In spite of the considerable debates and research that have been ongoing for several years, the concept of “normality” in labour and childbirth is not universal or standardized. There has been a substantial increase over the last two decades in the application of a range of labour practices to initiate, accelerate, terminate, regulate or monitor the physiological process of labour, with the aim of improving outcomes for women and babies. This increasing medicalization of childbirth processes tends to undermine the woman’s own capability to give birth and negatively impacts her childbirth experience. In addition, the increasing use of labour interventions in the absence of clear indications continues to widen the health equity gap between high- and low-resource settings.1)http://apps.who.int/iris/bitstream/10665/260178/1/9789241550215-eng.pdf?ua=1
HOW LONG SHOULD CHILDBIRTH LABOR LAST?
We examined this question of labor length a couple of years ago when a new study was published. This study found that giving women just one hour longer in the second stage of childbirth would cut cesarean rates in half.2)http://www.ajog.org/article/S0002-9378(15)02594-6/abstract The World Health Organization (WHO) has previously stated that c-sections are overused when not medically necessary, especially in the United States. Surgical c-section birth is just one example where medical interventions are implemented to speed birth along.
WHO: Intrapartum Care for a Positive Childbirth Experience
In a new report issued February 2018, WHO issued new guidelines for childbirth. These are the first guidelines issued since Care in normal birth: a practical guide was published in 1996.3)http://www.who.int/maternal_child_adolescent/documents/who_frh_msm_9624/en/
56 Key Recommendations for Childbirth
- Respectful maternity care – which refers to care organized for and provided to all women in a manner that maintains their dignity, privacy and con dentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labour and childbirth – is recommended.
- Effective communication between maternity care providers and women in labour, using simple and culturally acceptable methods, is recommended.
- A companion of choice is recommended for all women throughout labour and childbirth.
- Midwife-led continuity-of-care models, in which a known midwife or small group of known midwives supports a woman throughout the antenatal, intrapartum and postnatal continuum, are recommended for pregnant women in settings with well functioning midwifery programmes.
- The use of the following definitions of the latent and active first stages of labour is recommended for practice. The latent first stage is a period of time characterized by painful uterine contractions and variable changes of the cervix, including some degree of effacement and slower progression of dilatation up to 5 cm for first and subsequent labours. The active first stage is a period of time characterized by regular painful uterine contractions, a substantial degree of cervical effacement and more rapid cervical dilatation from 5 cm until full dilatation for first and subsequent labours.
- 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.
- For pregnant women with spontaneous labour onset, the cervical dilatation rate threshold of1 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.
- 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 identi cation of normal labour progression. A slower than 1-cm/hour cervical dilatation rate alone should not be an indication for obstetric intervention.
- 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.
- For healthy pregnant women presenting in spontaneous labour, a policy of delaying labour ward admission until active first stage is recommended only in the context of rigorous research.
- Routine clinical pelvimetry on admission in labour is not recommended for healthy pregnant women.
- Routine cardiotocography is not recommended for the assessment of fetal well-being on labour admission in healthy pregnant women presenting in spontaneous labour.
- Auscultation using a Doppler ultrasound device or Pinard fetal stethoscope is recommended for the assessment of fetal well-being on labour admission.
- Routine perineal/pubic shaving prior to giving vaginal birth is not recommended.
- Administration of an enema for reducing the use of labour augmentation is not recommended.
- Digital vaginal examination at intervals of four hours is recommended for routine assessment of active first stage of labour in low-risk women.
- Continuous cardiotocography is not recommended for assessment of fetal well-being in healthy pregnant women undergoing spontaneous labour.
- Intermittent auscultation of the fetal heart rate with either a Doppler ultrasound device or a Pinard fetal stethoscope is recommended for healthy pregnant women in labor.
- Epidural analgesia is recommended for healthy pregnant women requesting pain relief during labour, depending on a woman’s preferences.
- 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.
- Relaxation techniques, including progressive muscle relaxation, breathing, music, mindfulness and other techniques, are recommended for healthy pregnant women requesting pain relief during labour, depending on a woman’s preferences.
- 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.
- Pain relief for preventing delay and reducing the use of augmentation in labour is not recommended.
- For women at low risk, oral fluid and food intake during labour is recommended.
- Encouraging the adoption of mobility and an upright position during labour in women at low risk is recommended.
- Routine vaginal cleansing with chlorhexidine during labour for the purpose of preventing infectious morbidities is not recommended.
- A package of care for active management of labour for prevention of delay in labour is not recommended.
- The use of amniotomy alone for prevention of delay in labour is not recommended.
- The use of early amniotomy with early oxytocin augmentation for prevention of delay in labour is not recommended.
- The use of oxytocin for prevention of delay in labour in women receiving epidural analgesia is not recommended.
- The use of antispasmodic agents for prevention of delay in labour is not recommended.
- The use of intravenous fluids with the aim of shortening the duration of labour is not recommended.
- The use of the following definition and duration of the second stage of labour is recommended for practice. The second stage is the period of time between full cervical dilatation and birth of the baby, during which the woman has an involuntary urge to bear down, as a result of expulsive uterine contractions. Women should be informed that the duration of the second stage varies from one woman to another. In first labours, birth is usually completed within 3 hours whereas in subsequent labours, birth is usually completed within 2 hours.
- For women without epidural analgesia, encouraging the adoption of a birth position of the individual woman’s choice, including upright positions, is recommended.
- For women with epidural analgesia, encouraging the adoption of a birth position of the individual woman’s choice, including upright birth positions, is recommended.
- Women in the expulsive phase of the second stage of labour should be encouraged and supported to follow their own urge to push.
- For women with epidural analgesia in the second stage of labour, delaying pushing for one to two hours after full dilatation or until the woman regains the sensory urge to bear down is recommended in the context where resources are available for longer stay in second stage and perinatal hypoxia can be adequately assessed and managed.
- 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.
- Routine or liberal use of episiotomy is not recommended for women undergoing spontaneous vaginal birth.
- Application of manual fundal pressure to facilitate childbirth during the second stage of labour is not recommended.
- The use of uterotonics for the prevention of postpartum haemorrhage (PPH) during the third stage of labour is recommended for all births
- Oxytocin (10 IU, IM/IV) is the recommended uterotonic drug for the prevention of postpartum haemorrhage (PPH).
- In settings where oxytocin is unavailable, the use of other injectable uterotonics (if appropriate, ergometrine/methylergometrine, or the xed drug combination of oxytocin and ergometrine) or oral misoprostol (600 μg) is recommended.
- Delayed umbilical cord clamping (not earlier than 1 minute after birth) is recommended for improved maternal and infant health and nutrition outcomes.
- 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.
- Sustained uterine massage is not recommended as an intervention to prevent postpartum haemorrhage (PPH) in women who have received prophylactic oxytocin.
- In neonates born through clear amniotic fluid who start breathing on their own after birth, suctioning of the mouth and nose should not be performed.
- 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.
- 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.
- All newborns should be given 1 mg of vitamin K intramuscularly after birth (i.e. after the first hour by which the infant should be in skin-to-skin contact with the mother and breastfeeding should be initiated).
- Bathing should be delayed until 24 hours after birth. If this is not possible due to cultural reasons, bathing should be delayed for at least six hours. Appropriate clothing of the baby for ambient temperature is recommended. This means one to two layers of clothes more than adults, and use of hats/caps. The mother and baby should not be separated and should stay in the same room 24 hours a day.
- Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women.
- Routine antibiotic prophylaxis is not recommended for women with uncomplicated vaginal birth.
- Routine antibiotic prophylaxis is not recommended for women with episiotomy.
- All postpartum women should have regular assessment of vaginal bleeding, uterine contraction, fundal height, temperature and heart rate (pulse) routinely during the first 24 hours starting from the first hour after birth. Blood pressure should be measured shortly after birth. If normal, the second blood pressure measurement should be taken within six hours. Urine void should be documented within six hours.
- 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.4)http://apps.who.int/iris/bitstream/10665/260178/1/9789241550215-eng.pdf?ua=1
For mothers, a positive childbirth experience is stressed. This, of course, includes a healthy baby:
Women want a positive childbirth experience that ful ls or exceeds their prior personal and sociocultural beliefs and expectations. This includes giving birth to a healthy baby in a clinically and psychologically safe environment with continuity of practical and emotional support from birth companion(s) and kind, technically competent clinical sta . Most women want a physiological labour and birth, and to have a sense of personal achievement and control through involvement in decision- making, even when medical interventions are needed or wanted. 5)http://apps.who.int/iris/bitstream/10665/260178/1/9789241550215-eng.pdf?ua=1
WHO Recommends Slower Labor in Positive Childbirth Guidelines
Women need to be allowed to progress in childbirth at their own rate. Previous guidelines caused unnecessary medical interventions that affected the childbirth experience, as well as mother and child health and morbidity.
Dr. Olufemi Oladapo, author of the report told NPR:
This is a game-changing kind of recommendation. It goes against an ages-long benchmark categorizing how quickly labor should progress. Previous thinking was that less than one centimeter per hour was abnormally slow. But we now know that this benchmark is unrealistically fast for some women, and interventions to correct the rate of dilation can do more harm than good. If a woman is dilating slower than one centimeter per hour, as long as she’s making some progress, she can still have a vaginal delivery. Using that old, fixed rule for every woman doesn’t make sense. Just like in many things, humans tend to differ.6)https://www.npr.org/sections/goatsandsoda/2018/03/01/589860155/new-guidelines-establish-the-rights-of-women-when-giving-birth?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=20180301
In addition to recommending more patient childbirth labors, WHO endorses midwifery and doula care. All women should have a positive childbirth experience with positive outcomes for mother and baby. The new WHO guidelines aim to make this a reality worldwide.
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