MD women, 155 trial, (1 scale analogue with avisual measured as position, upright with an of labour stage second pain in the in difference no or little may be there that suggests pain Pain intensity: to moderate. increased evidence of this more]). certainty the analysis, sensitivity On 4 [from 43 to 1000 per more 21 difference: risk 95% CI 1.10–1.98; absolute 1.48, RR 5615 women, trials, (15 mL 500 than greater loss blood estimated may increase position upright an that suggests Maternal morbidity: 95% CI 0.44–4.79). 1.46, RR women, 872 trials, (3 tears or on fourth-degree third- effect no or little may have positions upright that suggests evidence however, low-certainty analysis, sensitivity on Moderate-certainty evidence Low-certainty evidence on maternal maternal on evidence Low-certainty The review did not report on birth birth on review report not did The Low-certainty evidence evidence Low-certainty Low-certainty evidence evidence Low-certainty The review not did The . Squatting and and . Squatting . (e.g. birth cushions).(e.g. birth props additional require necessarily not do positions Upright position. upright inan to givewomen birth how to on training support require would positions in recumbent to give women birth to supporting accustomed professionals is unclear. care Health cost-effectiveness the therefore, PPH, and tears second-degree increase might episiotomy but and births vaginal instrumental reduce might positions birth upright that suggests effects on Evidence considerations Additional found. was resources on evidence research No Resources evidence). in the to (high confidence move around freedom the may that include environment supportive safe, like Women also would ina to give birth needs. sensitiveare who to their staff caring of kind, support with the process labour of the incontrol be like they would but to to painful be childbirth and labour expect women that suggest also Findings outcomes (high confidence in the evidence). of kinds to potential these exposure their reduces morbidities), that any technique value they would so fetal and maternal and interventions medical (including ofevents potentially traumatic fearful are and childbirth and of labour unpredictability aware are of the women that suggest also in evidence).the Findings (highbaby confidence and mother for outcomes with good childbirth (23) care intrapartum during to women matters what at looking areview from of qualitative studies Findings Values analgesia. epidural with involving women inacomparison occur not did effects 95% CI 0.66–0.99). These 0.81, RR women, (9 use 2107 trials, epidural and 95% CI 0.54–0.94) 0.71, RR women, 2682 (14 trials, section caesarean reduce probably stage first inthe positions upright (155) to-2.22 -0.51) 95% CI hours, -1.36 average MD women 2503 trials, (15 shorter minutes 22 and 1hour about probably is of labour stage first the for care bed and positions with recumbent compared positions ambulant and with upright of labour duration the that review systematic found Cochrane A 2013 to use. according its separately not reported were findings and study inthis analgesia epidural underwent women parous indicate that most women want a normal anormal want women most that indicate . Findings also suggest that that suggest also . Findings Table 3.48 Main resource requirements for upright birth positions

Resource Description Staff  Midwives/nurses/doctors: same as for recumbent birth positions Training  In-service training to support upright birth positions Supplies  Usual supplies  Bed: same as for recumbent positions Equipment  Birthing cushion or other options to support upright birth (optional) Infrastructure  Birthing room with space to accommodate a birthing stool (optional) Supervision and  Good access to medical supervision: same as for recumbent birth positions monitoring

Equity tended to favour the supine position as it made No direct evidence was found on the impact of the monitoring, medical intervention and the childbirth different birth positions on equity. However, indirect process easier for them to manage (moderate evidence from a review of barriers and facilitators to confidence in the evidence). facility-based birth indicates that many women have a “fear of cutting” by health workers (e.g. episiotomy Additional considerations and caesarean section) and that this is probably a Data from cross-sectional surveys conducted in significant barrier to the uptake of facility-based Africa (Malawi and Nigeria) showed that more than birth by disadvantaged women in LMICs (moderate 90% of women were aware of the supine or semi- confidence in the evidence) (8). Therefore, birth recumbent positions for labour and childbirth but practices that reduce these medical interventions less than 5% were aware of alternative positions might improve equity. (e.g. squatting, kneeling, and on hands and knees). Data from the study in Nigeria also showed that only Additional considerations 18.9% of women would have been prepared to adopt Offering women birthing options that include those an alternative position if it had been suggested by a that are acceptable within their local customs and health care professional (157, 158). norms could positively impact on equity, through increasing facility-based births in settings where Feasibility women generally avoid hospital birth because of the A systematic review of qualitative studies exploring lack of alternative birthing options. women’s experiences of intrapartum care (26) found In addition, encouraging upright labour and birth that women were sometimes unaware of non- positions in well resourced settings might have a supine positions and felt that different options for positive impact on equity by reducing unnecessary birth positions should have been highlighted during medical interventions and associated resource use antenatal care (low confidence in the findings). among more advantaged women. Findings on health care professionals’ experiences from the same systematic review showed that Acceptability providers were often unaware of or inexperienced A systematic review of qualitative studies exploring in the use of non-supine positions. Staff also raised women’s experiences of intrapartum care (26) safety concerns about women coming “off the found that women wanted the freedom to adopt bed” and in certain contexts (LMICs) felt that various positions during the second stage of labour overcrowding in birth rooms prevented women from (low confidence in the evidence). In most cases, adopting an upright position (low confidence in the a non-supine position was perceived to be more evidence). empowering and less painful and to facilitate an easier birth, although the supine position (on a bed) Additional considerations was still viewed as the more traditional approach to The adoption of upright positions will require giving birth (low confidence in the evidence). additional training and practise as many practising The review also reported findings on health care doctors and midwives may not be familiar with professionals’ experiences (26), which showed that the method. Facilities employing a younger staff tried to be responsive to women’s needs but generation of doctors and midwives may not have

experienced personnel on staff, which may slow 3. EVIDENCE AND RECOMMENDATIONS

127 128 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.49 an during floor the on falling baby the about concerns Safety is inplace. options birth upright of offering apolicy even when implementation down effects Desirable effectiveness Cost- Values effects Undesirable effects of Balance the evidence of Certainty resources required of evidence of Certainty Feasibility Equity Acceptability required Resources compared with recumbent birth positions birth with recumbent compared analgesia epidural without women for positions birth Upright judgements: of Summary No included included No No included included No Don’t know Don’t know Don’t know Don’t know know Don’t Don’t know Don’t know Don’t know Don’t know studies studies ✓ – – – – – – – – – Varies Varies Varies Varies Varies Varies Varies Varies ✓ ✓ – – – – – – Large costs Large recumbent recumbent Reduced Favours Favours Favours Favours – – – – uncertainty or or uncertainty birthing facilities. birthing provision of supportive and training by appropriate to addressed be need would stage expulsive second recumbent recumbent Important Important Moderate variability Probably Probably Probably Very low Very Very low Very reduced favours favours favours favours Trivial Large costs No No – – – – – – – – – – – uncertainty or or uncertainty favour upright upright favour favour upright upright favour or recumbent or recumbent Probably No Probably No Probably no no Probably important important Negligible Moderate variability Does not not Does Does not not Does Possibly costs or or costs savings impact Small Low Low ✓ ✓ ✓ ✓ ✓ ✓ – – – – – uncertainty or or uncertainty Probably Yes Probably Yes Probably no no Probably important important Moderate Moderate Moderate Moderate variability increased Probably Probably Probably savings favours favours favours favours upright upright Small ✓ ✓ – – – – – – – – - uncertainty or or uncertainty Large savings Large No important important No variability Increased Favours Favours Favours Favours upright upright Trivial Large High High Yes Yes – – – – – – – – – – – 3.3.3 Birth position for women with epidural analgesia

RECOMMENDATION 35

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

Remarks

 Evidence suggests that there might be little or no difference in most birth outcomes according to birth position among women with epidural analgesia. Having a choice of birth positions during the second stage of labour might positively impact maternal birth experience and improve equity.  Upright positions with traditional epidural analgesia, which provides a dense neuroaxial block, might not be feasible; however, most epidural analgesia currently provided are “low dose” and “mobile” epidural analgesia, which should enable a choice of birth positions.  It is important that any particular position is not forced on the woman and that she is encouraged and supported to adopt any position that she finds most comfortable.  The health care professional should ensure that the well-being of the baby can be adequately monitored in the woman’s chosen position. Should a change in position be necessary to ensure adequate fetal monitoring, this should be effectively communicated to the woman.

Summary of evidence and considerations the main axis of the body less than 45° from the horizontal). Effects of the intervention (EB Table 3.3.3) The evidence is derived from a Cochrane systematic Comparison: Upright position compared with review that included five individual RCTs conducted recumbent position in second stage of labour in the United Kingdom (4 trials) and France, with epidural analgesia involving 879 women (159). Participants were Maternal outcomes nulliparous and parous women with term singleton Duration of labour: Low-certainty evidence gestations and epidural analgesia for pain relief suggests there may be little or no difference in the in labour. Three studies used mobile epidural mean duration of the second stage with upright analgesia, one study used traditional epidural versus recumbent positions (2 trials, 322 women, analgesia, and the other study did not state the type MD 22.98 minutes lower, 95% CI 99.09 lower to of epidural used. Two studies reported that women 53.13 higher). One study with data for 3093 women with spontaneous and induced labour were included; reported a median reduction in duration of the however, it is unclear whether the other studies second stage of 7 minutes (interquartile range [IQR] included women with induced labour. 0–13 minutes). Positions of the study groups varied between Mode of birth: Low-certainty evidence from six studies but all studies distinguished two groups that trials (3967 women) suggests there may be little or could be classified as upright or recumbent for the no difference in spontaneous vaginal birth (RR 0.97, purpose of the review. 95% CI 0.82–1.14), and moderate-certainty evidence Upright positions included sitting (on a bed or a from the same trials suggests there is probably tilting bed more than 45° from the horizontal), little or no difference in operative birth (caesarean squatting (unaided or using squatting bars or a section and instrumental vaginal birth) (RR 1.04, birth cushion, semi-recumbent (with the main axis 95% CI 0.89–1.20) or instrumental vaginal birth (RR of the body 45° or more from the horizontal), and 1.05, 95% CI 0.94–1.18). Low-certainty evidence kneeling (upright, leaning on the head of the bed, suggests there may be little or no difference in or supported by a partner). Recumbent positions caesarean section (6 trials, 3967 women, RR 1.05, included lithotomy position, lateral position (left or 95% CI 0.71–1.55). right), Trendelenburg’s position (head lower than Perineal/vaginal trauma: Moderate-certainty pelvis), knee-elbow (all fours) position (with axis evidence suggests there is probably little or no of the trunk horizontal), and semi-recumbent (with difference in perineal/vaginal trauma that requires 3. EVIDENCE AND RECOMMENDATIONS

129 130 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE 26% of parous women underwent epidural analgesia analgesia epidural 26% underwent women of parous and women of nulliparous 57% Overall, women. innulliparous not but women of OASI inparous risk increased with an were associated seats birth (156) all-fours positions or standing kneeling, risk with in supine, difference clear no and women, innulliparous position birth a lateral of risk OASI with adecreased women, parous and ofrisk OASI with lithotomy innulliparous position increased an (OASI) found position injury birth and sphincter of anal inSweden obstetric conducted women of 113 000 study A population-based considerations Additional 95%2.96, CI 0.12–72.69). RR infants, (there 3093 event, death asingle was perinatal in difference no or little suggests study one Perinatal mortality: certainty. low is of very intervention requiring patterns Fetal distress: 0.75–1.32). 95% CI 1.00, RR study, (1 infants, resuscitation 3093 neonatal rates in of difference no or little may be there 13 fewer]). suggests evidence Low-certainty 2 [from to 1000 per 9 fewer difference: absolute 95% CI 0.20–0.90; 0.43, RR infants, 3159 studies, 1 pH low that cord suggests evidence Moderate-certainty 95% CI 0.11–3.94). 0.66, (RR 5minutes 7at below scores Apgar in difference no or little may be there infants) (3200 suggests studies two from evidence Perinatal hypoxia-ischaemia: Fetal and neonatal outcomes 0.98, 95% CI 0.93–1.03). (RR groups between difference no or little probably is there suggests evidence moderate-certainty experience; overall with childbirth their satisfaction expressing of women number the on reported experience: Birth 95% CI 0.83–1.72). 1.20, outcome (RR this for groups between difference no or little may be there suggests evidence low-certainty transfusion; requiring loss with blood of women number the women) reported (3093 study one although outcomes, morbidity other Maternal morbidity: 0.89–1.14). 95% CI 1.01, RR women, 3266 trials, (3 suturing (n =66). study <7.20 other (n a pH the in and =3093) study of < pH as a one in 7.05 defined was pH cord Low 1 is probably reduced with an upright position (2 position upright with an reduced is probably The evidence on abnormal FHR FHR abnormal on evidence The One study (3093 women) (3093 study One Low-certainty evidence from from evidence Low-certainty No studies reported PPH or or PPH reported studies No Low-certainty Low-certainty . Squatting and and . Squatting birth in an upright position. upright inan birth to give them how to on training support refresher additional/ require could positions recumbent in to analgesia give birth with epidural women to supporting accustomed professionals care Health beds. and toregard time staff with implications resource no have or plausibly little might analgesia with epidural women for position of birth choice the outcomes, birth other and stage second of the duration in the difference no or little be might there suggests effects on evidence the As considerations Additional positions. with birth associated costs on found was evidence research No Resources babies. their or to them harm cause not does if it position birth upright of an option the may prefer with epidurals women above, qualitative evidence the on based Therefore, with epidural. women for outcomes on impact little has position birth that suggests it is limited, with epidural positions birth of effect the on evidence the Although considerations Additional evidence). in the to (high confidence move around freedom the may that include environment supportive a safe, like Women also would in to give birth needs. their sensitiveare who to staff caring of kind, support with the process labour ofto the incontrol be like would but to painful be childbirth and labour expect that women suggest findings addition, In outcomes (high confidence in the evidence). of kinds to potential these exposure their reduces that any technique value morbidities) would so fetal and maternal and interventions medical (including ofevents potentially traumatic fearful are and childbirth and of labour unpredictability aware are of the women that suggest also in evidence).the Findings (highbaby confidence and mother for outcomes with good childbirth (23) care intrapartum during to women matters what at looking areview from of qualitative studies Findings Values to use. according its separately not reported were findings and in this study indicate that most women want a normal anormal want women most that indicate Equity Feasibility No research evidence on equity was found. A systematic review of qualitative studies exploring women’s experiences of intrapartum care (26) Additional considerations found that women generally wanted to move around during childbirth but the lack of space in some Having a choice of birth positions might have a birth facilities prevented them from doing so (low positive impact on equity if it reduces unnecessary confidence in the evidence). Findings also showed medical interventions among more advantaged that women were sometimes unaware of non-supine women using epidural analgesia. positions and felt different options for birth positions should have been highlighted during antenatal care Acceptability (low confidence in the findings). A systematic review of qualitative studies exploring women’s experiences of intrapartum care (26) Findings on health care professionals’ experiences found that women wanted the freedom to adopt of intrapartum care (26) showed that providers were various positions during the second stage of labour often unaware of or inexperienced in the use of non- (low confidence in the evidence). In most cases supine positions. Staff also raised safety concerns a non-supine position was perceived to be more about women coming “off the bed” and in certain empowering and less painful, and to facilitate an contexts (LMICs) felt that overcrowding in delivery easier birth, although the supine position (on a bed) rooms prevented women from adopting an upright was still viewed as the more traditional approach to position (low confidence in the evidence). giving birth (low confidence in the evidence). Additional considerations Findings on health care professionals’ experiences Upright birth positions might be more feasible to from the same review showed that staff tried to be implement in settings where “walking” epidurals are responsive to women’s needs but tended to favour available, as these are less restrictive than traditional the supine position as it made monitoring, medical epidurals. The adoption of upright positions will intervention and the birth process easier for them to require additional training and practise, as many manage (moderate confidence in the evidence) (26). practising doctors and midwives may not be familiar with the method. Facilities employing a younger Additional considerations generation of doctors and midwives may not have Data from cross-sectional surveys conducted in experienced personnel on staff, which may slow Africa (Malawi and Nigeria) showed that more than down implementation even when a policy of offering 90% of women were aware of the supine or semi- upright birth options is in place. Safety concerns recumbent positions for labour and birth but less about the baby falling on the floor during an than 5% were aware of alternative positions (e.g. expulsive second stage would need to be addressed squatting, kneeling, and on hands and knees). Data by appropriate training and provision of supportive from the Nigerian study also showed that only 18.9% birthing facilities. of women would have been prepared to adopt an alternative position if it had been suggested by a health care professional (157, 158). 3. EVIDENCE AND RECOMMENDATIONS

131 132 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.50 a

effectiveness Cost- Feasibility Acceptability effects Desirable effects of Balance Values the evidence of Certainty Equity effects Undesirable resources required of evidence of Certainty required Resources The cost-effectiveness domain was not judged because the desirable effects of the intervention were trivial. were intervention the of effects desirable the because judged not was domain cost-effectiveness The a women with epiduralanalgesia in positions birth recumbent with compared positions birth Upright judgements: of Summary No included included No included No Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know know Don’t Don’t know Don’t know studies studies ✓ ✓ – – – – – – – – Varies Varies Varies Varies Varies Varies Varies Varies ✓ ✓ – – – – – – comparison comparison Favours the the Favours Favours the the Favours Large costs Large Reduced – – – – uncertainty or or uncertainty recumbent recumbent Important Important Moderate variability Probably Probably Probably Very low Very low Very reduced favours favours favours favours Trivial Large costs No No ✓ – – – – – – – – – – uncertainty or or uncertainty favour upright upright favour favour upright upright favour or recumbent or recumbent Probably No Probably No Probably no no Probably important important Negligible Moderate variability Does not not Does Does not not Does Possibly costs or or costs savings impact Small Low Low ✓ ✓ ✓ – – – – – – – – uncertainty or or uncertainty Probably Yes Probably Yes Probably no no Probably important important Moderate Moderate Moderate Moderate variability increased Probably Probably Probably savings favours favours favours favours upright upright Small ✓ – – – – – – – – – – uncertainty or or uncertainty Large savings Large No important important No variability Increased Favours Favours Favours Favours upright upright Trivial Large High High Yes Yes ✓ – – – – – – – – – – 3.3.4 Method of pushing

RECOMMENDATION 36

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

REMARKS

 Qualitative evidence on what matters to women during intrapartum care shows that women want to feel in control of their birth process, with the support of kind, reassuring staff who are sensitive to their needs (23).  Health care providers should avoid imposing directed pushing on women in the second stage of labour, as there is no evidence of any benefit with this technique.

Summary of evidence and considerations RR 0.56, 95% CI 0.06–5.10). Evidence on caesarean section is of very low certainty. Effects of the intervention (EB Table 3.3.4) This evidence is derived from a Cochrane systematic Perineal/vaginal trauma: Moderate-certainty review on pushing techniques (160). Eight RCTs evidence suggests there is probably little or no involving 884 women compared spontaneous difference between spontaneous and directed pushing with directed pushing. Most participants pushing on perineal lacerations (1 trial, 320 women, in these studies, which were conducted in Hong RR 0.87, 95% CI 0.45–1.66). Evidence on episiotomy Kong Special Administrative Region, Iran, Turkey, is of very low certainty. the United Kingdom (1 study each) and the Long-term morbidity: Low-certainty evidence USA (3 studies), were nulliparous women with suggests there may be little or no difference uncomplicated singleton vertex gestations at term. in postpartum urinary incontinence between Sample sizes ranged from 32 to 320 participants. spontaneous and directed pushing (1 trial, 128 One trial (258 women) also included parous women women, RR 0.77, 95% CI 0.29–1.69). No studies and another comprised a proportion of women with reported perineal pain, dyspareunia or pelvic floor epidural analgesia. The birth position of participants prolapse. in the studies was not consistent across studies, Birth experience: There may be little or no with one study (72 women) managing the directed difference in maternal satisfaction between these pushing group in a supine position, whereas women techniques, measured on a visual analogue scale, in the spontaneous group pushed in an upright however the evidence is of low certainty (1 trial, 31 position. Other aspects of the techniques differed women, MD 0.91 higher satisfaction score [from 1.3 slightly across studies but, in general, women in lower to 3.12 higher]). Evidence on maternal fatigue the spontaneous group were not given specific after birth is of very low certainty and no studies instructions on how to push and were encouraged, reported on pain during the second stage. rather, to do what comes naturally.

Fetal and neonatal outcomes Comparison: Spontaneous pushing compared with directed pushing Perinatal hypoxia-ischaemia: Low-certainty Maternal outcomes evidence suggests there may be little or no difference between spontaneous compared with Duration of labour: Evidence on duration of the directed pushing on 5-minute Apgar score less than second stage of labour and the duration of pushing is 7 (1 trial, RR 0.35, 95% CI 0.01–8.43), umbilical of very low certainty. arterial cord blood pH less than 7.2 (1 trial, 320 Mode of birth: High-certainty evidence shows that women, RR 0.74, 95% CI 0.24–2.29), and delivery spontaneous pushing makes little or no difference room neonatal resuscitation (2 trials, 352 babies, RR to spontaneous vaginal birth (5 trials, 688 women, 0.83, 95% CI 0.40–1.75). RR 1.01, 95% CI 0.97–1.05), and low-certainty Fetal distress: The review did not report this evidence suggests that it may have little or no effect outcome. on instrumental vaginal birth (2 trials, 393 women, 3. EVIDENCE AND RECOMMENDATIONS

133 134 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE second stage and/or more interventions, it would itwould and/or stage interventions, more second of duration to alonger leads technique apushing If considerations Additional techniques. pushing two these with associated costs review on is no evidence There Resources (55) level of support perceived their and environment the of nature the level the ofexperienced, pain including of inter-related avariety on factors, dependent (54) of labour phases time-bound recognize defined, likely providers) (than less are care to health women that suggests studies other from Evidence considerations Additional evidence). in the (high confidence sensitiveare to needs their who staff reassuring byto kind, push), supported urge the (including signals own physiological their trusting and being aware of by “go flow” with the like would women to that suggest also Findings outcomes (high confidence in the evidence). of kinds to potential these exposure their reduces that any technique morbidities) value they would so fetal and maternal and interventions medical (including ofevents potentially traumatic fearful are and childbirth and of labour unpredictability aware are of the women that suggest also Findings in evidence).the (low confidence intervention likely more they the to are medical require lasts labour longer the that perception the on based often this is but arelatively labour for quick hope also (high confidence in the evidence).Some women baby and mother for outcomes with good childbirth (23) care intrapartum during to women matters what at looking areview from of qualitative studies Findings Values (55) level of support perceived their and environment the of nature the level the ofexperienced, pain including of inter-related avariety on factors, dependent (54) of labour phases time-bound recognize defined, likely providers) (than less are care to health women that suggests studies other from Evidence considerations Additional outcome. Perinatal mortality: . . , and their ability to cope is more likely is more to to cope be ability their , and likely is more to to cope be ability their , and indicate that most women want a normal anormal want women most that indicate The review did not report this review report not did The unlikely to be any concerns around feasibility. around unlikely to any concerns be (26) relating to women’sevidence pushing views on direct no found childbirth and of labour experiences reviewA qualitative systematic of women’s Feasibility (161) to, not vice versa or them tell professionals care health is but todesire push internal their when messages, external and internal like not do conflicting the women that indicates study analysis areview case from Evidence and considerations Additional (26) to pushing views relating professionals’ care health on evidence direct no review qualitative systematic found The in evidence).the state (low confidence psychological and physiological perceived with their inaccord and coherent is it consistent, provided professionals, care health reassuring from advice and support welcome but progress of labour “in control” to feel like women that indicate also evidence).the Findings in (low confidence childbirth and to labour approach adirective adopt professionals care health when care abusive or disrespectful likely to experience more are women contexts LMIC incertain that this review from suggests evidence Indirect pushing. relating to women’s evidence views on direct no (26) childbirth and of labour experiences reviewA qualitative systematic of women’s Acceptability rights. reproductive their to enjoy them empower and experience childbirth of their incontrol more to feel women help might stage second inthe of pushing method physiological own natural, to their use women Encouraging considerations Additional found. was evidence research No Equity negligible. be may techniques different with these implications cost that suggest overall, findings evidence certainty low- on based although Therefore, outcomes. birth other and of labour duration on the effect no or little had review the found, which, techniques, pushing directed and with spontaneous case the However, to be costs. appear not other this does and time of staff interms have implications cost . Indirect evidence would suggest that there are are there that suggest would evidence . Indirect . . found found The qualitative systematic review found no direct Additional considerations evidence on health care professionals’ views relating The teaching of women, by health care to pushing (26). Indirect evidence would suggest professionals, to follow their own instincts to that organizational pressures relating to time and push when they feel the urge is more feasible bed space may encourage health care professionals than teaching women to perform the Valsalva to favour directed pushing in certain contexts based manoeuvre. on the perception that it shortens labour (very low confidence in the evidence).

Table 3.51 Summary of judgements: Spontaneous pushing compared with directed pushing

Desirable – – ✓ – – – effects Don’t know Varies Trivial Small Moderate Large Undesirable – – – – – ✓ effects Don’t know Varies Large Moderate Small Trivial Certainty of – – ✓ – – the evidence No included Very low Low Moderate High studies Values – – ✓ – Important Possibly Probably no No important uncertainty or important important uncertainty or variability uncertainty or uncertainty or variability variability variability Balance of – – – – ✓ – – effects Don’t know Varies Favours the Probably Does not Probably Favours comparison favours favour favours spontaneous directed spontaneous spontaneous pushing pushing or directed pushing pushing Resources – – – – ✓ – – required Don’t know Varies Large costs Moderate Negligible Moderate Large savings costs costs or savings savings Certainty ✓ – – – – of evidence No included Very low Low Moderate High of required studies resources Cost- – – – – – – – effectivenessa Don’t know Varies Favours the Probably Does not Probably Favours comparison favours favour favours spontaneous directed spontaneous spontaneous pushing pushing or directed pushing pushing Equity ✓ – – – – – – Don’t know Varies Reduced Probably Probably no Probably Increased reduced impact increased Acceptability – – – – ✓ – Don’t know Varies No Probably No Probably Yes Yes Feasibility – – – – ✓ – Don’t know Varies No Probably No Probably Yes Yes a The cost-effectiveness domain was not judged because the desirable effects of the intervention were trivial. 3. EVIDENCE AND RECOMMENDATIONS

135 136 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE 3.3.5 shorten the duration of labour. duration the shorten to indication amedical was there or perineum, the of inspection visualized was routine on head fetal the down, to urge bear irresistible an had woman the unless group, intervention in the 2hours for delayed was pushing women, trial of 1862 largest the In trial protocols. individual the on depending 3hours, 2or 1, for or to urge push, irresistible an experienced women until the delayed was pushing of onset group, the other in the whereas identified, was dilatation cervical full as soon as pushing began group pushing immediate inthe women general, In down. bearing for technique pushing spontaneous or to aclosed-glottis use encouraged were women whether report trials not did most fiveand trials inonly reported was participants of position Birth trials. the across mobile) varying walking/ (e.g. or analgesia traditional of epidural types and schemes with dosing analgesia, epidural had All participants women. parous included also however, term; at gestations vertex trials two singleton with uncomplicated women nulliparous were participants Most 37 to participants. 1862 (Malaysia), country from middle-income ranged one [2studies]Kingdom [8 USA the and studies]) and United Switzerland, (Canada, Ireland, in HICs mainly were conducted which trials, sizes of these of labour. stage Sample second inthe analgesia with epidural in2879 women pushing immediate RCTs withindividual pushing delaying compared (160) techniques review pushing on systematic aCochrane from is derived evidence The intervention (EB the of 3.3.5) Effects Table ofSummary evidence and considerations   Remarks be adequately assessed and managed. (Context-specific recommendation) hypoxia can perinatal and stage second in stay longer for available are resources where context the in recommended is down to bear urge sensory the regains woman the until or dilatation full after hours to two one for pushing labour, of delaying stage second the in analgesia epidural with women For RECOMMENDATION 37   further medical intervention. medical further to lead might practice the and pushing with immediate of anylabour, benefit evidence is no there as of stage second inthe women on pushing immediate avoid imposing should providers care Health uncertain. is very limited evidence of this importance clinical the that agreed GDG the and is of low cord pH certainty of low umbilical risk the increase might pushing delaying that labour. evidence aslightly longer The after birth vaginal spontaneous of likelihood the increases probably pushing delaying that suggests effects on Evidence Method of pushing for women with epidural analgesia epidural with women for pushing of Method . Twelve analgesia immediate pushing in women with epidural Comparison: Delaying pushing compared with 95% CI 0.87–1.04). 0.95, RR women, episiotomy (5 2320 and trials, 0.94, 95% RR CI 0.78–1.14) women, 2775 trials, (7 lacerations perineal to difference no or little makes probably pushing delaying that suggests evidence Perineal/vaginal trauma: 0.61–1.14). CI 95% 0.82, RR women, (5 2151 use trials, forceps and 0.89, 95% RR CI 0.74–1.07) women, 3007 trials, (10 evidence), birth instrumental moderate-certainty 95% CI 0.65–1.05; 0.83, RR (9 2783 women, trials, section of caesarean outcomes individual to the difference no or may make little pushing delaying that suggests evidence Moderate-certainty (from 14 to 78 more). 1000 per births spontaneous more 50 of difference 1.07,RR 95% CI 1.02–1.11), risk absolute with an women, 3114 (12 trials, pushing with delaying increased is probably birth vaginal that suggests of birth: Mode shorter). minutes shorter, 95% 19 minutes MD CI 6–32 women, 2932 trials, (11 shorter may be itself of pushing 95% CI 42–71 longer) minutes duration the that but longer, minutes 56.4 MD women, 3049 trials, (11 technique pushing delaying with the longer hour an about may be of labour duration the that suggests Duration of labour: Maternal outcomes Moderate-certainty evidence Low-certainty evidence evidence Low-certainty Moderate-certainty Long-term morbidity: Low-certainty evidence Additional considerations suggests that delaying pushing has little or no effect The qualitative evidence above suggests that on postpartum dyspareunia (1 trial, 162 women, RR women are likely to value the increased chance of 1.15, 95% CI 0.63–2.10) or faecal incontinence (1 spontaneous birth with delaying pushing, but would trial, 178 women, RR 1.47, 95% CI 0.94–2.29). worry about the increase in cord pH if this translated Birth experience: Low-certainty evidence into poor birth outcomes. suggests that delaying pushing may make little or no difference to maternal satisfaction (1 trial, 73 Resources women, MD 0.4 higher, 95% CI 7.34 lower to 8.14 The Cochrane systematic review (160) included higher), as measured on a visual analogue scale. evidence on costs, with one large trial (1862 women) reporting this outcome (162). Delaying pushing was Fetal and neonatal outcomes associated with an increase of approximately 80 Perinatal hypoxia-ischaemia: Low-certainty Canadian dollars (Can$) (approximately US$ 60) in evidence suggests that delaying pushing might total hospital costs in a private health care setting, increase rates of low umbilical cord pH (arterial which could mostly be attributed to an increase in and/or venous pH as defined by trial authors) cost of intrapartum care for the delaying pushing (4 trials, 2145 babies, RR 2.24, 95% CI 1.37–3.68). group (MD 68.22 Can$, 95% CI 55.37–81.07 Can$). The absolute risk difference might be approximately 25 more events per 1000 (from 7 to 53 more) with Equity delaying pushing. Evidence on a 5-minute Apgar No research evidence on equity was found. score less than 7 is of very low certainty. No trials reported hypoxic-ischaemic encephalopathy (HIE). Additional considerations Fetal distress: This outcome was not reported in the Epidural analgesia is a technique for pain relief that, review. in healthy pregnant women, is mainly employed in Perinatal mortality: This outcome was not reported well resourced settings and HICs. in the review. Higher costs associated with the technique of delaying pushing might further reduce equity if Values women undergoing epidural analgesia require Findings from a review of qualitative studies looking additional resources to accommodate delaying at what matters to women during intrapartum pushing in the second stage of labour. care (23) indicate that most women want a normal childbirth with good outcomes for mother and Acceptability baby (high confidence in the evidence). Findings A qualitative systematic review of women’s also suggest that women are aware of the experiences of labour and childbirth found no unpredictability of labour and childbirth and are direct evidence relating to women’s views on fearful of potentially traumatic events (including pushing (26). Indirect evidence from this review medical interventions and maternal and fetal suggests that women like to feel in control of labour morbidities), so they would value any technique that progress but welcome the support and advice from reduces their potential exposure to these kinds of a reassuring health care professional, provided it outcomes (high confidence in the evidence). is consistent, coherent and in accord with their Some women also hope for a relatively quick labour, perceived physiological and psychological state (low but this is often based on the perception that the confidence in the evidence). longer labour lasts the more likely they are to The same review also found no direct evidence on require medical intervention (low confidence in the health care professionals’ views relating to pushing evidence). (26). Findings also suggest that women would like to “go with the flow” by being aware of and trusting Feasibility their own physiological signals (including the urge A qualitative systematic review of women’s to push), supported by kind, reassuring staff who experiences of labour and childbirth found no direct are sensitive to their needs (high confidence in the evidence relating to women’s views on pushing (26). evidence). Indirect evidence would suggest there are unlikely to be any concerns around feasibility. 3. EVIDENCE AND RECOMMENDATIONS

137 138 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.52 confidence in the evidence). (very practice on low may have impact an contexts incertain of training alack that suggest would views (26) relating to pushing professionals’ care health on evidence direct no review qualitative systematic found also The Feasibility Acceptability Equity effectiveness Cost- resources required of evidence of Certainty required Resources effects of Balance Values effects Desirable the evidence of Certainty effects Undesirable epidural analgesia epidural analgesia with women in pushing immediate with compared pushing Delaying judgements: of Summary No included included No No included included No Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know know Don’t Don’t know Don’t know studies studies – – – – – – – – – – . Indirect evidence evidence . Indirect Varies Varies Varies Varies Varies Varies Varies Varies – – – – – – – – Large costs Large immediate immediate immediate immediate Reduced pushing pushing Favours Favours Favours Favours – – – – uncertainty or or uncertainty settings. inresource-constrained feasible less be this might duration labour to longer leads pushing delaying If considerations Additional immediate immediate immediate immediate Important Important Moderate variability Probably Probably Probably Very low Very Very low Very reduced pushing pushing favours favours favours favours Trivial Large costs No No ✓ ✓ – – – – – – – – – uncertainty or or uncertainty Probably No Probably No Probably no no Probably delaying or or delaying delaying or or delaying immediate immediate immediate immediate Negligible important important Moderate variability Does not not Does Does not not Does Possibly costs or or costs pushing pushing savings impact favour favour favour favour Small Low Low – – – – – – – – – – – uncertainty or or uncertainty Probably Yes Probably Yes Probably no no Probably important important Moderate Moderate Moderate Moderate variability increased Probably Probably Probably delaying delaying pushing pushing savings favours favours favours favours Small ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ – – uncertainty or or uncertainty Large savings Large No important important No variability Increased delaying delaying pushing pushing Favours Favours Favours Favours Trivial Large High High Yes Yes – – – – – – – – – – – 3.3.6 Techniques for preventing perineal trauma

RECOMMENDATION 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. (Recommended)

Remarks

 Evidence suggests that perineal massage may increase the chance of the keeping the perineum intact and reduces the risk of serious perineal tears, that warm perineal compresses reduce third- and fourth-degree perineal tears, and that a “hands-on” approach (guarding) probably reduces first- degree perineal tears. Most women accept these low-cost preventative perineal techniques and highly value the outcomes that they impact.  Evidence on Ritgen’s manoeuvre (using one hand to pull the fetal from between the maternal anus and the coccyx, and the other hand placed on the fetal occiput to control speed of birth) is very uncertain; therefore, this technique is not recommended.

Summary of evidence and considerations with a lubricant. It generally involved the midwife inserting two fingers into the and applying Effects of the intervention (EB Table 3.3.6) mild, downward pressure to the vagina towards the The evidence is derived from a Cochrane systematic rectum, while moving the fingers with steady strokes review that included 22 individual RCTs (163). from side to side. Massage in some studies was Twenty trials involving 15 181 women contributed performed only during contractions in the second data. The trials were conducted in Australia (2 stage and in others was continued during and trials), Austria (1 trial), Brazil (2 trials), Denmark between pushes. (1 trial), Iran (8 trials), Israel (1 trial), Spain (1 trial), Sweden (2 trials), the United Kingdom (1 trial) and Maternal outcomes the USA (1 trial). Perineal techniques performed in Perineal/vaginal trauma: Low-certainty evidence the second stage of labour that are included in this suggests that perineal massage may increase the framework are: likelihood of having an intact perineum after giving  perineal massage compared with a “hands-off” birth (6 trials, 2618 women, RR 1.74, 95% CI 1.11– approach or usual care; 2.73). The absolute effect is estimated as 168 more  a “hands-off” compared with a “hands-on” women having an intact perineum per 1000 (from approach; 25 to 393 more).  a warm compress compared with a “hands-off” High-certainty evidence indicates that perineal approach or no warm compress; and massage reduces third- or fourth-degree perineal  Ritgen’s manoeuvre compared with usual tears (5 trials, 2477 women, RR 0.49, 95% CI 0.25– practice. 0.94). The absolute effect is estimated as 5 fewer Other interventions assessed in the review that were per 1000 (from 2 to 22 fewer). Evidence on first- and associated with very limited evidence included cold second-degree tears, episiotomy and the need for compresses, delivery of the posterior shoulder first perineal suturing is of very low certainty. compared with the anterior shoulder, the application Long-term morbidity: The review found no evidence of petroleum jelly, enriched oil compared with on long-term outcomes. liquid wax, and a perineal protection device. These interventions are not evaluated in this framework. Birth experience: The review found no evidence on maternal satisfaction or other outcomes related to Comparison 1: Perineal massage compared with birth experience. control (“hands off” approach or usual care) Seven studies (2684 participants) from Australia, Fetal and neonatal outcomes Iran and the USA contributed data to this Perinatal hypoxia-ischaemia: The review found no comparison. In these studies, perineal massage evidence on Apgar scores less than 7 at 5 minutes. 3. EVIDENCE AND RECOMMENDATIONS in the second stage of labour was performed

139 140 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.53 women with an intact perineum after childbirth and and childbirth after perineum intact with an women of proportion the increases massage perineal If cost. main the be would training in-service which for intervention alow-cost are techniques Perineal considerations Additional found. review was No evidence Resources (164) following childbirth is damaged perineum their of when failure a sense have and depressed dismissed, devalued, may feel women that suggest trauma of perineal experiences of women’s ameta-synthesis from Findings considerations Additional (high confidence in the evidence) (23) achoice given possible, where and, interventions of nature the the about likewould to informed be women considered, being are interventions when that, shows also evidence Qualitative evidence).the in (high confidence sensitive are to needs who their professionals care health competent kind, by offered if is it particularly trauma, maythat perineal limit any technique will likely value therefore women that in evidence).the It is (high confidence process birthing the during occur morbidities) can that fetal and maternal and interventions medical (including ofevents potentially traumatic fearful are and childbirth and of labour unpredictability aware are of the women that suggest also in evidence).the Findings (highbaby confidence and mother for outcomes with good childbirth (23) care intrapartum during to women matters what at looking areview from of qualitative studies Findings Values outcome. an as trauma trauma: Birth Supervision and monitoring and Supervision Time Equipment and infrastructure Supplies Training Staff Resource indicate that most women want a normal anormal want women most that indicate Main resource requirements of perineal massage perineal of requirements resource Main The review did not include birth birth review include not did The . Description               Same as for usual care usual for as Same care usual for as same is the time so stage second the during Performed None optional jelly: petroleum e.g. Lubricant, care to usual similar Gloves: technique perineal this to how perform on training in-service and Pre-service Midwives/nurses/doctors . direct evidence on health care professionals’ views professionals’ care health on evidence direct no review qualitative systematic found also The confidence in the evidence). (very low embarrassing or uncomfortable painful, techniques these may find women contexts, other in evidence).the In (low confidence professionals care sensitive health and by kind they applied are provided trauma, limit perineal that techniques may appreciate women some contexts, certain in that, this review from suggests evidence (26) techniques massage perineal relating to women’s evidence views on direct no found childbirth and of labour experiences reviewA qualitative systematic of women’s Acceptability equity. on a positive impact have could which services, birth to facility-based use inclined more be might inLMICs women techniques, perineal simple through of labour stage second inthe perineum of the integrity the preserving to contribute could professionals care health If considerations Additional found. was equity and techniques perineal on evidence No Equity perineum. inintact increase an and tears fourth-degree third- and with reduced birth per occur might that savings cost of possible (165) suturing for need areduced and performed being episiotomies to fewer led that inepisiotomy policy a change with birth per of US$ 20.21 saving cost provider average an reported Argentina from study A 2002 to suture. required time professional care health swabs) and anaesthetics, (e.g. local materials, suture supplies with suturing associated costs the reducing care by usual cost-effective than more be logically itwould tears, fourth-degree third- and reduces , which gives an indirect indication indication indirect an gives , which . Indirect . Indirect on perineal techniques to prevent perineal trauma would suggest that there are unlikely to be any (26). concerns around feasibility. The qualitative systematic review also found Additional considerations no direct evidence on health care professionals’ In a Canadian survey of women’s views of prenatal views relating to perineal techniques (26). perineal massage (n = 684), the authors found that Indirect evidence would suggest that health care women held positive views of the technique and professionals in certain contexts may lack the would use it again in a subsequent pregnancy (166). training and/or experience to use some or all of the It is likely that women would appreciate any of perineal techniques described (very low confidence the perineal techniques if there was evidence to in the evidence). suggest they might help or limit any of the potential long-term consequences of a damaged perineum Additional considerations (dyspareunia, sexual dysfunction, urinary or faecal In a small survey of 54 Australian midwives taking incontinence). part in an RCT on perineal massage during labour (167), the author found that midwives did not always Feasibility apply the intervention for a variety of reasons, A qualitative systematic review of women’s including: (i) women found it uncomfortable; (ii) experiences of labour and childbirth found no direct labour progressed too quickly; (iii) there was fetal evidence relating to women’s views on perineal distress; (iv) they didn’t have time and (v) they techniques (26). Indirect evidence from this review felt it was intrusive. After the trial, the number of midwives who felt the technique was “definitely beneficial” increased from 8 to 15.

Table 3.54 Summary of judgements: Perineal massage compared with usual care (no perineal massage) (comparison 1)

Desirable – – – – ✓ – effects Don’t know Varies Trivial Small Moderate Large Undesirable – – – – – ✓ effects Don’t know Varies Large Moderate Small Trivial Certainty of – ✓ – – – the evidence No included Very low Low Moderate High studies Values – – – ✓ Important Possibly Probably no No important uncertainty or important important uncertainty or variability uncertainty or uncertainty or variability variability variability Balance of – – – – – – ✓ effects Don’t know Varies Favours usual Probably Does not Probably Favours care favours usual favour perineal favours perineal care massage or perineal massage usual care massage Resources – – – – ✓ – – required Don’t know Varies Large costs Moderate Negligible costs Moderate Large savings costs or savings savings Certainty – ✓ – – – of evidence No included Very low Low Moderate High of required studies resources Cost- – – – – – ✓ – effectiveness Don’t know Varies Favours usual Probably Does not Probably Favours care favours usual favour perineal favours perineal care massage or perineal massage usual care massage Equity – – – – – ✓ – Don’t know Varies Reduced Probably Probably no Probably Increased reduced impact increased Acceptability – – – – ✓ – Don’t know Varies No Probably No Probably Yes Yes Feasibility – – – – ✓ –

Don’t know Varies No Probably No Probably Yes Yes 3. EVIDENCE AND RECOMMENDATIONS

141 142 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.55 5minutes. 7at than less scores Apgar on evidence Perinatal hypoxia-ischaemia: Fetal and neonatal outcomes experience. birth related to outcomes other or satisfaction maternal experience: Birth on long-term outcomes. Long-term morbidity: low certainty. is of very suturing perineal for need Evidence on first- and second-degree tears and the 95% CI 0.60–1.23). (4 0.86, RR women, 1799 trial, episiotomyto difference no or make little probably compresses warm that suggests evidence certainty (from 9to fewer). 33 1000 fewer per Moderate- 24 as is estimated tears fourth-degree third- or on 95% CI 0.27–0.79). 0.46, RR effect absolute The (4 tears women, perineal 1799 trials, fourth-degree of third- or incidence the reduce compresses warm that indicates evidence High-certainty 0.85–1.21). 95% CI 1.02, (4 RR birth giving women, 1799 trials, after perineum an intact havingto difference no or make little compresses warm that suggests Perineal/vaginal trauma: Maternal outcomes review. inthe indetail described were not studies two other inthe provided compresses warm The stage. second inthe contractions between continually, and were applied during compresses (808 study participants), warm another In warmth. to maintain contractions between re-soaked was pad The perineum. the distended baby’sthe head once contractions during 59 applied and °C) and 45° to water (heated sterile between in warm soaked pads as were provided compresses perineal participants), warm (717 study one In comparison. to data this contributed USA the and Spain Iran, Australia, from participants) (1799 studies Four care) compared with controlor usual (“hands off” Comparison 2: Warm compress perineal Supervision and monitoring and Supervision Time Equipment and infrastructure Supplies Training Staff Resource Main resource requirements of warm perineal compresses perineal warm of requirements resource Main The review found no evidence on on evidence no review found The The review found no evidence evidence no review found The High-certainty evidence evidence High-certainty The review found no no review found The Description             Same as for usual care usual for as Same care usual for as same is the time so stage second the during Performed water warm to clean access Ready water warm and Pads technique perineal this to how perform on training in-service and Pre-service Midwives/nurses/doctors No review evidence was found. review found. was No evidence Resources (164) following childbirth is damaged perineum their of when failure a sense have and depressed dismissed, devalued, may feel women that suggest trauma of perineal experiences of women’s ameta-synthesis from Findings considerations Additional (high confidence in the evidence). achoice given possible, where and, interventions of nature the the about likewould to informed be women considered, being are interventions when that, shows also evidence Qualitative evidence).the in (high confidence sensitive are to needs who their professionals care health competent kind, by offered if is it particularly trauma, maythat perineal limit any technique will likely value therefore women that in evidence).the It is (high confidence process birthing the during occur morbidities) can that fetal and maternal and interventions medical (including ofevents potentially traumatic fearful are and childbirth and of labour unpredictability aware are of the women that suggest also Findings in evidence)the (23) (highbaby confidence and mother for outcomes with good childbirth anormal want women most that indicate care intrapartum during to women matters what at looking areview from of qualitative studies Findings Values uncertain. very largely being as assessed was evidence resulting the which women) for 64 study, (1 group with acontrol compared compresses of analysis cold aseparate review included also The considerations Additional outcome. an as trauma trauma: Birth The review did not include birth birth review include not did The . . Additional considerations appreciate techniques that limit perineal trauma, Warm compresses are a low-cost intervention for provided they are applied by kind and sensitive which supplies of pads/packs and in-service training health care professionals (low confidence in the would be the main cost. However, sterile water was evidence). In other contexts, women may find these used in at least one of the included trials, and this techniques painful, uncomfortable or embarrassing would have additional cost implications. (very low confidence in the evidence). Health care providers would need access to clean The qualitative systematic review also found no warm water, which may not be possible in some direct evidence relating to health care professionals’ low-resource settings. As warm compresses views on perineal techniques to prevent perineal reduce third- and fourth-degree tears, this practice trauma (26). should be more cost-effective than usual care, as costs associated with suturing supplies (e.g. suture Additional considerations materials, local anaesthetics, swabs) and health It is likely that women would appreciate any perineal care professional time required to suture should be techniques if there was evidence to suggest they reduced. might help or limit any of the potential long-term A 2002 study from Argentina reported an average consequences of a damaged perineum (dyspareunia, provider cost saving of US$ 20.21 per birth with sexual dysfunction, urinary or faecal incontinence). a change in episiotomy policy that led to fewer Women might plausibly perceive warm compresses episiotomies being performed and a reduced need as less uncomfortable and embarrassing than for suturing (165), which gives an indirect indication perineal massage, but no evidence on this was of possible cost savings that might occur per birth found. with reduced third- and fourth-degree tears. Feasibility Equity A qualitative systematic review of women’s No evidence on perineal techniques and equity was experiences of labour and childbirth found no direct found. evidence relating to women’s views on perineal techniques (26). Indirect evidence from this review Additional considerations would suggest that there are unlikely to be any If health care professionals could contribute to concerns around feasibility. preserving the integrity of the perineum in the The qualitative systematic review also found no second stage of labour through simple perineal direct evidence on health care professionals’ views techniques, women in LMICs might be more inclined relating to perineal techniques (26). to use facility-based birth services, which could have a positive impact on equity. Additional considerations Although it is a low-cost intervention, warm Acceptability compresses might be less feasible to implement in A qualitative systematic review of women’s settings where resources are limited, particularly if experiences of labour and childbirth found no direct warm running tap water is not available in delivery evidence relating to women’s views on perineal rooms. techniques (26). Indirect evidence from this review suggests that, in certain contexts, some women may 3. EVIDENCE AND RECOMMENDATIONS

143 144 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE makes little or no difference to the likelihood of likelihood to the difference no or little makes probably approach hands-on with the compared hands-off of the use that suggests evidence Perineal/vaginal trauma: Maternal outcomes head. fetal of the expulsion the of, control, and flexion maintain and to protect/guard perineum hands the with both perineum posterior and anterior the supporting (or involved approach on midwife the guarding) Ahands- shoulders. of the birth allow spontaneous to and otherwise, perineum or to head not the touch plan with the expulsion, of rapid incase baby’s head to the applied be could pressure light that extent to the observational and expectant generally was comparison. The hands-off (orpoised) approach to data this contributed Kingdom United the and Iran Brazil, Austria, from participants) (7317 Five studies “hands-on” approach perineum compared with Comparison 3: “Hands-off” Table 3.56 effects of Balance Values effectiveness Cost- effects Desirable the evidence of Certainty resources required of evidence of Certainty effects Undesirable required Resources Equity Acceptability Feasibility (comparison 2) compress warm no with compared compress Warm perineal judgements: of Summary No included included No No included included No Don’t know know Don’t Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know studies studies – – – – – – – – – – Moderate-certainty Varies Varies Varies Varies Varies Varies Varies Varies – – – – – – – – Favours usual usual Favours Favours usual usual Favours Large costs Large Reduced care care – – – – uncertainty or or uncertainty favours usual usual favours favours usual usual favours evidence on Apgar scores less than 7 at 5minutes. 7at than less scores Apgar on evidence Perinatal hypoxia-ischaemia: Fetal and neonatal outcomes experience. childbirth related to outcomes other or satisfaction maternal experience: Birth on long-term outcomes. Long-term morbidity: low certainty. episiotomy is and of very tears on third- and fourth-degree tears, second-degree (from 2fewer to more). 139 1000 per Evidence more 58 as estimated is effect absolute The difference. no of possibility the includes of effect estimate the 95% CI 0.99–1.77), 1.32, however, RR participants, 700 (2 trials, approach hands-on with the compared first-degreetears may increase approach off hands- the that suggests evidence Low-certainty 95% CI 0.95–1.12). 1.03, RR women, 6547 (2 trials, birth giving after perineum intact having an Important Important Moderate variability Probably Probably Probably Very low Very Very low Very reduced Trivial Large costs care care No No ✓ ✓ – – – – – – – – – uncertainty or or uncertainty favour warm warm favour favour warm warm favour compress or or compress compress or or compress Probably No Probably No Probably no no Probably usual care usual usual care usual important important Negligible Moderate variability Does not not Does Does not not Does Possibly perineal perineal perineal perineal costs or or costs savings impact Small Low Low The review found no evidence on on evidence no review found The ✓ – – – – – – – – – – The review found no evidence evidence no review found The uncertainty or or uncertainty favours warm warm favours favours warm warm favours Probably Yes Probably Yes Probably no no Probably important important Moderate Moderate Moderate Moderate variability compress compress increased Probably Probably Probably perineal perineal perineal perineal savings The review found no no review found The Small ✓ ✓ ✓ ✓ ✓ – – – – – – uncertainty or or uncertainty Favours warm warm Favours Favours warm warm Favours Large savings Large No important important No variability compress Increased compress perineal perineal perineal perineal Trivial Large High High Yes Yes ✓ ✓ ✓ – – – – – – – – Table 3.57 Main resource requirements of “hands-off” and “hands-on” perineal approaches

Resource Description Staff  Midwives/nurse/doctors Training  Pre-service and in-service training on how to perform these perineal techniques Supplies  Same as for usual care Equipment  None Time  Performed during the second stage so time is the same as for usual care Supervision and monitoring  Same as for usual care

Birth trauma: The review did not include birth Additional considerations trauma as an outcome. Perineal techniques are low-cost interventions for which in-service training would be the main cost. Values Although the evidence suggests that the hands-off Findings from a review of qualitative studies looking approach might increase first-degree perineal tears, at what matters to women during intrapartum these do not usually require suturing and are not care (23) indicate that most women want a normal associated with other poor outcomes, therefore this childbirth with good outcomes for mother and may not have cost implications. baby (high confidence in the evidence). Findings also suggest that women are aware of the Equity unpredictability of labour and childbirth and are No evidence on perineal techniques and equity was fearful of potentially traumatic events (including found. medical interventions and maternal and fetal morbidities) that can occur during the birthing Additional considerations process (high confidence in the evidence). It is If health care professionals could contribute to therefore likely that women will value any technique preserving the integrity of the perineum in the that may limit perineal trauma, particularly if it is second stage of labour through simple perineal offered by kind, competent health care professionals techniques, women in LMICs might be more inclined who are sensitive to their needs (high confidence in to use facility-based birth services, which could the evidence). have a positive impact on equity. However, from the Qualitative evidence also shows that, when evidence on effects, it is not clear whether these interventions are being considered, women perineal techniques reduce perineal trauma. would like to be informed about the nature of the interventions and, where possible, given a choice Acceptability (high confidence in the evidence). A qualitative systematic review of women’s experiences of labour and childbirth found no direct Additional considerations evidence relating to women’s views on perineal Findings from a meta-synthesis of women’s techniques (26). Indirect evidence from this review experiences of perineal trauma suggest that women suggests that, in certain contexts, some women may may feel devalued, dismissed and depressed and appreciate techniques that limit perineal trauma, may have a sense of failure when their perineum is provided they are applied by kind and sensitive damaged following childbirth (164). health care professionals (low confidence in the The quantitative evidence suggests that there may evidence). In other contexts, women may find these be little difference between these approaches; techniques painful, uncomfortable or embarrassing however, the possibility of more first-degree tears (very low confidence in the evidence). with the hands-off approach might incline some The qualitative systematic review also found no women to prefer the hands-on approach. direct evidence on health care professionals’ views relating to perineal techniques to prevent perineal Resources trauma (26). No review evidence was found. 3. EVIDENCE AND RECOMMENDATIONS

145 146 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.58 relating to women’sevidence perineal views on direct no found childbirth and of labour experiences reviewA qualitative systematic of women’s Feasibility incontinence). faecal or urinary (dyspareunia, dysfunction, sexual perineum of adamaged long-term consequences any limit potential of the or help they might suggest to evidence was if there techniques perineal the any of appreciate would is likelyIt women that considerations Additional effectiveness Cost- effects of Balance Values effects Desirable resources required of evidence of Certainty Feasibility Acceptability Equity the evidence of Certainty effects Undesirable required Resources

(comparison 3) approachSummary of judgements:compared with “Hands-off” “hands-on” approach No included included No No included included No Don’t know Don’t know know Don’t Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know studies studies ✓ – – – – – – – – – Varies Varies Varies Varies Varies Varies Varies Varies – – – – – – – – Large costs Large hands-on hands-on approach approach Reduced Favours Favours Favours Favours – – – – uncertainty or or uncertainty in the evidence).in the (very low confidence described techniques perineal all of the or to some and/ortraining use experience the may lack contexts incertain professionals care health that suggest would evidence Indirect (26) techniques views relating to perineal professionals’ care health on evidence direct no review qualitative systematic found also The feasibility. around concerns unlikely are to there any that be suggest would (26) techniques Important Important Moderate variability hands-on hands-on approach approach Probably Probably Probably Very low Very Very low Very reduced favours favours favours favours Trivial Large costs No No ✓ ✓ ✓ – – – – – – – – uncertainty or or uncertainty favour hands- favour hands- off or hands- or off off or hands- or off on approach on approach Probably No Probably No Probably no no Probably important important Negligible Moderate variability Does not not Does Does not not Does Possibly costs or or costs savings impact . Indirect evidence from this review from evidence . Indirect Small Low Low ✓ ✓ ✓ – – – – – – – – uncertainty or or uncertainty Probably Yes Probably Yes Probably no no Probably important important Moderate Moderate Moderate Moderate variability increased hands-off hands-off approach approach Probably Probably Probably savings favours favours favours favours Small ✓ ✓ ✓ ✓ – – – – – – – uncertainty or or uncertainty Large savings Large No important important No . variability Increased hands-off hands-off approach approach Favours Favours Favours Favours Trivial Large High High Yes Yes – – – – – – – – – – – Comparison 4: Ritgen’s manoeuvre compared Additional considerations with usual practice (“hands-on” approach) The review also included a comparison of another Two studies (1489 participants) from Iran and type of guiding procedure: delivery of the posterior Sweden contributed data to this comparison. A shoulder first compared with delivery of the modified Ritgen’s manoeuvre was performed in the anterior shoulder first; however, data for the review second stage of labour in the largest study (1423 outcomes were limited and the resulting evidence participants). This involved “using one hand to pull was of very low certainty. the fetal chin from between the maternal anus and the coccyx, and the other (hand placed) on the Values fetal occiput to control speed of birth”. In this study, Findings from a review of qualitative studies looking the manoeuvre was considered to be modified as at what matters to women during intrapartum it was used during a uterine contraction instead of care indicate that most women want a normal between contractions. The “standard practice” arm childbirth with good outcomes for mother and comprised using one hand to support the perineum baby (high confidence in the evidence) (23). and the other hand to control the expulsion of the Findings also suggest that women are aware of the fetal head. Standard practice was also to perform unpredictability of labour and childbirth and are selective episiotomy for certain indications not fearful of potentially traumatic events (including described in the review. medical interventions and maternal and fetal morbidities) that can occur during the birthing Maternal outcomes process (high confidence in the evidence). It is Perineal/vaginal trauma: Low-certainty evidence therefore likely that women will value any technique suggests that Ritgen’s manoeuvre may have little or that may limit perineal trauma, particularly if it is no impact on third- and fourth-degree perineal tears offered by kind, competent health care professionals (1 trial, 1423 participants, RR 1.24, 95% CI 0.78– who are sensitive to their needs (high confidence in 1.96) and episiotomy (2 trials, 1489 participants, the evidence). RR 0.81, 95% CI 0.63–1.03). The evidence on the Qualitative evidence also shows that, when likelihood of having an intact perineum and other interventions are being considered, women perineal outcomes is of very low certainty. would like to be informed about the nature of the Long-term morbidity: The review found no evidence interventions and, where possible, given a choice on long-term outcomes. (high confidence in the evidence). Birth experience: The review found no evidence on maternal satisfaction or other outcomes related to Resources birth experience. No review evidence was found.

Fetal and neonatal outcomes Additional considerations Apgar scores: The review found no evidence on Perineal techniques are a low-cost intervention for Apgar scores less than 7 at 5 minutes. which in-service training would be the main cost. Birth trauma: The review did not include birth trauma as an outcome. Equity No evidence on perineal techniques and equity was found.

Table 3.59 Main resource requirements of Ritgen’s manoeuvre

Resource Description Staff  Midwives/nurses/doctors Training  Pre-service and in-service training on how to perform this perineal technique Supplies  Similar to standard practice Equipment  None Time  Performed during the second stage so time is the same as for usual care  Probably more than with standard practice, to ensure adherence to technique Supervision and monitoring and to monitor potential adverse outcomes 3. EVIDENCE AND RECOMMENDATIONS

147 148 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE trauma (26) to prevent perineal techniques perineal views on professionals’ relating care to health evidence direct no review qualitative systematic found also The confidence in the evidence). (very low embarrassing or uncomfortable painful, techniques these may find women contexts, other in evidence).the In (low confidence professionals care sensitive health and by kind they applied are provided trauma perineal limit that techniques may appreciate women some contexts, certain in that, this review from suggests evidence (26) techniques massage perineal relating to women’s evidence views on direct no found childbirth and of labour experiences reviewA qualitative systematic of women’s Acceptability uncertain. is very manoeuvre Ritgen’s on evidence equity. However, on a positive impact effects the have could which services, birth to facility-based use inclined more be might inLMICs women techniques, perineal simple through of labour stage second inthe perineum of the integrity the preserving to contribute could professionals care health If considerations Additional . . Indirect . Indirect to understand the anatomy of the fetal head. head. fetal anatomy of the the to understand expertise obstetric or level of midwifery reasonable a demands technique of the application Appropriate considerations Additional evidence).in the (very low confidence described techniques perineal all of the or to some and/ortraining use experience the may lack contexts incertain professionals care health that suggest would evidence Indirect (26) techniques views relating to perineal professionals’ care health on evidence direct no review qualitative systematic found also The (26) techniques relating to women’sevidence perineal views on direct no found childbirth and of labour experiences reviewA qualitative systematic of women’s Feasibility techniques, such as warm compresses. perineal other than women for comfortable less be plausibly might manoeuvre Ritgen’s incontinence). faecal or urinary dysfunction, sexual (dyspareunia, perineum of adamaged consequences any limit potential long-term of the or help might they to suggest evidence was if there technique any perineal appreciate would is likelyIt women that considerations Additional . . Table 3.60 Summary of judgements: Ritgen’s manoeuvre compared with usual practice (“hands on”) (comparison 4)

Desirable – – ✓ – – – effects Don’t know Varies Trivial Small Moderate Large Undesirable ✓ – – – – – effects Don’t know Varies Large Moderate Small Trivial Certainty of – ✓ – – – the evidence No included Very low Low Moderate High studies Values – ✓ – – Important Possibly Probably no No important uncertainty or important important uncertainty or variability uncertainty or uncertainty or variability variability variability Balance of – – – – ✓ – – effects Don’t know Varies Favours usual Probably Does not Probably Favours practice favours usual favour favours Ritgen’s practice Ritgen’s Ritgen’s manoeuvre manoeuvre or manoeuvre usual practice Resources – – – – ✓ – – required Don’t know Varies Large costs Moderate Negligible Moderate Large savings costs costs or savings savings Certainty ✓ – – – – of evidence No included Very low Low Moderate High of required studies resources Cost- – – – – – – – effectivenessa Don’t know Varies Favours usual Probably Does not Probably Favours practice favours usual favour favours Ritgen’s practice Ritgen’s Ritgen’s manoeuvre manoeuvre or manoeuvre usual practice Equity – – – – ✓ – – Don’t know Varies Reduced Probably Probably no Probably Increased reduced impact increased Acceptability ✓ – – – – – Don’t know Varies No Probably No Probably Yes Yes Feasibility – – – ✓ – – Don’t know Varies No Probably No Probably Yes Yes a The cost-effectiveness domain was not judged because the desirable effects of the intervention were trivial. 3. EVIDENCE AND RECOMMENDATIONS

149 150 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE from 51% to 100% (median 83%). to 51% from 100% they ranged episiotomy groups liberal or routine to 8% from 59% (median 32%),ranged inthe and episiotomy rates episiotomy groups, selective the In 30%. than less of adifference trials reporting three with to 21% 91%, from trials varied inthe groups study the episiotomybetween in rates Differences women. parous and nulliparous both trials included only, women four and nulliparous trials included trial each). (1 Seven Kingdom United the and Spain Arabia, Saudi Pakistan, Malaysia, Germany, Ireland, (2 trials), in Argentina Colombia, conducted Canada, were to trials 11 relevant this recommendation The this recommendation. for considered were not and review inthe separately this trial werefrom analysed data birth; vaginal instrumental undergoing women trial involved One anticipated. was birth a vaginal whom for inlabour were women participants trials, 12 RCTs reviewsystematic included that (168) aCochrane from derived was evidence The intervention (EB the of 3.3.7) Effects Table ofSummary evidence and considerations 3.3.7     Remarks (Notbirth. recommended) vaginal spontaneous undergoing women for recommended not is episiotomy of use liberal or Routine RECOMMENDATION 39    

measures should be respected at all times (114) all times at respected be should measures control infection general as antibiotics, of prophylactic use routine the warrant not do Episiotomies (168) suturing to interrupted preferred (OASI). is injury technique suturing sphincter anal obstetric Acontinuous of risk complex a higher with associated are incisions midline as incision, is amedio-lateral technique preferred The essential. is consent the woman’sand informed anaesthesia local effective episiotomy an If is performed, to established. remains be birth, vaginal instrumental requiring distress fetal as such of episiotomy emergencies, inobstetric Therole rate “acceptable” of an episiotomydetermine. to is and difficult episiotomy care, inroutine any for need the corroborating evidence is no there time, present the at that, acknowledged GDG The of episiotomy. use selective/restrictive the recommending than rather recommended”, of episiotomy use is “not to routine/liberal that emphasize important was it that felt GDG the settings, all episiotomy excessive of the routine across to use discourage need the and of episiotomy ingeneral, effectiveness the on episiotomy policy, of evidence lack the with routine/liberal compared restrictive selective/ of effects of episiotomy, use to beneficial the due routine/liberal versus selective/restrictive as presented episiotomy was of policies effects comparative review on the evidence Although Episiotomy policy . . In 11 11 . In . evidence uncertain. uncertain. evidence episiotomy repair,may have the included making however,95% CI 0.58–0.78); trials insome data the episiotomy repair) 0.68, RR (6 women, 4333 trials, (excluding suturing perineal for need the may reduce episiotomy Aselective/restrictive policy uncertain. is very evidence the but women, in multigravid trauma perineal/vaginal to make adifference not might episiotomy the that policy suggests evidence). by analysis parity Subgroup certainty moderate- 95% CI 0.38–0.81; 0.55, RR women, (8 4877 were trials, included arms study between episiotomy in rate difference 30% than a larger trials with the only when increased impact The 0.70, RR 95% 6177 CI women, trials, 0.52–0.94). episiotomy (11 liberal or with routine compared tears) (mainlytrauma fourth-degree third- and severeepisiotomy perineal/vaginal may reduce of selective/restrictive apolicy that suggests morbidity: Short-term Maternal outcomes episiotomy compared with routine liberal or of use selective/restrictive of Policy Comparison: Low-certainty evidence evidence Low-certainty Low-certainty evidence suggests that selective/ The review did not evaluate any other outcomes restrictive episiotomy may have little or no effect on according to the type of incision. perineal infection (3 trials, 1467 women, RR 0.90, At the present time, there is no evidence 95% CI 0.45–1.82). Evidence on relative blood loss corroborating the need for episiotomy in any at birth is very uncertain. situation. One small clinical trial (237 women) Long-term morbidity: For long-term morbidity at has published findings on the effects of selective/ 6 months or more after childbirth, low-certainty restrictive use of episiotomy compared with no evidence suggests there may be little or no effect episiotomy and reported no difference with respect of selective/restrictive versus routine or liberal to any maternal and perinatal outcomes (169). There episiotomy on dyspareunia (pain during intercourse) is an ongoing trial of selective/restrictive episiotomy (3 trials, 1107 women, RR 1.14, 95% CI 0.84–1.53). compared with no episiotomy, with a target sample Evidence on other long-term morbidity is sparse size of 6006 women. and very uncertain (urinary incontinence, genital prolapse), or lacking (faecal incontinence, sexual Values dysfunction). Findings from a review of qualitative studies looking Duration of the second stage of labour: The review at what matters to women during intrapartum did not report this outcome. care indicate that most women want a normal childbirth with good outcomes for mother and baby, Use of pain relief options: Use of pain relief but acknowledge that medical intervention may options was not reported in the review but low- sometimes be necessary (high confidence in the certainty evidence suggests there may be little or evidence) (23). no difference between selective/restrictive and routine or liberal episiotomy on perineal pain 10 days Women are scared of interventions like episiotomy after birth (1 trial, 2587 women, RR 1.00, 95% CI (high confidence in the evidence), so they will 0.78–1.27). invariably feel more anxious when they are introduced. However, in certain countries (e.g. Birth experience: According to the review, outcomes Brazil) where episiotomy is liberally practised, there related to maternal birth experience, such as may be an expectation that its use will facilitate an maternal satisfaction, were not reported in the trials. easier birth (low confidence in the evidence).

Fetal and neonatal outcomes When an episiotomy is indicated, women would like to receive relevant information about it, and for Perinatal hypoxia-ischaemia: Evidence on low it to be performed by technically competent health Apgar scores (< 7 at 5 minutes) is of very low care providers who are sensitive to their needs (high certainty, mainly because the sample size is small (2 confidence in the evidence). trials, 511 babies) and no events occurred in either comparison group. Additional considerations Birth trauma: Birth trauma was not reported in the Given that a policy of selective/restrictive use review. of episiotomy is associated with less maternal morbidity than liberal use of episiotomy, it is unlikely Additional considerations that there is important uncertainty or variability in The evidence on severe perineal/vaginal trauma how much women value the outcomes related to was derived mainly from trials employing a medio- episiotomy policies, as it stands to reason that most lateral incision technique. Two trials involving 1143 women would prefer not to sustain severe perineal women employed a midline episiotomy incision and or vaginal trauma. statistical tests employed in the review suggest that the overall effect on perineal/vaginal trauma for this Resources subgroup of trials is not different from medio-lateral No review evidence on the relative cost and cost- incisions. However, the individual trials of midline effectiveness of these policies was found. However, incisions produced inconsistent results. In addition, a 2002 study from Argentina found that, for severe perineal/vaginal trauma occurred more each low-risk vaginal birth, there was a potential frequently in the trials of midline incisions than in average reduction in provider cost of US$ 20.21 and trials of medio-lateral incisions (106/1143 [9%] vs US$ 11.63, in two Argentinian provinces (170). This 58/4834 [1%], respectively), suggesting that medio- seems plausible, based on the effects evidence, lateral incisions are safer than midline incisions. 3. EVIDENCE AND RECOMMENDATIONS

151 152 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE LMICs (moderateLMICs confidence in the evidence) (8) in women by disadvantaged birth of facility-based uptake to the barrier asignificant this is probably episiotomy) and section and workers by health (caesarean of cutting” have a“fear women many that indicates birth to facility-based facilitators and areview from of barriers evidence indirect However, found. was equity on episiotomy policies different of the impact of the evidence direct No Equity profits for practitioners. financial to over-medicalization ensuring on based of episiotomy linked use may be liberal or Routine (172) performed episiotomy been which has in births for costs birth additional incur women where episiotomy insettings liberal or with routine lower compared with selective/restrictive be also Out-of-pocket might women to individual costs episiotomy policies. liberal or with routine compared lower with selective/restrictive be also logically would complications, with associated episiotomy for repair, those equipment and and etc.) analgesics, agents, anaesthetic materials, (suture supplies to medical due costs, Other (171) respectively minutes, 25 and is 21 sutures interrupted or episiotomy an suture with continuous to required average time the that suggest methods episiotomy review repair evaluating different aCochrane from Findings saving. cost important with episiotomy repair.associated an be might This time provider less means Fewer procedures considerations Additional reduced. be might morbidity maternal and performed are feweras procedures Table 3.61 Training Resource Supplies Equipment Time monitoring and Supervision Main resource requirements for episiotomy for requirements resource Main Description                 how to repair an episiotomy an tohow repair episiotomy, and of restrictive apolicy to how in apply training practice-based 1–2 weeks Syringe/needle/swabs = US$ 0.08 (31) =US$ 0.08 Syringe/needle/swabs Lidocaine (31) = US$ 0.34 thread per =US$ 2.25 [171]) technique and extent on episiotomy, per depending polyglycol absorbable (1–3 packets material Suture Equipment maintenance Equipment scissors) holders, stitch (forceps, instruments sterilizers, lighting, Appropriate factors, such as extent of incision, provider skills, supplies, etc. supplies, skills, provider of incision, extent as such factors, respectively) (171) sutures, interrupted (continuous or of method type the on depending closure, wound episiotomy each for is 21–25 minutes needed Average time Regular supervision and review lead by ward/clinic/facility and supervision Regular . . . are prevalent in LMICs and in the treatment of treatment inthe and inLMICs prevalent are 178–181) (173, consent asked to not give informed often are and interventions for reasons of and risks the about informed not often are settings Women in LMIC equity. on positive impact with a women, relative towomen advantaged more of disadvantaged experience improve childbirth the differentially could settings episiotomy inthese (177) facilities with private-sector episiotomy compared to excessive of employ use reported have been facilities care health public inBrazil, example, in episiotomy (176) exist coverage also 175)(174, stage with transition obstetric increasing practices birth interventionist more and with medicalization might be a symptom of the obstetric transition, obstetric of the asymptom be might (173) countries in middle-income episiotomy occur rates highest of the some that suggests practices A review of evidence-based women. disadvantaged coverage among birth facility-based increasing by equity health on havemight apositive impact episiotomy,of selective/restrictive intervention the policy communicated of cutting”, with aclearly “fear (33) women advantaged more the than outcomes health worse coverage and have intervention areas lower health inrural residing and poor, are educated who least women that indicates WHO’s State report 2015 of inequality considerations Additional 1 in direct obstetric causes of mortality. of causes obstetric direct in reductions through mortality to maternal low mortality maternal high of patterns from shift they as countries of trend asecular of concept the is transition Obstetric . Therefore, employing a restrictive policy of policy arestrictive employing . Therefore, . Significant within-country differences differences within-country . Significant . Non-consented, invasive procedures invasive procedures . Non-consented, . Therefore, by reducing the the by reducing . Therefore, . This overuse overuse . This . For . For and other other and 1 disadvantaged pregnant women globally. Therefore, Additional considerations clinical protocols and provider training on episiotomy Reluctance to change established behaviour in some should emphasize the need for informed consent, to settings might be financially motivated: a study of ensure that women’s human rights are respected. health care provider practice in Cambodia found that providers performed episiotomies to justify charging Acceptability women a higher fee (172). From the above evidence, In a qualitative systematic review exploring women’s it seems that most women would find selective/ and providers’ views and experiences of intrapartum restrictive episiotomy more acceptable than routine care, women felt they were poorly informed about or liberal episiotomy. the reasons for performing an episiotomy and were Acceptability among providers, in LMIC settings rarely asked for their permission (high confidence where episiotomy is routinely practised, might vary. in the evidence) (26). Review findings suggest that women preferred to minimize the level of pain Feasibility experienced from cutting and stitching, as well as the levels of discomfort experienced following Findings from a qualitative systematic review episiotomy (high confidence in the evidence). In exploring women’s and providers views and addition, they may be ill-prepared for the pain experiences of intrapartum care suggest that a associated with the procedure or the potential practice of selective/restrictive episiotomy would short- and long-term consequences (perineal be easier to implement, especially in settings discomfort, difficulty performing normal day-to-day where resources may be limited (high confidence activities, aesthetic deformities, effect on sex life) in the evidence) (26). However, in certain contexts, (low confidence in the evidence). In some instances, staff may have limited access to current research women felt that their concerns were ignored or evidence (because of resource constraints) and dismissed by staff, whom they perceived to be rude subsequently have no clear policies or protocols to and insensitive (low confidence in the evidence). guide practice in this area (high confidence in the evidence). As a result, clinical practice is based on The review findings also suggest that in certain established, hierarchical, unwritten “rules” and/ countries (e.g. Brazil) women might hold the belief or competence in performing the procedure (high that an episiotomy facilitates a smoother birth confidence in the evidence). (shorter labour, less pain) (low confidence in the evidence). This may be based on an established Additional considerations cultural acceptance of the procedure, largely Findings from a cluster RCT conducted in Mexico generated by health care providers (low confidence and Thailand of a multifaceted educational strategy in the evidence). to promote the use of the WHO Reproductive Health Review findings also showed that staff were Library (RHL) on obstetric practices, including generally aware of the recommendations for promotion of selective/restrictive over routine selective/restrictive use of episiotomy, but in some or liberal episiotomy, showed that implementing regions (South America, the Middle East, South-East selective/restrictive episiotomy was feasible in Asia) they were reluctant to change established Thailand and led to a reduction in episiotomy rates behaviour, particularly for primigravid women, (182). where episiotomy was practised routinely (high Shifting from a policy of routine or liberal to confidence in the evidence). For primigravid women selective/restrictive use of episiotomy will require a in these contexts, staff felt that an episiotomy was change in organization culture, training, monitoring safer, more easily managed (by them) than a tear, and continuous clinical practice audit. and facilitated an “easier” birth (for them) (high confidence in the evidence). 3. EVIDENCE AND RECOMMENDATIONS

153 154 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.62 effectiveness Cost- effects of Balance Values Feasibility Equity resources required of evidence of Certainty the evidence of Certainty effects Desirable Acceptability required Resources effects Undesirable routine/liberal use of episiotomy routine/liberal with compared episiotomy selective/restrictive of Policy judgements: of Summary No included included No No included included No Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know studies studies – – – – – – – – – – Varies Varies Varies Varies Varies Varies Varies Varies ✓ – – – – – – – liberal policy liberal Large costs Large episiotomy Reduced routine/ Favours Favours Favours routine routine – – – – uncertainty or or uncertainty liberal policy liberal liberal policy liberal Important Important Moderate variability Probably Probably Probably Very low Very Very low Very routine/ routine/ reduced favours favours favours favours Trivial Large costs No No – – – – – – – – – – – uncertainty or or uncertainty liberal policy liberal liberal policy liberal Probably No Probably No Probably no no Probably or routine/ or routine/ selective / selective selective / selective restrictive restrictive restrictive restrictive important important Negligible Moderate variability Does not not Does Does not not Does Possibly costs or or costs savings impact favour favour favour favour Small Low Low ✓ ✓ – – – – – – – – – uncertainty or or uncertainty Probably Yes Probably Yes Probably no no Probably selective/ selective/ restrictive restrictive restrictive restrictive important important Moderate Moderate Moderate Moderate variability increased Probably Probably Probably savings favours favours favours favours policy policy Small ✓ ✓ ✓ ✓ ✓ ✓ ✓ – – – uncertainty or or uncertainty Large savings Large No important important No selective/ selective/ restrictive restrictive restrictive restrictive variability Increased Favours Favours Favours Favours Trivial policy policy Large High High Yes Yes ✓ – – – – – – – – – - 3.3.8 Fundal pressure

RECOMMENDATION 40

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

Remarks

 The GDG had serious concerns about the potential for harm to mother and baby with this procedure.  The panel is aware of an ongoing trial, the Gentle Assisted Pushing (GAP) trial (183), which could help to provide important evidence on the effects of applying fundal pressure according to a specific protocol.

Summary of evidence and considerations Mortality: This outcome was not assessed in the studies. Effects of the intervention (EB Table 3.3.8) The evidence was derived from a Cochrane Morbidity: Low-certainty evidence suggests that systematic review that included nine trials involving fundal pressure compared with no fundal pressure 3948 women (184). Five trials (3057 women) may have little or no effect on PPH (1 trial, 110 conducted in India, Iran, South Africa and Turkey women, RR 1.87, 95% CI 0.58–6.06). Evidence on (2 trials) evaluated manual fundal pressure in the effect of fundal pressure on soft tissue damage women with low-risk pregnancies compared with no (vagina, perineum or ) is very uncertain, fundal pressure. Four trials (891 women) conducted mainly due to sparse data. Low-certainty evidence in Italy, Republic of Korea (2 trials) and the United suggests that applying fundal pressure may make Kingdom evaluated fundal pressure by means of an little or no difference to episiotomy rates compared inflatable belt compared with no fundal pressure. For with no fundal pressure (1 trial, 317 women, RR 1.18, the purposes of this guideline, only the evidence on 95% CI 0.92–1.50). The outcome “severe maternal manual fundal pressure was considered, as the use morbidity or death” was not reported in any of the of inflatable belt devices has not progressed beyond trials. research settings. Birth experience: The trials did not report maternal Manual fundal pressure was applied according to satisfaction; however, low-certainty evidence the Kristeller manoeuvre in four trials, and as “gentle suggests that women receiving manual fundal assisted pushing” (see Additional considerations) pressure may experience more pain after birth in one small trial (120 women); two of these trials (assessed in terms of analgesic requirements) than recruited primigravid women only. One trial limited those not receiving fundal pressure (1 trial, 209 the application of fundal pressure to three attempts. women, RR 4.54, 95% CI 2.21–9.34). Most of the included trials had design limitations. Fetal and neonatal outcome Comparison: Manual fundal pressure compared Birth trauma: Evidence on birth trauma, including with no fundal pressure fractures and haematomas, is of very low certainty Maternal outcomes due to sparse data (small sample, no events). Mode of birth: Evidence on the relative effects on Perinatal hypoxia-ischaemia: Evidence on low caesarean section and instrumental birth rates is of arterial cord pH and Apgar score less than 7 at 5 very low certainty. minutes is of very low certainty. Duration of the second stage of labour: Evidence on Perinatal mortality: No neonatal deaths occurred the duration of the second stage of labour is of very in the comparison groups (2 trials, 2445 neonates), low certainty. Low-certainty evidence on the failure therefore evidence on neonatal death is of very low of women to give birth spontaneously within a time certainty. frame specified by the authors suggests that there may be little or no difference between manual fundal Additional considerations pressure and no fundal pressure (1 trial, 110 women, Concerns relating to the practice of fundal pressure

RR 0.96, 95% CI 0.71–1.28). 3. EVIDENCE AND RECOMMENDATIONS are due to the possibility that serious harm might

155 156 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Table 3.63 sometimes be necessary. Most women, especially may intervention medical that acknowledge but baby, and mother for outcomes with good childbirth (23) care intrapartum during to women matters what at looking areview from of qualitative studies Findings Values outcomes. improve birth can pressure of fundal form agentler not or whether will establish women, this involving that trial, 1145 hope investigators The (whichever seconds 30 or is shorter).contraction of each duration full the for pressure the maintain to is required professional care health The weight. body additional to not apply and forearms of her strength the to only care use taking pelvis, the of direction inthe hands, of her palms with the pressure” fundal “steady firm applies professional care health the whereby pushing” “gentle assisted (183) posture upright in an woman pregnant with the is applied which pressure, to of fundal Africa evaluate technique anew South way in under trial is multicentre currently A large stage. research the beyond have devices progressed not belt Inflatable 15.69, RR 95% CI 2.10–117.02). women, 500 trial, (1 tear) pressure degree fundal with no compared (third- damage sphincter anal increases probably belt by inflatable an pressure fundal that suggests evidence moderate-certainty resultant The belts. inflatable on studies review included also The are applied. pressure of fundal techniques other where settings to applicable is not elbows); evidence the therefore, or forearms not (i.e. hands attendants’ birth with the trials applied was included inthe pressure Fundal literature. inthe reported be often not however, might death; perinatal occurrences these and maternal and rupture, organ other and uterine 186) (185, force of excessive uncontrolled application the from baby the or mother inthe arise monitoring and Supervision Time Equipment Supplies Training Staff Resource indicate that most women want a normal anormal want women most that indicate Main resource requirements for fundal pressure application pressure fundal for requirements resource Main Description             to fundal pressure protocol and to monitor safety to monitor and protocol pressure to fundal adherence to ensure review lead by ward/clinic/facility and audit supervision, Regular procedure of the duration the on depending vary would and is needed attendant birth skilled additional of an time The required None required None pressure fundal apply to how safely on training Practice-based pressure fundal apply howsafely in to trained Staff . The technique is called is called technique . The , including , including the absence of specific evidence on fundal pressure, pressure, fundal on evidence of specific absence the However, women. in by disadvantaged facilities care to of by health low use contributing equity on impact have might anegative intervention the practice, undesirable and unfamiliar an pressure fundal consider women if disadvantaged above, evidence (33) women advantaged more the than outcomes health worse coverage and have intervention areas lower health inrural residing and poor, are educated who least women that indicates WHO’s State report 2015 of inequality considerations Additional evidence)the (8) in (high confidence inLMICs women disadvantaged by birth to uptake of the facility-based barrier important an are positions, birth unfamiliar as such infacilities, workers by health practices birth undesirable and unfamiliar that indicates birth based to facility- facilitators and areviewfrom of barriers However, found. was evidence equity indirect on pressure of fundal impact of the evidence direct No Equity practice. of this effectiveness cost- or costs the on evidence is no There Resources in evidence).the (high confidence interventions of use the around to involved be indecision-making like would and process birth ofto their incontrol be desire women showthat also evidence). Findings in the (high confidence sensitive to needs their are who professionals care health competent like technically from to information receive relevant would women introduced, are interventions When in evidence).the (low pain relief from confidence provide or labour to shorten interventions welcome and/or contexts women situations in certain although interventions, medical of some fearful and in evidence)the (high confidence childbirth about apprehensive are time, first the for birth giving those . . Based on the research research the on . Based the converse could also be true. Findings from authors of a qualitative study conducted in Guinea a study conducted in a rural population in India found that health care providers were using extreme suggest that fundal pressure might be a desirable force when pushing on the fundus (41). Women part of some traditional birth practices (187). found this disturbing, painful and tantamount to . In many settings where fundal pressure is used, women might not be given adequate information In a study in rural India (187), the authors found about the procedure and might not be asked that fundal pressure was being used routinely, for their consent. If non-consented, or applied often beginning in early labour, to the extent that indiscriminately and with excessive force, applying the practice often left providers feeling exhausted. fundal pressure could be considered an abuse of a The authors did not discuss women’s experiences woman’s human rights. but noted that babies were sometimes injured as a consequence of the procedure. Acceptability There is no specific evidence on receiving or Feasibility applying fundal pressure in a qualitative systematic There is no specific evidence on fundal pressure review on women’s and providers’ views and in a qualitative systematic review on women’s and experiences of intrapartum care (26). However, health care professionals’ views and experiences general findings from this document suggest that of intrapartum care (26). However, findings from women would rather avoid this type of procedure the review suggest that staff in certain contexts unless their baby is at risk (high confidence in the may lack the time, the training or the resources to evidence). They would also like to be cared for use fundal pressure in a competent and sensitive by competent, skilled and sensitive health care manner (moderate confidence in the evidence). professionals (high confidence in the evidence) and, even though they would prefer to have a quick Additional considerations labour (low confidence in the evidence), they would, Use of uncontrolled fundal pressure application where possible, like to remain in control of their appears to be prevalent in a variety of settings (118, labour and childbirth processes (high confidence in 173, 184–190), and it might not be feasible to ensure the evidence). that health care professionals deliver fundal pressure in a consistent, standardized and controlled way. Additional considerations The birth attendant needs assistance from another As part of a recent global initiative looking at how health care professional to perform this procedure. women are treated during labour and childbirth, the 3. EVIDENCE AND RECOMMENDATIONS

157 158 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE

Table 3.64 Feasibility Acceptability Equity effectiveness Cost- resources required of evidence of Certainty effects Undesirable effects Desirable required Resources Values evidence the of Certainty effects of Balance Summary of judgements: Fundal pressure compared with no fundal pressure fundal no with compared pressure Fundal judgements: of Summary No included included No No included included No Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know Don’t know know Don’t studies studies ✓ ✓ – – – – – – – – Varies Varies Varies Varies Varies Varies Varies Varies – – – – – – – – Large costs Large no fundal fundal no no fundal fundal no Reduced pressure pressure Favours Favours Favours Favours – – – – uncertainty or or uncertainty Important Important Moderate variability no fundal fundal no no fundal fundal no Probably Probably Very low Very Probably Very low Very pressure pressure reduced favours favours favours favours Trivial Large costs No No ✓ ✓ ✓ ✓ – – – – – – – uncertainty or or uncertainty favour fundal fundal favour favour fundal fundal favour Probably No Probably No Probably no no Probably pressure or or pressure pressure or or pressure Negligible important important Moderate variability no fundal fundal no no fundal fundal no Does not not Does Does not not Does pressure pressure Possibly costs or or costs savings impact Small Low Low ✓ ✓ ✓ ✓ – – – – – – – favours fundal fundal favours favours fundal fundal favours uncertainty or or uncertainty Probably Yes Probably Yes Probably no no Probably important important Moderate Moderate Moderate Moderate variability increased Probably Probably Probably pressure pressure savings Small ✓ – – – – – – – – – – uncertainty or or uncertainty Large savings Large No important important No variability Increased pressure pressure Favours Favours Favours Favours fundal fundal fundal fundal Trivial Large High High Yes Yes – – – – – – – – – – – 3.4 Third stage of labour 3.4.1 Prophylactic uterotonics

RECOMMENDATION 41

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

RECOMMENDATION 42

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

RECOMMENDATION 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. (Recommended)

Remarks

 These recommendations have been integrated from the WHO recommendations for the prevention and treatment of postpartum haemorrhage (191), in which the GDG for that guideline determined them to be strong recommendations based on moderate-quality evidence.  Available comparisons are limited, but a significant difference between the benefits of oxytocin and ergometrine is unlikely. These recommendations place a high value on avoiding the adverse effects of ergometrine and assume a similar benefit from using oxytocin and ergometrine for the prevention of PPH.  Caution should be exercised when opting for ergot derivatives for the prevention of PPH as these drugs have clear contraindications in women with hypertensive disorders. Thus, it is probably safer to avoid the use of ergot derivatives in unscreened populations.  Oral misoprostol (600 µg) was regarded by the GDG as an effective drug for the prevention of PPH. However, the GDG considered the relative benefits of oxytocin compared to misoprostol in preventing blood loss, as well as the increased adverse effects of misoprostol compared to oxytocin. The GDG acknowledged that there is no evidence to show that a 600-µg dose of misoprostol provides greater efficacy over a 400-µg dose. Lower doses have a lower side-effect profile but the efficacy of lower doses of misoprostol has not been evaluated sufficiently.  The recommendations concerning alternative uterotonics should not detract from the objective of making oxytocin as widely accessible as possible.  In view of past concerns regarding the community-level distribution of misoprostol and the potential for serious consequences of administration before birth, the GDG places emphasis on training persons administering misoprostol and monitoring community distribution interventions with scientifically sound methods and appropriate indicators.  The evidence supporting these recommendations can be found in the source guideline document, available at: http://apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf 3. EVIDENCE AND RECOMMENDATIONS

159 160 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE 3.4.4  Remarks (Recommended) outcomes. nutrition and health infant and maternal improved for recommended is birth) after 1minute than (not earlier clamping cord umbilical Delayed RECOMMENDATION 44        maternal and infant health and nutrition outcomes improved for cord delayed clamping WHOGuideline: the from integrated been has recommendation This it to be a strong recommendation based on moderate-quality evidence. evidence. moderate-quality on based recommendation toit astrong be available at: http://apps.who.int/iris/bitstream/10665/148793/1/9789241508209_eng.pdf document, guideline source inthe found be can this recommendation supporting evidence The status. HIV with unknown women or living with HIV women even among is recommended cord clamping Late harms. unproven, and theoretical, the 1–3 outweigh of a cord the delay,minute in clamping proven the benefits least, at Thus, blood). to maternal circulation is exposed newborn the separation placental isit unlikely during that circulation (i.e. placental fetal the unlikely is it disrupts highly it that and blood, to maternal exposure increases of the unlikely is highly separation delivery.It that before transmission fetal with arelatively low of risk maternal– pregnancy throughout space intervillous placental the through percolates blood Maternal to newborn. the mother the from transmission of HIV possibility the increases cord clamping delaying that evidence is no There period. postnatal and childbirth pregnancy, during of antiretroviral use the drugs through load viral of maternal reduction is the transmission child maternal-to- the to reduce intervention main the infection). this For reason, (postnatal breastfeeding transmission), during and (intrapartum deliveries invaginal canal birth the through passes fetus the when secretions vaginal and transmission), HIV blood to (intrauterine maternal exposure pregnancy during fetus to the blood maternal of micro-transfusions in time: points different three at place take mother-to-child potential for the can that of HIV transmission demonstrated baby. been has It to the blood of maternal to amicro-transfusion lead this could and blood to maternal exposed be could placenta detached apartially separation, placental during that concerned are professionals of third labour. of the stage These of management part as cord clamping delayed regarding concern have prevalence expressed HIV of high inareas working professionals care health Some care. newborn provision the of essential during performed be should cord clamping Delayed Delayed umbilical cord clamping cord umbilical Delayed (192) , in which the GDG for that guideline determined determined guideline that for GDG the , inwhich 3.4.6 Controlled cord traction (CCT)

RECOMMENDATION 45

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)

Remarks

 This recommendation has been integrated from the WHO recommendations for the prevention and treatment of postpartum haemorrhage (191), in which the GDG for that guideline determined it to be a strong recommendation based on moderate quality evidence.  This recommendation is based on a large RCT in which oxytocin 10 IU was used for the prevention of postpartum haemorrhage (PPH) in all participants. Based on this evidence, CCT was regarded as safe when applied by skilled birth attendants as it provides small beneficial effects on blood loss (average reduction in blood loss of 11 ml) and on the duration of the third stage of labour (average reduction of 6 minutes). The care provider should discuss the decision to implement CCT in the context of a prophylactic uterotonic drug with the woman.  If ergot alkaloids are used for the prevention of PPH, then CCT to minimize placenta retention is regarded as essential.  There is insufficient evidence to determine the benefits or risks of CCT when used in conjunction with misoprostol.  CCT is the first intervention to treat retained placenta; therefore, the teaching of CCT in medical and midwifery curricula is essential.  Based on the most recent evidence, understanding about the contribution of each component of the active management of the third stage of labour package has evolved. The GDG considered that this package has a primary intervention: the use of a uterotonic. In the context of oxytocin use, CCT may add a small benefit, while uterine massage may add no benefit for the prevention of PPH. Early cord clamping is generally contraindicated.  The evidence supporting this recommendation can be found in the source guideline document, available at: http://apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf 3. EVIDENCE AND RECOMMENDATIONS

161 162 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE 3.5.1 3.5 3.4.7    Remarks of the mouth and nose should (Not not be performed. recommended) In neonates born through clear amniotic fluid who breathing start on their suctioningown birth, after RECOMMENDATION 47      Remarks (Not recommended) oxytocin. prophylactic have received who (PPH) women in haemorrhage postpartum to prevent intervention an as recommended not is massage uterine Sustained RECOMMENDATION 46         available at: http://apps.who.int/iris/bitstream/10665/75157/1/9789241503693_eng.pdf document, guideline source inthe found be can this recommendation supporting evidence The were noted. remarks further No evidence. high-quality (193) WHO the from Guidelines integrated on basic been has newborn resuscitation recommendation This available at: http://apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf document, guideline source inthe found be can this recommendation supporting evidence The contraindicated. is generally clamping cordEarly preventionthe PPH. for of benefit no mayadd massage uterine while benefit, asmall add CCT may use, of oxytocin context the In of auterotonic. use the intervention: aprimary has package this that considered GDG evolved. The has package of third labour of the stage management active of the component of each contribution the about understanding evidence, recent most the on Based diagnosis. PPH of early optimization the for particularly care, postpartum of immediate part acrucial remains assessment tone uterine frequent However,and routine that considered GDG the benefits. other supporting evidence robust of is lack there uterotonics, of additional use inthe with areduction were associated expulsion clot and massage uterine sustained that reported study small one that acknowledged GDG the Although is used. oxytocin than if other auterotonic or drug used, are uterotonic drugs no prevention when PPH for massage of role uterine the regarding of evidence is alack There conditional recommendation based on low-quality evidence. treatment of postpartum haemorrhage WHO the from recommendations integrated been has for the prevention recommendation This and Care of thenewborn Routine nasal or oral suction oral or nasal Routine Uterine massage Uterine , in which the GDG for that guideline determined it to be a strong recommendation based on on based recommendation to it astrong be determined guideline that for GDG the , inwhich (191) , in which the GDG for that guideline determined itto a be determined guideline that for GDG the , inwhich

3.5.2 Skin-to-skin contact

RECOMMENDATION 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. (Recommended)

Remarks

 This recommendation has been integrated from the WHO Recommendations for management of common childhood conditions: evidence for technical update of pocket book recommendations (194), in which the GDG for that guideline determined it to be a strong recommendation based on low-quality evidence.  No further remarks were noted.  The evidence supporting this recommendation can be found in the source guideline document, available at: http://apps.who.int/iris/bitstream/10665/44774/1/9789241502825_eng.pdf

3.5.3 Breastfeeding

RECOMMENDATION 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. (Recommended)

Remarks

 This recommendation has been integrated from the WHO recommendations on newborn health (195). The evidence supporting this recommendation can be found in the WHO guidelines on optimal infant feeding for low infants in low- and middle-income countries (196). This recommendation was determined to be a strong recommendation based on low-quality evidence.  No further remarks were noted.  The source and the evidence supporting this recommendation can be found in the above-mentioned guideline documents, which are available, respectively, at: http://apps.who.int/iris/bitstream/10665/259269/1/WHO-MCA-17.07-eng.pdf and http://www.who.int/maternal_child_adolescent/documents/9789241548366.pdf 3. EVIDENCE AND RECOMMENDATIONS

163 164 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE 3.5.4 3.5.5    Remarks a day. (Recommended) hats/caps. The mother and baby should not be separated and should stay in the same room 24 hours of use and adults, than more clothes of layers to two one means This recommended. is temperature ambient for baby the of clothing Appropriate hours. six least at for delayed be should bathing reasons, to cultural due possible not is this If birth. after 24 hours until delayed be should Bathing RECOMMENDATION 51    Remarks initiated). (Recommended) by which the infant should be in skin-to-skin contact with the mother and breastfeeding should be hour first the after (i.e. birth after Kintramuscularly vitamin of 1mg given be should newborns All RECOMMENDATION 50      

recommendation based on GDG consensus. available at: http://apps.who.int/iris/bitstream/10665/97603/1/9789241506649_eng.pdf document, guideline source inthe found be can this recommendation supporting evidence The were noted. remarks further No mother and newborn of care the postnatal on WHOrecommendations the from integrated been has recommendation This available at: http://apps.who.int/iris/bitstream/10665/44774/1/9789241502825_eng.pdf document, guideline source inthe found be can this recommendation supporting evidence The were noted. remarks further No evidence. quality moderate- on based recommendation to it astrong be determined guideline that for GDG the which (194) evidence conditions: technical for recommendations of update pocket childhood book common WHO the from Recommendations integrated been has for management of recommendation This Haemorrhagic disease prophylaxis K usingvitamin disease Haemorrhagic Bathing and other postnatal care of the newborn (197) , in which the GDG for that guideline determined it to be a strong situational situational to it astrong be determined guideline that for GDG the , inwhich , in 3.6 Care of the woman after birth 3.6.1 Uterine tonus assessment

RECOMMENDATION 52

Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women. (Recommended)

Remarks

 This recommendation has been integrated from the WHO recommendations for the prevention and treatment of postpartum haemorrhage (191), in which the GDG for that guideline determined it to be a strong recommendation based on very low-quality evidence.  The GDG considered that routine and frequent uterine tone assessment remains a crucial part of immediate , particularly for the optimization of early PPH diagnosis.  The evidence supporting this recommendation can be found in the source guideline document, available at: http://apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf

3.6.2 Antibiotics for uncomplicated vaginal birth

RECOMMENDATION 53

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

Remarks

 This recommendation has been integrated from the WHO recommendations for prevention and treatment of maternal peripartum infections (114), in which the GDG for that guideline determined it to be a strong recommendation based on very low-quality evidence.  The GDG was concerned about the potential public health implications of the high rate of routine use of antibiotics following vaginal birth without any specific risk factors in some settings. The group places emphasis on the negative impact of such routine use on the global efforts to contain antimicrobial resistance and, therefore, made a strong recommendation against routine antibiotic prophylaxis.  “Uncomplicated vaginal birth” in this context connotes vaginal birth in the absence of any specific risk factor for, or clinical signs of, maternal peripartum infection.  Careful monitoring of all women after birth is essential to promptly identify any sign of endometritis and institute appropriate antibiotic treatment.  Recommendations on antibiotic use for common intrapartum conditions or interventions that often raise concerns about increased risk of infection are available in the original WHO guideline.  The evidence supporting this recommendation can be found in the source guideline document, available at: http://apps.who.int/iris/bitstream/10665/186171/1/9789241549363_eng.pdf 3. EVIDENCE AND RECOMMENDATIONS

165 166 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE 3.6.4 3.6.3    Remarks (Recommended) hours. six within blood pressure measurement should be taken within six Urine hours. void should be documented theBlood firstpressure hour birth. shouldafter Ifbe normal,measured birth. theshortly after second fundal height, temperature rate and heart (pulse) routinely during the first 24 hours starting from contraction, uterine bleeding, vaginal of assessment have regular should women postpartum All RECOMMENDATION 55        Remarks with women episiotomy. for antibiotic prophylaxisRoutine is not recommended (Not recommended) RECOMMENDATION 54          

WHO guidelines. WHO consensus. GDG on based recommendation astrong be available at: http://apps.who.int/iris/bitstream/10665/97603/1/9789241506649_eng.pdf document, guideline source inthe found be can this recommendation supporting evidence The were noted. remarks further No mother and newborn of care the postnatal on WHOrecommendations the from integrated been has recommendation This available at: http://apps.who.int/iris/bitstream/10665/186171/1/9789241549363_eng.pdf document, guideline source inthe found be can this recommendation supporting evidence The (114) document guideline source inthe recommended as administered be should antibiotics prophylactic tear, perineal fourth-degree athird- or to become extends episiotomy an wound where asituation In antibiotics. prophylactic of use the warrant not similar to does tear is episiotomy anatomically an and perineal Second-degree treatment. its for resources of additional use the and potential complications of episiotomyuse its to reduce routine than rather of restrictive apolicy to systems adopt health for need the emphasized GDG The episiotomy of an wound. infection of signs clinical are there when administered be only should Antibiotics birth. following vaginal episiotomy repair after immediately or before of to antibiotics use the applies recommendation This made a strong recommendation. therefore, level and, global the at resistance antimicrobial avoidance of emerging on emphasis places GDG The health. public for benefits of clinical absence inthe of antibiotics, potential impact the and inview rate of ahigh of episiotomy GDG of the aconsensus on based was recommendation This treatment of maternal peripartum infections WHO the from recommendations integrated been has for prevention recommendation This and Routine postpartum maternal assessment maternal postpartum Routine Routine antibiotic episiotomy prophylaxisRoutine for . (197) , in which the GDG for that guideline reached consensus based on existing on based consensus reached guideline that for GDG the , inwhich (114) , in which the GDG for this guideline determined itto determined this guideline for GDG the , inwhich 3.6.5 Postnatal discharge following uncomplicated vaginal birth

RECOMMENDATION 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. (Recommended)

Remarks

 This recommendation has been integrated from the WHO recommendations on postnatal care of the mother and newborn (197), in which the GDG for that guideline determined it to be a conditional recommendation based on low-quality evidence.  An appropriate standard of care for mothers and newborns should be provided in health care facilities, in accordance with other existing WHO guidelines. For the newborn this includes an immediate assessment at birth, and a full clinical examination around one hour after birth and again before discharge.  “Healthy mothers and newborns” are defined in the safe childbirth checklist that is to be used to assess mothers and newborns at the time of discharge (198). Before discharge, bleeding in the mother should be controlled, mother and baby should not have signs of infection, and baby should be breastfeeding well.  The evidence supporting this recommendation can be found in the source guideline document, available at: http://apps.who.int/iris/bitstream/10665/97603/1/9789241506649_eng.pdf 3. EVIDENCE AND RECOMMENDATIONS

167 168 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE and newborn health (12) health newborn and maternal for framework of care quality WHO the of to all domains subscribes that care intrapartum of model To aglobal proposes WHO this end, family. her and woman the for experience childbirth and outcomes both clinically relevant inimproving effective be to shown have that been components of critical to implementation the give priority providers care health inwhich of care amodel requires outcomes of these attainment that agreed group The countries. and systems health across within and may exist that policies of generic influence of the baby, her and woman irrespective the for outcomes psychological and emotional physical, possible best the of achieving by importance the is informed shift globally. is key delivered care This intrapartum that ways practical inthe is required akeythat shift recognized GDG the care, of intrapartum quality to the improvements To much-needed achieve the of context. irrespective by received all women be should that interventions non-clinical and clinical of cross-cutting interms delivered be should women pregnant healthy for care how intrapartum reviewed GDG the of care, by prevailing the model determined largely are baby her and woman the for of care experience and outcomes clinical that fact the and practice, incontemporary care childbirth and provision of labour and organization the driving philosophies inthe exist that variations substantial the Acknowledging inall settings. childbirth and labour around of care improve quality the to need urgent the emphasized GDG the First, lens. rights 3) ahuman (Section through and within this guideline practices of recommended range of the consideration with full care intrapartum (GDG), of delivering reviewed WHO existing models Group Development Guideline of the members the of contributions the With woman. individual the and contexts local countries, to different adapted be can that of care model appropriate within an to deliverable be need practices recommended The outcomes. newborn and fetal maternal, improving ultimate with of the goal care intrapartum essential of is to improve aimof quality this the guideline The 4. the WHO intrapartum WHO the care model Implementation of this guideline: introducing and places the woman and and woman the places and should be a top priority for all stakeholders. for atop priority be should care intrapartum of evidence-based this model implement to successfully required infrastructure the improving and providers care maternity skilled of shortage the addressing Thus, populations. disadvantaged for inequity improvements with consequent interventions, medical inunnecessary reductions through to savings cost lead should model care intrapartum WHO of the implementation The settings. inall country thriving, level the of at but surviving, levelthe of merely beyond goals sets It worldwide. communities and families lives of the women, to positively transform potential the has model care intrapartum WHO The 4.1. inBox below found be can model WHO the for considerations Implementation approach. rights-based with ahuman accordance in care, such for foundation to asound provide and need, and they want that care individualized of type the to access all women tocare empower of this model aimto implement should systems Health resources. physical to essential the access have who professionals care motivated health and competent by kind, settings, all facility-based in of care apackage as implemented be should recommendations these facilities, care in health care intrapartum good-quality and equitable based, receive evidence- all women that ensure and model Tothis guideline. optimize new potential of the the in included recommendations evidence-based 56 the on is founded model care intrapartum WHO The of care. organization current the disrupting without adoption for enough is flexible and care, of of existing models interms settings across differences the acknowledges model The they arise. if of complications management and identification appropriate and timely ensuring time same the at baby, of her while birth the to experience freedom together, delivered but her giving fragmented not are components evidence-based synergistic when interventions unnecessary without to give birth of awoman’s own capability supportive be only can labour during care that premise the on is based It provision of (Fig. 4.1). centre care the at baby her

Fig. 4.1 Schematic representation of the WHO intrapartum care model

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BOX 4.1 Considerations for the implementation of the WHO intrapartum care model Health policy considerations  A firm government commitment to increasing coverage of maternity care for all pregnant women giving birth in health care facilities is needed, irrespective of social, economic, ethnic, racial or other factors. National support must be secured for the whole package of recommendations, not just for specific components.  To set the policy agenda, to secure broad anchoring and to ensure progress in policy formulation and decision-making, representatives of training facilities and professional societies should be included in participatory processes at all stages.  To facilitate negotiations and planning, situation-specific information on the expected impact of the new intrapartum care model on service users, providers and costs should be compiled and disseminated.  To be able to adequately ensure access for all women to quality maternity care, in the context of universal health coverage (UHC), strategies for raising public funding for health care will need revision. In low-income countries, donors could play a significant role in scaling up implementation.

Organizational or health-system-level considerations  Long-term planning is needed for resource generation and budget allocation to address the shortage of skilled midwives, to improve facility infrastructure and referral pathways, and to strengthen and sustain good-quality maternity services.  Introduction of the model should involve training institutions and professional bodies so that pre- service and in-service training curricula can be updated as quickly and smoothly as possible.  Standardized labour monitoring tools, including a revised partograph, will need to be developed to ensure that all health care providers (i) understand the key concepts around what constitutes normal and abnormal labour and labour progress, and the appropriate support required, and (ii) apply the standardized tools. 4. IMPLEMENTATION OF THIS GUIDELINE: INTRODUCING THE WHO INTRAPARTUM CARE MODEL

169 170 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE  considerations User-level                   about: information to disseminate undertaken be should activities sensitization Community-level implementers. other for practice of best examples as shared and documented be should strategies implementation Successful entrenched. are practices care intrapartum non-evidence-based where in settings required be could stakeholders other and providers care health at aimed strategies change Behaviour inhigher-level prevalent interventions facilities. to unnecessary women pregnant healthy of exposure reduce and model care units) intrapartum to birthing WHO facilitate the midwife-led (e.g. facilities care on-site to given provision alternative at be care maternity should Consideration of supplies. stock maintaining and obtaining protocols for developing as such requirements, to according local to management chain to improve devised supply be willStrategies need pathways efficient. referral are to that ensure to established be need facilities higher-level and primary between links transport and communication supervision, Good-quality develop. complications if intrapartum care to level higher-level of the to ahigher transfer and facility) referral appropriate and to timely ensure travel into account time taking developed be to need will (e.g. guidance context- situation-specific or section, of availability caesarean without facilities care health For is needed. model care intrapartum WHO the on protocols and/or based facility-based revision guidelines or of national Development labour). relief during pain available for to be (e.g. medicines to updated to be include will need Lists Medicines Essential national The    amniotomy). routine of episiotomy, use (e.g. infacilities pressure, liberal fundal practised longer no are that and women pregnant healthy for recommended not are that practices birth unnecessary and relief method); pain of choice position, birth of choice communication, effective companionship, birth and labour (e.g. RMC, experience inwomen’s childbirth to improvements lead that practices facility-based facilities; in babies and women of pregnant right human afundamental as (RMC) care maternity respectful 5. Research implications

During the guideline development process, the supports more than one woman at a time) that Guideline Development Group (GDG) identified can be effective? important knowledge gaps that need to be  What is the best model for doula/companion addressed through primary research. Where the training that will improve birth outcomes? certainty of available evidence was rated as “low” or “very low”, the GDG considered whether further  What types of birth spaces and other facilities research should be prioritized, based on whether are needed at health care facilities that provide such research would contribute to improvements maternity services, to optimally accommodate in the childbirth experience of women, be likely to companions during labour without impacting promote equity, and be feasible to implement. GDG- negatively on maternity care provided by staff? prioritized research gaps are listed below.  What are the costs related to training and infrastructure that are associated with different Care throughout labour and birth companionship models? Respectful maternity care (RMC)  What are the effects of a policy of RMC on First stage of labour substantive maternal and perinatal outcomes, and Progress of labour on longer-term health and well-being?  What is the ideal paper-based or digital tool  Which components/sets of components are the for labour monitoring and for guiding decision- most effective and in which contexts? making to reduce unnecessary interventions and improve birth outcomes?  What are the best RMC indicators, in terms of validity and responsiveness in clinical settings?  What is the effectiveness of a reference line (such as the “alert line”) as a tool for triaging women for  What are the effective strategies for referral from peripheral to higher-level settings, in implementing RMC in different LMIC and HIC terms of improved birth outcomes? settings?  What is the impact of facilitating longer labour on  What are the innovative approaches that need to health outcomes and health service utilization? be further developed and tested to integrate RMC into quality improvement initiatives? Labour ward admission policy

Effective communication  For healthy pregnant women in early labour, does delayed labour ward admission compared  What are the effects of communication skills with direct labour ward admission improve birth training on women’s and providers’ experiences outcomes? of facility-based childbirth?

 What level, type and other characteristics of Clinical pelvimetry on admission communication are effective in allaying anxiety  In remote or rural facilities without caesarean and empowering women to take control of their section availability, is routine clinical pelvimetry at birth process? labour admission a useful assessment for triaging  What level, type and other characteristics of women at risk of cephalo-pelvic disproportion? communication are effective in keeping labour companions well informed? Routine cardiotocography (CTG) on admission  What is the optimal skilled birth attendant-  For women classified to be low risk in LMICs to-woman ratio for delivery of effective and any setting with inadequate antenatal care communication? provision, can routine CTG on labour admission improve birth outcomes? Companionship during labour and childbirth  What are the best health system models to Continuous CTG during labour guarantee companionship for women in different  What are the effects of mobile continuous facility settings and cultures? Are there other CTG on birth outcomes for women without risk models of companionship (e.g. where a doula factors? 5. RESEARCH IMPLICATIONS 5.

171 172 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE   during labour (IA) auscultation of intermittent Method         acceptable and feasible to feasible implement? and acceptable equitable, cost-effective, thisIs intervention birth outcomes? birth device on ultrasound with aDoppler performed with IA compared record) apaper without and CTG with performed (with of IA effects the are what inLMICs, inlabour women healthy For CTG technology? improved from benefit care of maternity quality with high insettings birth giving women Can LMICs? LMICs? cost-effective in and CTG feasible intermittent Is and timing) in terms of birth outcomes? of birth interms timing) and protocols IA harms) of different interval (duration, and (benefits effects comparative the are What  Fundal pressure  Episiotomy policy Second stage of labour   analgesia Opioid     discouraging the practice of fundal pressure? of fundal practice the discouraging in effective are strategies implementation What outcomes? episiotomyno improve birth with compared indications clinical defined clearly upon episiotomy based labour, selective does of stage second inthe women pregnant For offspring? in dependency opioid subsequent and use opioid intrapartum between association an there Is relief inlabour? pain for use opioid of experiences and women’s are What values 6. Dissemination

This guideline will be available online for download focused activities and products to be developed. and also as a printed publication. Online versions English, French, Portuguese and Spanish (the latter will be available via the websites of the WHO in collaboration with the WHO Regional Office for Departments of Reproductive Health and the Americas/Pan American Health Organization Research (RHR) and Maternal, Newborn, Child [PAHO]) web-based versions are planned and have and Adolescent Health (MCA), and through been budgeted for. the WHO Reproductive Health Library (RHL).1 The guideline will also be launched on the WHO Print versions will be distributed to WHO RHR departmental website as part of the monthly regional and country offices, ministries of health, HRP News. This site currently has over 4500 WHO collaborating centres, NGO partners subscribers including clinicians, programme and professional associations, using the same managers, policy-makers and health service users distribution list that was developed for the antenatal from all around the world. In addition, a number of care guideline: WHO recommendations on antenatal articles presenting the recommendations and key care for a positive pregnancy experience (35). This implementation considerations will be published, in guideline will be accompanied by an independent compliance with WHO’s open access and copyright critical appraisal based on the AGREE instrument policies. Relevant WHO clusters, departments and (Appraisal of Guidelines for Research & Evaluation) partnerships, such as the Partnership for Maternal, (199). Technical meetings will be held within the Newborn & Child Health (PMNCH), will also be part WHO RHR and MCA Departments to share the of this dissemination process. recommendations and derivative products, which will include a practical manual for implementation In an effort to increase dissemination of WHO of the new WHO intrapartum care model, with guidelines on sexual and reproductive health the teams responsible for policy and programme and rights, a search function with the ability to implementation. search the database of WHO guidelines and recommendations has been created and recently Two sets of evidence briefs will be developed: one launched by the RHR Department.2 The intrapartum set for policy-makers and programme managers care guideline recommendations will be made and the other set for health care professionals. available via this search function. These evidence briefs, which will highlight the recommendations and implementation- The Maternal and Perinatal Health and Preventing related contextual issues, will be developed and Unsafe team of the RHR Department, in disseminated in collaboration with USAID, FIGO and collaboration with the MCA Department and other ICM. partners, will support national and subnational working groups to adapt and implement the The executive summary and recommendations guideline. This process will include the development from this publication will be translated into the six or revision of existing national guidelines or UN languages for dissemination through the WHO protocols in line with the WHO guideline. The regional and country offices and during meetings GREAT Network (Guideline-driven, Research organized by, or attended by, staff of the WHO RHR priorities, Evidence synthesis, Application of and MCA Departments. evidence, and Transfer of knowledge) will be used In addition to online and print versions of this to bring together relevant stakeholders to identify guideline, an interactive web-based version is and assess the priorities, barriers and facilitators to planned, which will be developed by a professional guideline implementation, and to support the efforts content communication and design firm that of stakeholders to develop adaptations and guideline specializes in infographics. This will facilitate implementation strategies tailored to the local the dissemination and uptake of the guideline context (200). This includes technical support for recommendations by making them available online local guideline implementers in the development of in a user-friendly format, and will allow a platform training manuals, flow charts and quality indicators, for cross-referenced recommendations to be as well as participation in stakeholder meetings. updated or added on an ongoing basis to ensure that the recommendations are up to date and comprehensive. Furthermore, this would allow for

1 2 RHL is available at: http://apps.who.int/rhl/en/ This can be accessed at: search.optimizemnh.org 6. DISSEMINATION

173 174 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE  include: to implementation barriers potential The resources. care of health redistribution and of care reorganization may require this guideline in recommendations of the implementation Effective 7.1 7.              support recommendedsupport practices; and supervise skills to and implement, expertise necessary with the resources of human lack providers and system managers; system and providers care health among interventions recommended of newly value of the of understanding lack non-evidence-based to evidence-based practices; from to change providers care of health resistance companions); labour toilet for facilities compresses, perineal labour, inearly warm water for warm women for waiting rooms maternity (e.g. comfortable interventions to support of infrastructure lack (e.g. space to accommodate labour companions); labour (e.g. to space accommodate ofmanagement pain methods pharmacological non- certain for space of physical lack Pinard fetal stethoscope); fetal Pinard device and ultrasound (e.g. Doppler medicines and supplies equipment, of essential lack additional care; and needing as identified pathways women for care and mechanisms referral of effective lack

care on theorganization of intrapartum Anticipated impact of theguideline Applicability issues Applicability contained inthis guideline. contained practices the on data relevant to the obtain used be could audits criterion-based or audits clinical series, time Interrupted States. Member WHO individual of policies national on toterm evaluate impact their to medium short evaluated inthe and collected will be recommendations of the implementation regional-level and (MCA), country- on data Health Adolescent Child and Newborn, Maternal, and (RHR) Research and Health Reproductive of Departments WHO of the teams evaluation and monitoring with the collaboration In targets. agreed with locally indicators and criteria of care quality to define used be can which measures, outcome and output of input, prioritized lists facilities inhealth care newborn (201) and of maternal Standards quality improving for publication WHO The levels. country and regional service, health- the at monitored will be recommendations of these impact and implementation The 7.2 Annex 4. 4and inSection considerations of implementation lists inthe provided are implementation facilitating and barriers these addressing Various for strategies   registers). recommended practices (e.g. patient records, monitor and to document designed systems management information of health lack of theguideline Monitoring evaluating and theimpact provides provides 8. Updating of the guideline

In accordance with the process for updating The WHO Steering Group will continue to WHO maternal and perinatal health guidelines, a monitor the research developments in the systematic and continuous process of identifying area of intrapartum care, particularly for those and bridging evidence gaps following guideline questions for which no evidence was found and implementation will be employed. An Executive those that are supported by low-quality evidence, Guideline Steering Group (GSG) for maternal and where new recommendations or a change in the perinatal health recommendations will convene published recommendations may be warranted, annually to review WHO’s current portfolio of respectively. Any concern about the validity of any maternal and perinatal health recommendations, recommendation will be promptly communicated and to prioritize new and existing questions for via the website for the guideline,1 and plans will be recommendation development and updating. made to update the recommendation, as needed. Accordingly, the recommendations included in this WHO welcomes suggestions regarding additional guideline will be regularly reviewed and prioritized as questions for inclusion in future updates of this needed by the Executive GSG. In the event that new guideline; suggestions can be addressed to the evidence (that could potentially impact the current WHO Department of Reproductive Health and evidence base for any of the recommendations) is Research by email ([email protected]). identified, the recommendation will be updated. If no new reports or information are identified for a particular recommendation, the recommendation will be revalidated.

1 Available at: www.who.int/reproductivehealth/ publications/intrapartum-care-guidelines/en/index.

html 8. UPDATING OF THE GUIDELINE

175 176 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE 1 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. 9. purpose of this guideline. this of purpose the for completed or updated were “†” annotation the with beginning citations with reviews Cochrane References 2014;384(9948):1129–45. Lancet. care. newborn and maternal for framework new evidence-informed a from findings care: quality and NF, Midwifery Cheung al. et AA, Channon J, Campbell MH, Bastos A, McFadden MJ, Renfrew 2013%20V2.pdf, accessed 12 December 2017). europeristat.com/images/doc/Peristat%20 (http://www. 2013 Project; Euro-Peristat Report. Health Perinatal European 2010. in Europe in babies and women pregnant of care and health The 2012;39(3):183–91. Birth. adifference? make characteristics unit maternity do France: in women pregnant risk low- for interventions Obstetric B. Blondel J, Zeitlin N, Drewniak N, Lelong C, Ray Le B, Coulm 2014;11(1):71. Health. Reprod synthesis. evidence aqualitative countries: middle-income and low- in delivery to facility-based barriers JP, Vogel JP, G Souza HM, Munthe-Kaas EC, Hunter MA, Bohren 2014;384(9940):347–70. cost? Lancet. what at and stillbirths, and babies, newborn mothers, in deaths preventable end interventions available Can al. et VK, Paul RA, Salam JE, Lawn R, Bahl JK, Das ZA, Bhutta 2016;387(10018):587–603. Lancet. 2030. towards acceleration and factors, risk rates, Stillbirths: D, al. et Hogan C, Mathers Waiswa P, H, A, Blencowe Amouzou JE, Lawn 2014;2(6):e323–33. Health. Glob Lancet analysis. systematic a WHO death: maternal of causes Global al. et J, Daniels AB, Tunçalp Ö, Moller A, D, Gemmill Chou L, Say 2014;384(9947):980–1004. Lancet. 2013. Study Disease of Burden Global the for analysis asystematic 1990–2013: during mortality maternal of causes and levels national and regional, Global, al. et KR, Heuton C, Steiner KA, Shackelford MS, Coggeshall A, Bertozzi-Villa NJ, Kassebaum 2017). October 20 accessed NICE_clinical_guideline_190_dec2014.pdf, (http://www.geburtshaus.ch/documents/upload/ 2014 Excellence; Care and Health for Institute NICE clinical guideline 190. London: National babies. and women healthy for care Intrapartum 2015;212(6):809.e1-6. Gynecol. JObstet Am States. United the in pregnancies low-risk of complications AP, Unexpected VA, MG. Nunes Danilack Phipps 2017). October 20 accessed publications/files/UNICEF_SOWC_2016.pdf, Children’s Fund; 2016 (https://www.unicef.org/ Nations York United New (NY): child. every for chance afair 2016: children world’s the of state The u lmezoglu AM. Facilitators and and Facilitators AM. lmezoglu 1 25. 24. 23. 22. 21. 20. 19. 18. 17. 16. 15. 14. 13. 12.

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183 184 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Annex 1. admission (C),admission (O)? outcomes improve birth ward labour (I), of direct with apolicy compared phase until active ward admission labour delayed (P), term at of labour apolicy does spontaneous in presenting women pregnant healthy For outcomes? birth with normal associated patterns dilatation labour, cervical the are what of spontaneous onset the at factors risk without women pregnant For spontaneous labour onset? with a women pregnant healthy among outcomes birth of risk at adverse women to identify used be line) alert (as by partograph the hour per depicted of 1cm rate dilatation threshold acervical Should outcomes? birth with good associated are that labour spontaneous of stages phases) second active (latent and and first of definitions appropriate the are What (O)?outcomes another, than safer birth improving for and effective more staff) hospital or member family (e.g. adoula, support of continuous of provider type of aparticular (C),practice (O)? outcomes improve birth use the Is (I), with usual companionship and compared support (P), labour inlabour women For continuous does (C), practice with usual (O)? outcomes improve birth (I), staff care by health compared communication (P), inlabour women For effective does (O)? outcomes improve birth (C), (I), practice practice with usual compared maternity women-centred dignified, respectful, (P), promotes that inlabour women For apolicy does P=Population; I=Intervention; C=Comparator; O=Outcomes questions guideline Priority

Priority guideline questions outcomes and Priority outcomes Priority Born before arrival at facility at arrival before Born Perinatal/neonatal death Perinatal hypoxia-ischaemia experience birth Maternal morbidity Maternal ofrelief pain Use of labour Augmentation of labour Duration of birth Mode the next to dilatation level of cervical one from ofRate change to dilatation next the level of cervical one by from to 1cm dilatation advance cervical for Time Specificity Sensitivity False (FN) negative False positive (FP) True (TN) negative True positive (TP) stage of second Duration phase active of onset of Definition phase of latent onset of Definition stage of first Duration phase of active Duration of latent phase Duration Long-term outcomes infant Perinatal hypoxia-ischaemia experience birth Maternal ofrelief pain Use of labour Augmentation of labour Duration Perineal/vaginal trauma of birth Mode Perinatal hypoxia-ischaemia Perineal/vaginal trauma ofrelief methods pain Use of labour Duration of birth Mode experience birth Maternal Perinatal hypoxia-ischaemia trauma Perineal/vaginal ofrelief methods pain Use of labour Duration of birth Mode experience Maternal birth Priority guideline questions Priority outcomes P=Population; I=Intervention; C=Comparator; O=Outcomes For healthy pregnant women presenting in labour Mode of birth (P), does clinical pelvimetry routinely performed on Maternal morbidity admission (I), compared with no clinical pelvimetry Perineal/vaginal trauma (C), improve birth outcomes (O)? Maternal birth experience Birth trauma Perinatal hypoxia-ischaemia Perinatal/neonatal death For healthy pregnant women presenting Mode of birth in spontaneous labour (P), does routine Maternal birth experience cardiotocography for assessment of fetal status on Fetal distress labour admission (I), compared with intermittent Perinatal hypoxia-ischaemia auscultation (C), improve birth outcomes (O)? Perinatal/neonatal death Long-term infant outcomes For healthy pregnant women in labour (P), does Mode of birth continuous cardiotocography for assessment of fetal Use of pain relief status (I), compared with intermittent auscultation Maternal birth experience (C), improve birth outcomes (O)? Fetal distress Perinatal hypoxia-ischaemia Perinatal/neonatal death Long-term infant outcomes For healthy pregnant women in labour (P), is the use Mode of birth of a particular method of intermittent auscultation Maternal birth experience for monitoring of fetal heart rate (I), compared with Fetal distress other methods intermittent auscultation (C), more Perinatal hypoxia-ischaemia effective and safe for improving birth outcomes (O)? Perinatal/neonatal death Long-term infant outcomes For healthy pregnant women requesting pain relief Mode of birth during labour (P), should epidural analgesia (I), Pain relief compared with no pain relief or other forms of Maternal birth experience pain relief (C), be offered to relieve labour pain and Augmentation of labour improve birth outcomes (O)? Duration of labour Adverse effects Perinatal hypoxia-ischaemia Long-term infant outcomes For healthy pregnant women requesting for pain Mode of birth relief during labour (P), should relaxation techniques Pain relief for pain management (I), compared with no pain Maternal birth experience relief or other forms of pain relief (C), be offered to Augmentation of labour relieve labour pain and improve birth outcomes (O)? Duration of labour Adverse effects Perinatal hypoxia-ischaemia Long-term infant outcomes For healthy pregnant women requesting pain relief Mode of birth during labour (P), should parenteral opioid(s) (I), Pain relief compared with no pain relief or other forms of pain Maternal birth experience relief (C), be administered to relieve labour pain and Augmentation of labour improve birth outcomes (O)? Duration of labour Adverse effects If so, which parenteral opioid(s) should be offered to Perinatal hypoxia-ischaemia eligible women? Long-term infant outcomes ANNEX 1. PRIORITY GUIDELINE QUESTIONS AND OUTCOMES

185 186 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE usual practice (C), practice usual (O)? outcomes improve birth or technique (I),trauma perineal with no compared preventing for perineal used guiding) or compress warm (e.g. massage, technique any perineal does (P), of labour stage second inthe women For (C),dilatation (O)? outcomes improve birth cervical full after pushing with immediate compared (P), of labour (I),stage pushing delayed does second inthe analgesia with epidural women For (O)? outcomes improve birth (e.g.pushing with Valsalva/closed glottis) (C), (I), pushing with directed compared spontaneous (P), of labour stage second inthe does women For (O)? outcomes improve birth (C), position (I), with arecumbent compared squatting) or standing (e.g. position sitting, birthing (P), upright of an of labour stage adoption the does second inthe analgesia with epidural women For (O)? outcomes improve birth (C), position (I), with arecumbent compared squatting) or standing (e.g. position sitting, birthing (P), upright of an of labour stage adoption the does second inthe analgesia epidural without women For outcomes (O)? improveand birth pain to relieve offered labour be of relief (C), pain forms other relief or pain with no (I), management pain for compared techniques manual (P), other labour and during massage should relief pain requesting women pregnant healthy For P=Population; I=Intervention; C=Comparator; O=Outcomes questions guideline Priority Priority outcomes Priority Perinatal hypoxia-ischaemia trauma Birth experience birth Maternal Long-term morbidity maternal trauma Perineal/vaginal Perinatal/neonatal death Perinatal hypoxia-ischaemia Fetal distress experience birth Maternal Long-term morbidity maternal Perineal/vaginal trauma of birth Mode of labour Duration Perinatal/neonatal death Perinatal hypoxia-ischaemia distress Fetal experience birth Maternal Long-term morbidity maternal Perineal/vaginal trauma of birth Mode of labour Duration Perinatal/neonatal death Perinatal hypoxia-ischaemia distress Fetal experience birth Maternal trauma Perineal/vaginal Pain relief/intensity of birth Mode of labour Duration Perinatal/neonatal death Perinatal hypoxia-ischaemia distress Fetal experience birth Maternal trauma Perineal/vaginal Pain relief/intensity of birth Mode of labour Duration Long-term outcomes infant Perinatal hypoxia-ischaemia effects Adverse of labour Duration of labour Augmentation experience birth Maternal Pain relief of birth Mode Priority guideline questions Priority outcomes P=Population; I=Intervention; C=Comparator; O=Outcomes For women in the second stage of labour (P), does a Duration of labour policy of selective/restrictive use of episiotomy (I), Maternal morbidity compared with a policy of routine or liberal use of Long-term maternal morbidity episiotomy (C), improve birth outcomes (O)? Perineal/vaginal trauma Use of pain relief Maternal birth experience Birth trauma Perinatal hypoxia-ischaemia For women in the second stage of labour (P), does Mode of birth the application of fundal pressure (I), compared to Duration of labour no fundal pressure (C), improve birth outcomes (O)? Maternal mortality Serious maternal morbidity Perineal/vaginal trauma Maternal birth experience Birth trauma Perinatal hypoxia-ischaemia Perinatal/neonatal death ANNEX 1. PRIORITY GUIDELINE QUESTIONS AND OUTCOMES

187 188 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Argentina Aires Buenos (IECS) Health Policy and ClinicalInstitute Effectiveness for Research Child Health and of Mother Department Director Fernando Althabe Egypt Assiut Hospital University Assiut Hospital Health Women’s Gynecology and of Obstetrics Department Professor Hany Abdel-Aleem (GDG) Group Development Guideline Research and Health of Reproductive Department Technical Officer Joshua Vogel Research and Health of Reproductive Department Officer Medical PauloJoão Souza Health Adolescent Child and Newborn, of Maternal, Department Technical Officer Anayda Portela Research and Health of Reproductive Department Officer Medical Olufemi Oladapo Health Adolescent Child and Newborn, of Maternal, Department Officer Medical Maurice Bucagu Research and Health of Reproductive Department Officer Medical Mercedes Bonet Research and Health of Reproductive Department Officer Medical Betrán Pilar Ana Research and Health of Reproductive Department Coordinator Gülmezoglu Metin A. (Geneva, Group Switzerland) Steering WHO Annex 2. involved in preparation the of this guideline External and experts WHO staff Germany Munich (EFCNI)Infants of Newborn Care the for Foundation European Board Executive of the Chairwoman Mader Silke Thailand Kaen Khon University Kaen Khon Faculty of Medicine Network Convenor, Cochrane Thai Gynecology and of Obstetrics Professor and Dean consultation) (Chair, 2017 Lumbiganon Pisake September Kingdom) (United Ireland Northern and Britain of Great Kingdom United Manchester Work &Social Midwifery of Nursing, School of Manchester University Professor Tina Lavender India Delhi New India) CEDPA (formerly Change Catalyzing for Centre Director Executive Gogoi Aparajita Switzerland Geneva Hospital University Geneva Gynaecology and of Obstetrics Department Professor Boulvain Michael Brazil Recife Figueira Fernando Professor Integral Medicina Instituto de Professor and Brazil Campina Grande Neto Amorim Joaquim Professor Pesquisa de Instituto Paraibano Senior Researcher Amorim de Ramos Maria Melania Suellen Miller Mandisa Singata-Madliki Director, Safe Motherhood Program Deputy Director Department of Obstetrics, Gynecology and Effective Care Research Unit Reproductive Sciences East London Hospital Complex Bixby Center for Global Reproductive Health and University of Fort Hare Policy East London University of California, San Francisco South Africa San Francisco, California Jorge E. Tolosa Rintaro Mori Professor of Obstetrics and Gynecology Director Coordinator Global Network for Perinatal & Department of Health Policy Reproductive Health (GNPRH) (FUNDARED- National Research Institute for Child Health and MATERNA – Colombia) Development Division of Maternal Fetal Medicine Tokyo Oregon Health & Science University Japan Portland, Oregon USA James Neilson (Chair, May 2017 consultation) and Coordinating Editor Departamento de Ginecología y Obstetricia Cochrane Pregnancy and Childbirth Group Centro Nacer, Salud Sexual y Reproductiva and Facultad de Medicina, Universidad de Antioquia Professor Medellín University of Liverpool Colombia Liverpool United Kingdom Hayfaa Wahabi Professor and Chair Hiromi Obara Evidence-based Healthcare and Knowledge Health Policy Advisor Translation Japan International Cooperation Agency (JICA) College of Medicine, King Saud University Vientiane Riyadh Lao People’s Democratic Republic Saudi Arabia Oladapo Olayemi Professor and Head of Department External Review Group Department of Obstetrics and Gynaecology Blami Dao College of Medicine Technical Director, Western and Central Africa University of Ibadan Jhpiego, an affiliate of Johns Hopkins University Ibadan Baltimore, Maryland Nigeria USA Robert Pattinson G. Justus Hofmeyr Professor and Director Professor South African Medical Research Council/University Effective Care Research Unit of Pretoria (SAMRC/UP) Maternal and Infant Health Universities of Witwatersrand and Fort Hare Care Strategies Unit and Kalafong Hospital Eastern Cape Department of Health Pretoria, Gauteng East London South Africa South Africa Harshad Sanghvi Caroline Homer Chief Medical Officer Professor and Director Jhpiego, an affiliate of Johns Hopkins University Centre for Midwifery, Child and Family Health Baltimore, Maryland Faculty of Health USA University of Technology Sydney Sydney Australia ANNEX 2. EXTERNAL EXPERTS AND WHO INVOLVED IN STAFF THE PREPARATION OF THIS GUIDELINE

189 190 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Egypt Cairo Heliopolis, University Shams Ain Gynecology and of Obstetrics Department Professor Ashraf Nabhan USA Washington DC Gynecologists and of College Obstetricians American Policy Health President Vice Levy Barbara Kingdom United Bournemouth Bournemouth University Health Perinatal and Maternal Midwifery, for Centre Professor Vanora Hundley Argentina Argentina Moreno, Rosario Perinatales Estudios de Rosarino Centro Medical Doctor Diaz Virginia Argentina Rosario Moreno, Perinatales Estudios de Rosarino Centro Medical Doctor Chamillard Monica Switzerland Geneva World Organization Health Research and Health of Reproductive Department Consultant Meghan Bohren Kingdom United London London College King’s ofDivision Women’s Health Midwifery and Faculty of Nursing Nightingale Florence Practice Midwifery Based of Evidence Professor Debra Bick Argentina Moreno, Rosario Perinatales Estudios de Rosarino Centro Director Vice Abalos Edgardo Technical Working Group United Kingdom Kingdom United Lancashire Preston, Lancashire of Central University &Midwifery Health of Community School Unit &Nurture Nutrition Infant and Maternal Associate Professor Gill Thomson Iran Tehran Tehran University of Medical Sciences Health of Public School Promotion and Education of Health Department Associate Professor Shakibazadeh Elham Argentina Rosario Moreno, Perinatales Estudios de Rosarino Centro Medical Doctor Julia Pasquale Kingdom United Bath Ltd Consultancy Medicine Evidence-Based Consultant Lawrie Theresa Kingdom United Liverpool Trust Women’s Foundation Liverpool NHS University of Liverpool Department of Women’s and Children’s Health Childbirth and Pregnancy Cochrane Editor Managing Frances Kellie Kingdom United Lancashire Preston, Lancashire of Central University Studies Midwifery Assistant Research Senior Kenneth Finlayson Kingdom United Liverpool Trust Women’s Foundation Liverpool NHS of Liverpool University of Women’s Children’s and Health Department Childbirth and Pregnancy Cochrane Research Associate Therese Dowswell Kingdom United Lancashire Preston, Lancashire of Central University Studies Midwifery Professor Soo Downe External partners and meeting observers WHO Regional Office representatives Diogo Ayres-de-Campos Regional Office for Africa Member, FIGO Committee for Safe Motherhood and Léopold Ouedraogo Newborn Health (2015–2018) Regional Advisor International Federation of Gynecology and Research and Program Development Obstetrics (FIGO) Reproductive Health London Health Promotion Cluster United Kingdom Regional Office for the Americas/Pan American Petra ten Hoope-Bender Health Organization (PAHO) Technical Advisor, Sexual and Reproductive Health Bremen De Mucio United Nations Population Fund (UNFPA) Regional Advisor Geneva Sexual and Reproductive Health Switzerland Latin American Center for Perinatology Mechthild M. Gross Head of Midwifery Research and Education Unit Regional Office for the Eastern Mediterranean Hannover Medical School Karima Gholbzouri Hannover Medical Officer Germany Reproductive and Maternal Health and Representative Regional Office for Europe International Confederation of Midwives (ICM) Mavjuda Babamuradova The Hague Medical Officer The Netherlands Sexual and Reproductive Health Noncommunicable Diseases and Life-Course Mary Ellen Stanton Senior Reproductive Health Advisor Regional Office for the Western Pacific Center for Population, Health and Nutrition Mari Nagai United States Agency for International Development Technical Officer Washington, DC Reproductive, Maternal, Newborn, Child and USA Adolescent Health Alison Wright Division of Noncommunicable Diseases and Health Vice President for UK and Global Membership through the Life-Course Royal College of Obstetricians and Gynaecologists London United Kingdom ANNEX 2. EXTERNAL EXPERTS AND WHO INVOLVED IN STAFF THE PREPARATION OF THIS GUIDELINE

191 192 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Annex 3. Expertise: Obstetrics, content expert and end-user and expert content Obstetrics, Expertise: Abdel-Aleem Hany Professor Guideline Development Group (GDG) development guideline the to contributed expertise and Name Expertise: Obstetrics, content expert and end-user and expert content Obstetrics, Expertise: Dr Fernando Althabe Expertise: Obstetrics, content expert and end-user and expert content Obstetrics, Expertise: Amorim de Ramos Maria Melania Dr Expertise: Obstetrics, content expert and end-user and expert content Obstetrics, Expertise: Professor Michel Boulvain Expertise: Women’s representative Gogoi Aparajita Dr Expertise: Midwifery, content expert and end-user and expert content Midwifery, Expertise: Lavender Tina Professor Expertise: Obstetrics, content expert and end-user and expert content Obstetrics, Expertise: Professor Pisake Lumbiganon Expertise: Women’s representative Silke Mader Ms Expertise: Midwifery, content expert and end-user and expert content Midwifery, Expertise: Professor Suellen Miller user end- and Neonatology, content expert Expertise: Mori Rintaro Dr Expertise: Obstetrics, content expert and end-user and expert content Obstetrics, Expertise: Professor James Neilson expert and implementer content Child health, and Maternal Expertise: Obara Hiromi Dr Obstetrics, content expert and end-user and expert content Obstetrics, Professor Oladapo Olayemi Expertise: Obstetrics, content expert and end-user and expert content Obstetrics, Expertise: Pattinson Robert Professor how they were managed Technical Working and members, Group from Guideline Development and Group of declarationsSummary of interest None declared None declared None declared None declared None declared None declared None declared None declared training. conduct workshops and travelcoverage for to and US$ 2600 Received anti-shock garment. brand of non-pneumatic LifeWrap the produces which BlueFuzion, for Consultancy None declared None declared None declared None declared None declared Declared interest(s) None None None None None None None None None shock garments. anti- non-pneumatic or haemorrhage postpartum related to questions any new include not did development process guideline credibility. The its to or reduce process development guideline the any to risk to pose enough considered significant not was of interest conflict declared This None None None None None Management of conflict(s) conflict(s) of Management of interest Name and expertise contributed to the guideline Declared interest(s) Management of conflict(s) development of interest Dr Harshad Sanghvi None declared None Expertise: Maternal health, content expert and implementer Dr Mandisa Singata-Madliki None declared None Expertise: Midwifery, content expert and end-user Dr Jorge E. Tolosa None declared None Expertise: Obstetrics, content expert and end-user Professor Hayfaa Wahabi None declared None Expertise: Obstetrics, content expert and end-user Technical Working Group (TWG) Dr Edgardo Abalos None declared None Expertise: Obstetrics, content expert, systematic review, and guideline methodology Professor Debra Bick None declared None Expertise: Evidence-based midwifery, content expert, and systematic review Dr Meghan Bohren None declared None Expertise: Systematic review and guideline methodology Dr Monica Chamillard None declared None Expertise: Systematic review and guideline methodology Dr Virginia Diaz None declared None Expertise: Obstetrics, content expert, systematic review, and guideline methodology Professor Soo Downe Research grants from The declared academic Expertise: Midwifery, content expert, systematic the National Institute for conflict of interest review, and guideline methodology Health Research (NIHR) was not considered and the Royal College of significant enough to Midwives in the United pose a substantial risk Kingdom to conduct to Professor Downe’s research on self-hypnosis participation as a member for labour pain and survey of the TWG, nor does it on interventions in normal reduce the credibility of birth (completed in 2013 the systematic reviews and 2014, respectively); that she led. and a European Union (EU) grant for European Cooperation in Science & Technology (COST) Action on Building Intrapartum Research Through Health (BIRTH), 2014–2018. ANNEX 3. SUMMARY OF DECLARATIONS OF INTEREST

193 194 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE methodology Systematic review guideline and Expertise: Dowswell Therese Ms development guideline the to contributed expertise and Name review, methodology guideline and systematic expert, content Midwifery, Expertise: Mr Kenneth Finlayson methodology Systematic review guideline and Expertise: Kellie Frances Ms review, methodology guideline and systematic expert, content Obstetrics, Expertise: Lawrie Theresa Dr methodology Systematic review guideline and Expertise: Dr Julia Pasquale Expertise: Health education and systematic review systematic and education Health Expertise: Shakibazadeh Elham Dr systematic review systematic and expert content health, Perinatal Expertise: Thomson Gill Dr of Cochrane reviews. reviews. of Cochrane conclusions or funding the influence not does NIHR of Liverpool). University (via NIHR from funding the and programme grant infrastructure receives (PCG). PCG Cochrane The Group Childbirth and Pregnancy Cochrane the of Associate Research as of Liverpool University of the Employee None declared of Cochrane reviews. Cochrane of conclusions or funding the influence not does NIHR of Liverpool). University (via NIHR from funding the and programme grant infrastructure receives PCG Cochrane The PCG. Editor Cochrane of the Managing as of Liverpool University of the Employee None declared None declared None declared None declared Declared interest(s) perinatal health. perinatal relating and to maternal guidelines WHO for preparation base evidence in akey partner been PCG has Cochrane The TWG. inthe participation to affect enough considered significant not was of interest conflict declared The None perinatal health. perinatal relating and to maternal guidelines WHO for preparation base evidence in akey partner been PCG has Cochrane The TWG. inthe participation to affect enough considered significant not was of interest conflict declared The None None None None Management of conflict(s) conflict(s) of Management of interest Annex 4. Implementation considerations specific to individual recommendationsa

3.1 CARE THROUGHOUT LABOUR AND BIRTH 3.1.1  Multifaceted RMC interventions are most likely to be effective, and policy-makers Respectful should ensure that key stakeholders are engaged in RMC programmes, including maternity care facility administrators, training institutions, professional societies, providers and (RMC) communities; this will ensure shared responsibility.  As the drivers and types of mistreatment and abuse will vary across settings, stakeholders should ensure that these factors are clearly identified through communication with women and women’s groups in each different setting. RMC interventions should then be tailored to addressing these factors, to optimize implementation and impact.  Implementers should ensure the development and integration of up-to-date, written standards and benchmarks for RMC that clearly define goals, operational plans and monitoring mechanisms.  Protocols for RMC, accountability mechanisms for redress in the event of mistreatment or violations, and informed consent procedures, should all be reviewed continuously.  Mechanisms should be put in place to ensure that all women, and particularly those from disadvantaged backgrounds, are made aware of (i) their right to RMC and (ii) the existence of a mechanism for raising and addressing complaints (e.g. an audit and feedback mechanism that integrates women’s complaints and ensures that responses are provided).  RMC policies should be tailored to the context of each different setting to ensure that subgroups of women at particular risk of mistreatment and those with special needs (e.g. poor awareness of their rights, language difficulties) are targeted for more intensive efforts to promote RMC, especially where maternity care experiences among these subgroups are very poor.  Implementers should be aware that shifts in health system infrastructure (e.g. reorganization of staffing, increasing workload) could disrupt implementation; therefore, any infrastructural changes need close monitoring to ensure and evaluate the feasibility and sustainability of RMC practices.  Implementers should be aware that a commitment to providing the necessary physical and staff resources and supporting staff well-being/morale is needed for successful implementation and sustainability of RMC. In addition, ensuring a visible, sustained and participatory intervention process, with committed facility leadership, management support and staff engagement, is important.b  Implementers should be aware of the general principals of the Human Rights Council’s Technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce preventable maternal morbidity and mortality.c

a This annex refers only to implementation considerations for the new recommendations. Implementation considerations related to integrated recommendations can be found in the original guideline documents and accessed via the links provided in the respective “remarks” sections. b Ratcliffe HL, Sando D, Mwanyika-Sando M, Chalamilla G, Langer A, McDonald KP. Applying a participatory approach to the promotion of a culture of respect during childbirth. 2016;13:80. c United Nations Human Rights Council. Technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce preventable maternal morbidity and mortality. New York (NY):

United Nations; 2012. RECOMMENDATIONS INDIVIDUAL TO SPECIFIC CONSIDERATIONS ANNEX IMPLEMENTATION 4.

195 196 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE d childbirth during labour and Companionship 3.1.3 communication Effective 3.1.2 2017 (http://www.who.int/mediacentre/news/statements/2017/discrimination-in-health-care/en/). June 27 statement. WHO/UN Joint settings. care health in discrimination ending on statement Nations United Joint

                            statement on ending discrimination in health care settings. care inhealth discrimination ending on statement Nations WHO/United 2017 Joint with the compliance ensure should Policy-makers settings. indifferent care maternity quality better protocols for and guidelines of development to the inform documented be should programmes RMC Successful sanitation, hygiene measures and protective necessary. as clothing and measures hygiene sanitation, to access as such companions, for considered be should measures control Infection way”. “in the of risk being the to and reduce providers, care health her and both the woman to is beneficial presence their that ensure to responsibilities, and roles designated have clearly should companions Labour team. into woman’sintegrated the support be can well as how companions as childbirth, and labour during companionship of benefits the on them training to want consider might implementers providers, care health among to change resistance to reduce toPrior implementation, them. incentivizing and retaining ways of registering, consider and companions, for programmes sensitive training culturally develop should Policy-makers promote demand for and use of companionship. to help could activities promotional other and days, open hospital women’s groups, groups, counselling and education care antenatal companions, of volunteer groups of community-based organization the childbirth, and labour during companionship of benefits the or concept with the unfamiliar are women where settings In someone to her. support provide to offer would service health the acompanion, bring/have not does woman if a but possible, wherever own companion to their bring women tobe encourage could approach One population. of the needs the meets that birth and labour during women for service how to acompanionship provide consider should Policy-makers care. related to maternity their complaints addressing and raising for (ii)and mechanism existence of a the communication toright effective aware of (i) made are their backgrounds, disadvantaged from those particularly and all to women, that inplace ensure put be should mechanisms Culturally appropriate facility. care health by the served communities of the languages available inthe made be should format, pictorial or written accessible inan materials, education health understood Easily sustainable. more make and them interventions communication leadership) facilitate effective could clinical team working, of multidisciplinary capacity, promotion workload mix, skill staffing, of reorganization staff, (e.g. increased to infrastructure system Changes setting-specific. be women) might to disadvantaged attitudes (e.g. cultural barriers other while settings, across common may be workload) high barriers Some (e.g. addressed. and to identified be levelssystem will need health and facility care health individual, at to implementation Potential barriers staff. care skills of health counselling and communication interpersonal to the promote mechanisms monitoring and plans operational goals, clear outlines that policy written up-to-date, is an there ensure should facilities care Health interventions. communication effective way to feasible implement most the be could interventions training professional in-service and pre-service all in routinely training communication effective Including d  Integration of the lay companion (including male partners/husbands and female relatives) into antenatal care visits, childbirth education classes, etc., might empower companions with knowledge about the process of labour, familiarity with the health care facility structure, and the skills and confidence to better support the woman, while additionally providing the woman herself with information about how the companion will be able to support her throughout labour and birth. 3.2 FIRST STAGE OF LABOUR 3.2.1  Guidance and protocols for health care facilities without availability of caesarean Definitions of the section will need to be developed that are context- and situation-specific. latent and active  Introduction of these new definitions and concepts should involve pre-service first stages of training institutions and professional bodies, so that training curricula for labour intrapartum care can be updated as quickly and smoothly as possible. 3.2.2 Duration of the  Labour monitoring tools will need to be updated and/or developed to facilitate the first stage of new approach. labour  Practice manuals and labour ward protocols will need to be updated and 3.2.3 disseminated. Progress of the first stage of labour 3.2.4  This recommendation requires a well functioning health system with a sufficient Labour ward number of trained health care professionals. admission policy  It is important that health care professionals clearly communicate the reason for delaying admission to women in latent labour, and provide them with encouragement, support and advice on how to manage uncomfortable contractions, how to recognize active labour and, if a woman chooses to go home, when to return to the hospital. 3.2.5  In settings where clinical pelvimetry is routinely performed among healthy pregnant Clinical women on admission in labour, health care providers need to be aware that there is pelvimetry on insufficient evidence to support this practice. admission 3.2.6  In settings where cardiotocography (CTG) is performed routinely on admission for Routine labouring women with no risk factors for adverse outcomes, it is important to inform assessment of health care professionals and other stakeholders that this practice is not evidence- fetal well-being on based and increases the risk of unnecessary medical interventions. labour admission  Policy-makers and relevant stakeholders need to consider how records from auscultation can be validated for use in the defence against potential litigation claims, instead of reliance on admission CTG for this purpose. 3.2.10  The GDG panel is aware that in some countries and settings, continuous CTG is Continuous used to protect against litigation. In such settings, health care professionals and cardiotocography women should be advised that this practice is not evidence-based and does not during labour lead to better outcomes. Clinicians might be better protected against litigation by keeping good medical notes and records, which clearly indicate findings of intermittent auscultation (IA), than by relying on continuous CTG tracings. ANNEX 4. IMPLEMENTATION CONSIDERATIONS SPECIFIC TO INDIVIDUAL RECOMMENDATIONS INDIVIDUAL TO SPECIFIC CONSIDERATIONS ANNEX IMPLEMENTATION 4.

197 198 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE for pain relief pain for analgesia Epidural 3.2.12 during labour auscultation ratefetal heart Intermittent 3.2.11

                            to monitor complications. to protocols and clinical to adherence ensure procedures feedback and audit regular conduct should labour during analgesia epidural offering facilities care Health when needed. dispensed be can kept are and instock drugs necessary the to that options ensure pain relief pharmacological offering facilities at inplace be should Mechanisms they arise. should complications, to manage equipment necessary the protocols and clear staff, trained they have that ensure adequately should analgesia, epidural relief, pain for including options providing pharmacological facilities care Health to so. do need the like would ofrelief she feels pain if she type the about mind her free change be to should she in labour.admission addition, on In confirmed be should labour,A woman’s ofrelief during pain relief choice is if pain required, counselling. and education care of antenatal part as options, of these disadvantages and advantages the discuss facility, should their at and birth and labour available for relief options pain the to women communicate should professionals care Health provision of relief. pain equitable and to safe ensure and women’s decision-making, to support management, clinical to guide developed be should options non-pharmacological and of pharmacological providing arange for and pain relief for a woman’sneed protocolsassessing for Setting-specific analgesia. epidural undergoing all women for is necessary consent informed Signed ofrelief. pain this method considering to women explained clearly be should analgesia with epidural associated risks and benefits The complications. serious to lead can that procedure significant is a analgesia aware epidural that be should women and providers care Health for. cared are analgesia epidural have who undergone women wards where postnatal and available inlabour readily be should resuscitation for drugs appropriate and equipment resuscitation Oxygen, other resource requirements. and levels staffing techniques, doses, drugs, correct including analgesia, epidural to protocols for standardized to adherence inplace ensure be Systems should available. consistently not are resources these where insettings introduced be not should baby. analgesia and of mother Epidural safety to the ensure labour after and during procedure of the effects any to undesirable in place monitor, manage and detect systems and obstetricians) skills (anaesthetists, specialist well as equipment as appropriate the havewith to need staff analgesia epidural Facilities offering settings. intheir acceptable and feasible most are relief measures pain which to determine need Policy-makers potential litigation claims. against defence valid inthe (and be would IAingeneral) monitoring fetal non-electronic from records whether to consider need stakeholders relevant and policy-makers of litigation, prevalence with ahigh settings In training. in-service and pre-service with appropriate introduced be device could ultrasound Doppler the available, become resources as Then, stethoscope. fetal Pinard IAwith the to conduct providers care of health competence and availability widespread ensure to be firstly might settings inlow-resource approach A practical (e.g. supply). power requirements infrastructural no has and maintenance, equipment and related to supplies costs with ongoing (IA) associated is it as not auscultation intermittent for method feasible most the be would stethoscope fetal Pinard settings, low-resource In method(s) what consider is/are should Policy-makers settings. in their feasible most 3.2.13  Policy-makers need to determine which pain relief measures are most appropriate Opioid analgesia (feasible and acceptable) in their settings, in consultation with health care for pain relief professionals and the women using their facilities.  Opioid analgesia is not suitable in settings where women and babies cannot be adequately monitored due to staff shortages, or where resuscitation skills, equipment and supplies (oxygen, appropriate drugs) are lacking.  Setting-specific protocols for assessing a woman’s need for pain relief and for providing a range of pharmacological and non-pharmacological options should be developed to guide clinical management, to support women’s decision-making, and to ensure safe and equitable provision of pain relief.  Health care facilities providing opioid analgesia should ensure that personnel skilled in performing resuscitation are among the staff on duty at all times.  Health care facilities should monitor adherence to clinical protocols and complications related to opioid use (particularly maternal and neonatal respiratory depression) to reduce iatrogenic outcomes.  Health care professionals should communicate to women the pain relief options for labour and birth available at their facility, and should discuss the advantages and disadvantages of these options, as part of antenatal care education and counselling.  Health care facilities providing pharmacological options for pain relief, including opioid analgesia, should ensure that they have adequately trained staff, clear protocols and the necessary equipment to manage complications, should they arise.  Mechanisms should be in place at facilities offering pharmacological pain relief options to ensure that the drugs are kept in stock and can be dispensed when needed.  Opioid medication needs to be securely stored and a register kept of its dispensing, to reduce the risk of abuse. 3.2.14  Health care professionals should communicate to women the pain relief options for Relaxation labour and birth available at their facility, and should discuss the advantages and techniques for disadvantages of these options as early as possible in labour, and ideally as part of pain management antenatal care education and counselling. 3.2.15  Training institutions could cover these techniques in health care professionals’ Manual pre-service and in-service training. For lay companions, basic training in these techniques for techniques could be facilitated during the antenatal period. pain management 3.3 SECOND STAGE OF LABOUR 3.3.1  Same as considerations for 3.2.1–3.2.3. Definition and duration of the second stage of labour 3.3.2  In settings where women usually give birth in recumbent positions, policy-makers Birth position should ensure that (i) health care professionals receive in-service training on how to (for women support women to give birth in upright positions and (ii) the necessary facilities that without epidural can be used to support alternative upright positions for women are provided. analgesia)  Health care professionals should advise women about their options with regard to choice of birth positions; this should be done during antenatal care contacts as part of antenatal education and counselling. ANNEX 4. IMPLEMENTATION CONSIDERATIONS SPECIFIC TO INDIVIDUAL RECOMMENDATIONS INDIVIDUAL TO SPECIFIC CONSIDERATIONS ANNEX IMPLEMENTATION 4.

199 200 WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE Fundal pressure 3.3.8 Episiotomy policy 3.3.7 perineal trauma preventing for Techniques 3.3.6 analgesia) epidural with women (for pushing of Method 3.3.5 pushing of Method 3.3.4 analgesia) with epidural (for women position Birth 3.3.3

                              how best to reduce unnecessary childbirth practices in their settings. intheir practices childbirth unnecessary to reduce how best to determine research implementation undertaking consider could Stakeholders outcomes. birth to adverse lead can and recommended is not aware this that practice made be should providers care Health episiotomy removed. are perform incentives to other and any financial that ensure should facilities care private health and public both for administrators and managers care health Policy-makers, facilities. displayed inmaternity clearly be protocols should and Episiotomy indications episiotomy.for consent to awoman give for informed aware need of be the should All stakeholders of episiotomy use is the now restricted. that informed be should providers care health and women childbirth, for facilities with care low utilization of health settings in and employed, of episiotomy been use has liberal or routine where settings In of episiotomy use is permissible. selective only that and episiotomyliberally that notused be is to recommendation the to reflect updated be protocols should facility care health and societies of professional Guidelines processes. inparticipatory bodies professional and facilities of training representatives include should policy-makers support, and training receive appropriate workers health to that and ensure To support broad secure noted. be should of labour stage second the during care her for woman’s the and preferences counselling, of BPCR part as contacts care antenatal during done be this should trauma; preventingavailable for perineal options different the to women communicate should professionals care Health settings. intheir feasible most are techniques which consider can Stakeholders compresses and a “hands-on” guarding approach. warm massage, perineal trauma: preventingperineal for options different these to include of labour stage second inthe women supporting on guidance and training their update should facilities care health and societies bodies, Professional trauma. preventing for perineal intechniques training includes professionals care of health training pre-service to that institutions ensure training and societies bodies, liaise with professional should Policy-makers analgesia. with epidural women for of labour stage second inthe pushing delayed to support updated be should content training in-service and pre-service Clinical protocols, pushing. spontaneous to support updated be should content training in-service and pre-service protocols, clinical techniques, pushing to directed using accustomed are professionals care health where settings In row). (previous item 3.3.2 for as considerations implementation Same For more information, please contact: World Health Organization Avenue Appia 20, CH-1211 Geneva 27, Switzerland

Department of Reproductive Health and Research ISBN 978-92-4-155021-5 E-mail: [email protected] Website: www.who.int/reproductivehealth Department of Maternal, Newborn, Child and Adolescent Health Email: [email protected] Website: www.who.int/maternal_child_adolescent