Normal Labor
- Recommendations
1. Definition
Normal labor is labor that:
· Occurs between 37+0 and 42+0 weeks completed weeks
· Spontaneous onset
· Singleton gestation
· Vertex presentation
· Normal labor progress
· Spontaneous vaginal birth
· No maternal or fetal complications or risk factors. (1-3)
Justification
The benefits of normal labor and birth for the woman and baby include:
– Enhances labor effectiveness
– Promotes fetal readiness for birth
– Protects the baby from reduced oxygen during labor
– Improves physiological response to labor stress and pain
– Promotes maternal and newborn transitions
– Helps to minimize maternal bleeding after birth
– Promotes optimal mother-infant attachment (1, 2, 7)
2. Initial maternal assessment
2.1
History
taking
2.1.1 Review history, pregnancy notes
and screening results including:
– Gestational age.
– Past history (medical, obstetric, gynecological, surgical, social, family).
– Medications, allergies.
– Pregnancy complications.
– Investigation results (including placental location).
2.1.2 Ask her about the length,
strength and frequency of her contractions.
2.1.3 Ask about fetal movements in the
last 24 hours.
2.1.4 Ask for vaginal losses.
2.1.5 Review if there are any antenatal
or intrapartum risk factors for fetal hypoxia.
2.1.6 Review ER visit history and
clinical circumstances at each visit.
Assess emotional and
psychological needs. (1, 2)
(Strong
recommendation, moderate-quality evidence)
2.2
General
Examination
2.2.1 Temperature, pulse, respiratory
rate, blood pressure (BP), and urinalysis
2.2.2 Assess nutrition and hydration
status and general appearance.(1, 2)
(Strong
recommendation, moderate-quality evidence)
2.3
Abdominal
examination
2.3.1 Observation, and palpation including:
– fundal
height, fetal lie, attitude, presentation, position, engagement/descent
2.3.2 Record time of maternal account of regular,
painful contractions
–
Assess strength, frequency,
duration and resting tone for 10 minutes.(1, 2)
(Strong
recommendation, moderate-quality evidence)
Justification
An assessment of
early labor by maternity care providers should review history, pregnancy notes
and screening results. Accurate and consistent triage and information sharing
supports and empowers remaining at home during the latent phase of labor. Ascertain reason for presentation or contact,
assess emotional and psychological needs, perform general, abdominal
examinations and discuss preferences for labor and birth.(1, 2, 8)
2.4
Auscultation
of fetal heart rate
2.4.1 Intermittent auscultation using either a Pinard
stethoscope or a handheld Doppler ultrasound device (e.g. Doptone® or
SonicAid®).
2.4.2 Auscultate the fetal heart rate for a minimum of
1 minute immediately after a contraction; palpate the woman's pulse to
differentiate between the heartbeats of the woman and the baby
2.4.3 Differentiate between maternal and fetal
heartbeat.(2)
(Strong
recommendation, moderate-quality evidence)
Justification
Several societies
recommend intermittent auscultation to women in labor at low risk of
complications.(9-11) The
evidence was derived from a Cochrane systematic review comparing continuous CTG
versus intermittent auscultation (IA) for assessment of fetal well-being during
labor.(12) For the purposes
of this guideline, only evidence derived from the low-risk subgroup of the
review was included. Three trials were individual RCTs and one was a quasi-RCT
(the USA study), which alternated interventions for each month of the trial.
The latter study was assessed as being at a high risk of bias. The method of IA
varied across trials to include auscultation using a Pinard fetal stethoscope
and/or Doppler ultrasound device.(12)
2.5
Vaginal
examination
Indication of VE
2.5.1 if there is uncertainty about whether the woman
is in established labor, a vaginal examination may be helpful after a period of
assessment, but is not always necessary
2.5.2 if the woman appears to be in established labor,
offer a vaginal examination.
2.5.3 If spontaneous rupture of membranes (SROM)
suspected, consider a dry sterile speculum examination.
2.5.4 Routine clinical pelvimetry on admission in labor
is not recommended for healthy pregnant women.
2.5.5 Assess and record vaginal loss
– Discharge—note color, odor, consistency
– Blood—note color, volume
– Liquor—note color, volume, odor, consistency
– Presence of meconium
2.5.6 Document the presence or absence of meconium.
– If meconium is present, consider the character of
the meconium.
– Meconium may increase the risk to the baby means
that: Continuous CTG monitoring may be advised
– Healthcare professionals trained in advanced
neonatal life support are needed as soon as the baby is born.
Contraindication to VE
– Antepartum hemorrhage
– Ruptured membranes and not in labor
– Placenta previa
– Placental position unknown
– Suspected preterm labor
Prior to VE
2.5.7 Review history and most recent ultrasound scan
result
2.5.8 Explain procedure and gain verbal consent prior
to each examination
2.5.9 Ensure the woman's privacy, dignity and comfort
Ensure bladder is empty
2.5.10 Perform abdominal examination and FHR
auscultation
2.5.11 Tap water may be used if cleansing is required
before vaginal examination.
During VE
2.5.12 Maintain privacy, dignity and respect
2.5.13 Keep the woman informed of findings during the
examination
2.5.14 Perform VE between contractions
2.5.15 Assessment:
-
Observe general appearance of perineal
and vulval area
-
Position of cervix—posterior, mid,
anterior
-
Dilatation
-
Effacement
-
Consistency—soft, medium, firm
-
Application of presenting part
-
Membranes intact/no membranes felt
-
Liquor—note color, volume, odor
-
Fetal station: level of presenting
part in relation to ischial spines (- 3 to + 3)
-
Presence of caput and molding
-
Fetal position and attitude
After VE
2.5.16 Discuss any potential impact on the birth plan
2.5.17 Auscultate FHR
2.5.18 Document findings.(1-3)
(Strong recommendation, moderate-quality evidence)
Justification
The committee were aware that the guideline recommended a vaginal examination be carried out at a number of different timepoints but did not specify what should be assessed as part of this vaginal examination. Based on their knowledge and experience, the committee therefore added a recommendation with these details. Where membranes are intact, there is no evidence to support or reject the use of routine VE in labor to improve outcomes for women and babies.(1, 3, 13)
3. Laboratory investigation
3.1.1 Hb concentration (if not performed in the past
month).
3.1.2 Blood group and Rh typing (if not performed before).
3.1.2.1 In Rh negative mothers with Rh positive husband,
request indirect Coomb’s test if available.
(GPS,
Consensus-based)
4. Admission
4.1
Criteria
for admission to labor ward
4.1.1 Admission decisions should take into account:
– Maternal
and fetal wellbeing
– Labor
progress (e.g., dilation, contractions)
– Complicating
risk factor indicating hospital admission.
4.1.2 Criteria of admission to labor ward in low-risk
women:
– Active stage of labor
– ROM
4.1.3 Women with cervical dilatation < 5cm and good uterine contractions should be observed for 2 hours and admit to labor ward if the cervix dilates 1 cm or more.(1, 2, 5)
(Conditional recommendation, moderate-quality evidence)
Justification
Observational studies have found that admission in the latent phase of labor is associated with more arrests of labor and cesarean births in the active phase and with a greater use of oxytocin, intrauterine pressure catheters, and antibiotics for intrapartum fever.(14-16) However, these studies were unable to determine whether these outcomes reflected interventions associated with earlier and longer exposure to the hospital environment or a propensity for dysfunctional labor among women who present for care during the latent phase. A randomized controlled trial that compared admission at initial presentation to the labor unit (immediate admission) versus admission when in active labor (delayed admission) found that those allocated to the delayed admission group had lower rates of epidural use and augmentation of labor, had greater satisfaction, and spent less time in the labor and delivery unit. Although there were no significant differences between study groups in operative vaginal or cesarean births or new- born outcomes, the study was underpowered to assess these outcomes.(17)
Importantly, recent data from the Consortium for Safe Labor support updated definitions for latent and active labor. In contrast to the prior suggested threshold of 4 cm, the onset of active labor for many women may not occur until 5–6 cm.(18-20) These data suggest that expectant management is reasonable for women at 4–6 cm dilatation and considered to be in latent labor, as long as maternal and fetal status are reassuring. For women who are in latent labor and are not admitted to the labor unit, a process of shared decision making is recommended to create a plan for self-care activities and coping techniques. An agreed-upon time for reassessment should be determined at the time of each contact. Care of women in latent labor may be enhanced by having an alternate unit where such women can rest and be offered support techniques before admission to labor and delivery.
Admission during the latent phase of labor may be necessary for a variety of reasons, including pain management or maternal fatigue.(21, 22) When women are observed or admitted for pain or fatigue in latent labor, techniques such as education and support, oral hydration, positions of comfort, and nonpharmacologic pain management techniques such as massage or water immersion may be beneficial.(23, 24)
4.2 General
Care and support for normal labor
4.2.1 Providers, senior staff and all healthcare
professionals should ensure that in all birth settings there is a culture of
respect for each woman as an individual undergoing a significant and
emotionally intense life experience, so that the woman is in control, is listened
to and is cared for with compassion, and that appropriate informed consent is
sought.(1)
(GPS,
Consensus- based)
4.2.2 Maintain the minimum level of birth intervention
compatible with safety.(2)
(Strong recommendation, Low-moderate quality evidence)
Justification
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 labor 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 labor 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. Interventions
should aim to ensure a respectful and dignified working environment for those
providing care, acknowledging that staff may also experience disrespect and
abuse in the workplace and/or violence at home or in the community.(3)
Evidence on the effects of respectful
maternity care (RMC) interventions on birth outcomes was derived from a
systematic review of five studies.(25) Types of components included in the RMC
interventions were: training in values and attitudes transformation; training I
interpersonal communication skills; setting up quality improvement teams;
monitoring of disrespect and abuse; staff mentorship; improving privacy in
wards (e.g. with curtains or partitions between beds); maternity open days;
community workshops; mediation/alternative dispute resolution; counselling of
community members who have experienced disrespect and abuse; providing a method
for submitting complaints; and educating women on their rights.
Data were not pooled due to
heterogeneity across studies in study design and the definitions and reporting
of outcomes. Data were relatively sparse and all of the studies were at unclear
or high risk of bias. Therefore, the level of certainty of the evidence was
downgraded for risk of bias for all outcomes.(3, 25)
4.3
Eating
and drinking
Explain to the woman or pregnant
person that they should drink during labor when they are thirsty, and that
isotonic drinks may be more beneficial than water. Also explain that there is
no benefit to drinking any more than normal, and over consumption may be
harmful.(1)
(Strong
recommendation, moderate quality evidence)
4.3.1 Inform the woman or pregnant person that they can
eat a light diet in established labor if they wish, unless they have received
opioids or they develop risk factors that make a caesarean birth more likely.(1)
(Conditional
recommendation, low quality evidence)
Justification
For
low-risk women, restricting oral intake has shown no improvement on maternal or
fetal birth outcomes,(26) therefore,
it is recommended to support woman to eat and drink as desired, offer frequent
sips of water. Intrapartum isotonic and carbohydrate drinks are not any more
beneficial than drinking water. Oral carbohydrate supplements do not alter
labor outcomes.(27)
4.4
Fluid
intake and output
4.4.1 Discuss with the woman or pregnant person that:
– it is
important to drink during labor when thirsty
– it is
important to regularly empty the bladder
– excessive
intake of oral or intravenous fluids may be harmful as this can cause
hyponatremia (a sodium level of less than 130 mmol/L in a pregnant woman or
pregnant person) and lead to maternal and neonatal seizures or death
– their
midwife will ask about and check up on their fluid intake and output throughout
labor
– fluid
balance monitoring may be advised during labor to reduce the risk of
hyponatremia or dehydration.(1)
(Strong
recommendation, low-quality evidence)
Justification
Natural changes in water and sodium balance in the body during
pregnancy mean that normal sodium levels in the blood during pregnancy (130 to
140 mmol/L) are slightly lower than the level in the general population (135 to
145 mmol/L). Women and people in labor are at higher risk of hyponatremia
(sodium less than 130 mmol/L) because of physiological changes in pregnancy and
in labor, including a lower blood osmolality, a lower sodium level and the
antidiuretic effect of both endogenous and exogenous oxytocin in labor. The
liberal use of intravenous fluids and excessive oral intake further increases
the risk. Maternal hyponatremia impacts the unborn baby because water crosses
the placenta freely, which can lead to hyponatremia in the newborn. Mild
hyponatremia can be asymptomatic, but more severe hyponatremia can cause
maternal or neonatal neurological morbidity, including seizures, coma and
death.(1)
4.4.2 Monitor and record fluid balance, if:
– there
are any concerns about fluid intake, for example the woman or pregnant person
is drinking too much (also take into account fluid intake before labor care
began)
– the
woman or pregnant person is receiving intravenous fluids
– the
woman or pregnant person is receiving an oxytocin infusion
– there
are any concerns about fluid output, for example there is an inability to pass
urine, nausea, vomiting or diarrhea
– there
are certain medical conditions, such as hemorrhage or pre-eclampsia.(1)
(Strong
recommendation, low-quality evidence)
Justification
The best way to prevent hyponatremia is to monitor fluid balance
by recording the volume of fluid intake (oral and intravenous) and output
(primarily urine) in a chart. Fluid balance monitoring may also be important
for other clinical reasons, including to prevent dehydration if the person is
vomiting or in the context of pre-eclampsia, for example. The committee agreed
that the benefits of monitoring fluid balance in all labors needs to be
balanced with the implications of it in terms of, for example, midwife time and
the birth experience of the woman or pregnant person. The committee discussed
that, as standard practice, the midwife would keep an eye on the woman's or
pregnant person's fluid intake and output and if there were any concerns or
risks, this would prompt a formal fluid balance monitoring. So, the committee
did not recommend fluid balance monitoring in all labors as it may not always
be clinically necessary, but based on their expertise, they recommended indicators
for when it should be done. The committee agreed that if healthcare
professionals have any concerns about the person's fluid intake or output,
fluid balance monitoring should be carried out.(1)
4.4.3 If there is a positive fluid balance of 1500 ml
or more, or there are clinical concerns (for example, signs and symptoms of
hyponatremia):
– explain
to the woman or pregnant person that it is possible they are developing, or
have developed, hyponatremia
– request
an obstetric review
– offer
a blood test to check their sodium level
(Conditional
recommendation, low-quality evidence)
4.4.4 Do not routinely advise oral fluids or give
intravenous fluids for the treatment of ketonuria in pregnant women who are not
diabetic.(1)
(Strong
recommendation, low-quality evidence)
Justification
The committee agreed that a positive fluid balance of 1500 ml is a reasonable cut-off for prompting an obstetric review and a blood test to check for sodium levels. These should also happen when there are clinical concerns, such as signs and symptoms of hyponatremia. For women and pregnant people giving birth in a midwifery-led setting, this will mean transferring to an obstetric unit. The committee agreed that administering intravenous fluids or advising oral fluid intake to treat ketosis in women and people in labor who are not diabetic was common practice, but often unnecessary and potentially harmful because of the increased risk of hyponatremia.(1)
The committee did not make recommendations about how to manage hyponatremia and instead advised the use of local protocols. However, they emphasized the importance of informing the consultant obstetrician, consultant anesthetist and the neonatal team so that appropriate oversight and care plans are in place. The urgency of this depends on severity of hyponatremia demonstrated by symptoms or blood sodium level.(1)
The recommendations will improve awareness of the risk of excessive fluid intake in labor, and the subsequent risk of hyponatremia. This will in some cases lead to a change in practice with the increased use of fluid balance monitoring in labor. Increased use of fluid balance monitoring will have a small impact on midwife's time and there may be a small increase in need for blood tests and transfers to obstetric units, but the benefits of preventing adverse outcomes from hyponatremia should outweigh this. The recommendations are unlikely to have any significant resource impact.(1)
4.5
Pain
management:
4.5.1 When women are observed or admitted for pain or
fatigue in latent labor, techniques such as education and support, oral
hydration, positions of comfort, and nonpharmacologic pain management
techniques (such as breathing exercises, having a shower or bath, massage or
application of warm packs) may be beneficial.(1, 3, 5)
(Conditional
recommendation, low-quality evidence)
Justification
Findings from a review of qualitative studies looking at what matters to women during intrapartum care(28) suggest that most women, especially those giving birth for the first time, are apprehensive about childbirth (high confidence in the evidence), and in certain contexts and/or situations may welcome interventions that provide relief from pain (low confidence in the evidence). When interventions are being considered, women would like to be informed about the nature of the interventions and, where possible, given a choice (high confidence in the evidence).
In a separate review of qualitative studies related to labor pain coping techniques,(29) women valued massage techniques as a form of pain relief when these techniques enabled them to relax and feel calm, and to retain control over childbirth (low confidence in the evidence). Benefits to women’s overall well-being, such as feeling safe, reassured and less anxious, were also reported (low confidence in the evidence). However, while some women found that massage enabled them to effectively work with labor pain (low confidence in the evidence), others found it to be ineffective (very low confidence in the evidence).
4.6
Hygiene
4.6.1 Routine hygiene measures taken by staff caring
for women in labor, including standard hand hygiene and single-use non-sterile
gloves, are appropriate to reduce cross-contamination between women, babies and
healthcare professionals.(1)
(GPS, consensus
based)
Justification
Selection
of personal protective equipment for healthcare professionals must be based on
an assessment of the risk of exposure to blood and/or bodily fluids, non-intact
skin or mucous membranes. Standard infection control procedures to prevent
transmission of recognized and unrecognized infections must be followed.(1)
4.7
Perineal/pubic
shaving
4.7.1 We recommend against routine perineal/pubic
shaving prior to giving vaginal birth.
(Conditional recommendation,
very low-quality evidence)
Justification
This
recommendation applies to all hair shavings around the female external genital
area within the context of vaginal birth. It does not apply to women being
prepared for caesarean section. The decision regarding perineal/pubic shaving
should be left to the woman and not her health care giver. In situations where
a woman chooses to have perineal/pubic shaving prior to birth, she could be
advised to shave wherever, and by whomever she is most comfortable with (e.g.
at home shortly before the time of labor and childbirth).(30)
Evidence
on routine perineal/pubic shaving before childbirth for the prevention of
maternal and neonatal infectious morbidities was extracted from a Cochrane
systematic review of three randomized trials involving 1039 women.(31) The
trials were conducted in hospitals in the USA (Baltimore, Dallas) and Thailand
(Bangkok). All trials included women admitted to hospital prior to giving
birth. The trials compared perineal shaving versus no perineal shaving (which
included clipping or cutting of perineal hair). In two trials (involving 650
women), skin preparation was performed in both intervention and control groups
by scrubbing the external genitalia and inner thighs with soap and water or
povidone iodine spray; or with 4% chlorhexidine and rinsing with 1:100 savlon
solution.(31)
There is
no evidence of any clinical benefit of routine perineal (or pubic) shaving
before childbirth, although the quality of evidence is very low. Potential
complications of perineal shaving, such as irritation and redness of the
perineum, multiple superficial scratches from the razor, vulval itching and
burning sensation, are not clinically serious but can be discomforting to
women. Non-clinical outcomes that are considered very important to women such
as embarrassment during the procedure and discomfort during hair regrowth were
not reported by any of the studies. In the absence of any clinical benefits, it
is reasonable to conclude that perineal shaving has a higher potential of
leading to undesirable consequences for women.(30)
4.8
Enema
on admission
4.8.1 We recommend against administration of an enema
for reducing the use of labor augmentation.(3)
(Strong
recommendation, very low-quality evidence)
Justification
Evidence
was drawn from a Cochrane systematic review of four trials (almost 2000 women),(32) although
for most of the outcomes reported, data were available from only one or two
trials. Few critical and important maternal and infant outcomes were reported
and overall, there were no significant differences between groups. Enema versus
no enema: maternal outcomes.
Two trials
(1179 women) reported on the total duration of labor; no statistically
significant difference was observed in the duration of labor (MD
28.04 min, 95% CI –131.01 to 187.10) but there was a high level of
heterogeneity between the findings of the two trials. There was also no
observed difference between groups regarding the duration of the second stage
of labor (MD 5.2 min, 95% CI –2.56 to 12.96). No significant differences
were observed in the rates of second- or third-degree perineal trauma
(RR 0.68, 95% CI 0.39 to 1.21).(32)
Intrapartum
infection was marginally increased among women who received routine enema
(RR 4.62, 95% CI 1.03 to 20.68) but women requiring systemic
antibiotics following the birth were similar between the two comparison groups
(RR 1.16, 95% CI 0.73 to 1.84; one trial, 428 women). One trial (1027
women) reported women’s level of satisfaction with childbirth, the mean scores
were identical in the two groups (MD 0.00, 95% CI –0.10 to 0.10).(32)
The review
reported very little information on infant outcomes. There was no significant
difference in the rate of infants with low Apgar scores at five minutes
(RR 1.31, 95% CI 0.57 to 3.06). Rates of neonatal infection
(variously defined) were similar between the groups (RR 0.61, 95%
CI 0.24 to 1.52).(33)
4.9
Return/remain
at home
4.9.1 If there is no indication for immediate
admission, and the woman returns or remains at home, provide information on:
–
When to return/make contact, including if:
Increased
frequency, strength and duration of contractions
Increased
pain or discomfort requiring additional support
Vaginal
bleeding and/or membrane rupture
Reduced
or concern about fetal movements
– Plan
an agreed time for reassessment at each contact.(1, 2)
(Strong
recommendation, moderate-quality evidence)
Justification
The evidence was derived from a Cochrane
systematic review that included pregnant women without risk factors in early
labor.(34) Only one trial conducted in the
Canada, involving 209 nulliparous pregnant women, was directly relevant to this
guideline question; the evidence from this trial is described below.(17)
In this trial, after ascertaining that the
women were not in active labor (defined in the study as the presence of
regular, painful contractions and cervical dilatation greater than 3 cm), the
women in the intervention group were given support, encouragement and advice,
and instructed to walk around outside the facility or return home until labor
became more active, with instructions on when to return. If it was not clear
whether a woman in the intervention group was in active labor or not, she was
asked to remain in the assessment area for several hours, where armchairs and
magazines were available to her and her partner, until re-assessment. The
intervention group was compared with a control group of women who were admitted
directly to labor ward after the initial assessment.
The review found that these interventions have
little or no effect on childbirth outcomes, including caesarean section,
instrumental vaginal birth, oxytocin augmentation, epidural analgesia, serious
maternal morbidity, Apgar scores less than 7 at 5 minutes, and perinatal death.
However, low-certainty evidence from the review suggests that maternal
satisfaction may be increased with the home assessment and support
intervention.(34)
5. First stage of labor
5.1
Latent
phase
5.1.1 Duration of the latent stage:
5.1.1.1
Women
should be informed that a standard duration of the latent first stage has not
been established.(3)
(GPS, consensus-based)
5.1.2 Assessment in latent phase:
5.1.2.1
Review
birth plan and provide individualized support including:
o
Encourage ongoing resilience and
positive self-belief
o
Rest, hydration, nutrition,
mobilization, support
o
Reassurance.(2)
(Strong recommendation,
moderate-quality evidence)
Justification
Health care professionals should advise
healthy pregnant women that the duration of labor is highly variable and
depends on their individual physiological process and pregnancy characteristics.
Evidence was derived from a systematic review
of 37 studies evaluating the duration of spontaneous labor in women without
risk factors for complications.(35) The studies were published between
1960 and 2016 in 17 low-, middle- and high-income countries (China, Colombia,
Croatia, Egypt, Finland, Germany, Israel, Japan, Korea, Myanmar, Nigeria,
Norway, Taiwan [China], Uganda, the United Kingdom, the USA and Zambia), and
involving over 200 000 women of different ethnic origins and socioeconomic
status. Most of the included studies(36) were conducted in tertiary hospitals.
Among nulliparous, very low-certainty evidence
from two studies reported a median duration of the latent phase of the first
stage of labor of 6.0–7.5 hours without any indication of the percentile
distributions. One of these studies reported the latent phase as the period
from the onset of regular contractions until the slope of labor record was more
than 1.2 cm/hour while the other defined the latent phase as the “duration of
labor before presentation” (at hospital). One study reported the latent phase
as from admission to hospital until 4 cm cervical dilatation while the other
did not provide any reference points.(35,
36)
Among Parous women, very low-certainty
evidence from two studies presenting data reported median durations of the
latent phase of 4.5 and 5.5 hours. However, no percentile distributions were
reported. One of these studies reported the latent phase as the period from the
onset of regular contractions until the slope of labor record was more than 1.2
cm/hour while the other defined the latent phase as the “duration of labor
before presentation” (at hospital). Very low-certainty evidence from two
studies suggests that the mean duration of the latent phase ranges from 2.2 to
5.7 hours and statistical (“maximum”) limits were estimated as 5.4–8.7 hours.
One of these studies defined the latent phase as the period from hospital
admission until 4 cm dilatation.(35,
36)
5.1.3 Slow progress in latent stage:
5.1.3.1
Limited
high-quality evidence to provide a contemporary definition
5.1.3.2
Historically,
limits of more than 20 hours (nulliparous women) and more than 14 hours
(multiparous women) were applied to identify prolonged latent phase
5.1.3.3
Limits
not recommended as an indication for intervention when maternal and fetal
condition are reassuring
5.1.3.4
Labor
may not naturally accelerate until a cervical dilatation threshold of 5 cm is
reached. Therefore, the use of medical interventions to accelerate labor and
birth (such as oxytocin augmentation or caesarean section) before this
threshold is not recommended, provided fetal and maternal conditions are
reassuring
5.1.3.5
If
slow progress is suspected, assess to identify:
o
Developing complications
o
Reassuring maternal and fetal
condition
o
Emotional
and physical needs.(2, 3)
(Strong recommendation,
moderate-quality evidence)
Justification
The GDG emphasized that the decision to intervene when the first stage of
labor appears to be prolonged must not be taken on the basis of duration alone.
Health care professionals should support pregnant women with spontaneous labor
onset to experience labor and childbirth according to each individual woman’s
natural reproductive process without interventions to shorten the duration of
labor, provided the condition of the mother and baby is reassuring, there is
progressive cervical dilatation, and the expected duration of labor is within
the recommended limits.(3)
Women with suspected slow labor 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 labor
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
amniotic fluid, 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.(3)
5.2
Active
phase of 1st stage
5.2.1 Duration of the active first stage: the duration of active first stage (from 5 cm until full
cervical dilatation) usually does not extend beyond 12 hours in first labors,
and usually does not extend beyond 10 hours in subsequent labors.
(GPS, consensus
based)
Justification
Among nulliparous
active phase, moderate certainty evidence from two studies suggests that the
median duration of the active phase when the starting reference point was 4 cm
was 3.7–5.9 hours (with 95th percentile thresholds of 14.5–16.7 hours). When
the starting reference point was 5 cm, the median duration was 3.8–4.3 hours
(with 95th percentile thresholds of 11.3–12.7 hours). The only study reporting
6 cm as the starting reference point reported the median duration of the active
phase as 2.9 hours and the 95th percentile duration as 9.5 hours. For studies
reporting means, moderate-certainty evidence suggests that the mean duration of
labor progressing from 4 to 10 cm dilatation was 3.1–8.1 hours, with
statistical limits of 7.1–19.4 hours. One study reported a mean duration of 4.7
hours and statistical limits of 9.9 hours for the active phase with a starting
reference point of 3 cm. However, no study reporting a mean duration of the
active phase with a starting reference point of 5 or 6 cm was included in the
review.(35, 36)
Among parous
active phase, moderate-certainty evidence from two studies suggests that the
median duration of the active phase for women with parity of 1 and parity of
more than 1, with onset defined as 4 cm, was 2.2–4.7 hours, with a range of
13.0–14.2 hours for 95th percentile thresholds. One study presenting data
separately for women with parity of 1 and parity of more than 1, with reference
points for active phase starting from 5 cm, reported median durations of 3.4
and 3.1 hours, and 95th percentile thresholds of 10.1 and 10.8 hours,
respectively. The same study reported median durations of 2.2 and 2.4 hours and
95th percentile thresholds of 7.5 and 7.4 hours, respectively, when the
starting reference point for the active phase was 6 cm.(35, 36)
5.2.2 Progress of the first stage of labor: in active labor,
cervical dilatation of 0.5 cm per hour (2 cm in 4 hours) is considered normal.(2)
(Strong
recommendation, moderate-quality evidence)
5.2.3 Consider all aspects of labor progress including:
– Maternal
behavior
– Fetal
condition
– Cervical
dilatation and rate of change
– Descent
and rotation of the fetal head
– Strength,
duration and frequency of contractions
– Parity
– Previous
labor history
– Slowing of progress in the multiparous woman.(2, 3)
(Strong
recommendation, moderate-quality evidence)
Justification
The GDG acknowledged that in hospital settings the use of the alert line and
attempts to maintain cervical dilatation progression of 1 cm/hour led to
unnecessary interventions due to the perception that labor progress is
pathologically slow.(37)
Women with suspected slow labor 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 labor
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
amniotic fluid, 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.(3)
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 labor for most women.(3)
5.2.4 We recommend against the use of active management
of labor for prevention of delay in labor.(2, 3)
(Conditional, low-quality
evidence)
5.2.5 Do not routinely use amniotomy and or oxytocin to
prevent delayed progress in 1st stage of labor.(1)
(Conditional, low-quality
evidence)
5.2.6 We recommend against the use of intravenous
fluids with the aim of shortening the duration of labor.(3)
(Strong
recommendation, low-quality evidence)
5.2.7 We recommend against the use of oxytocin for prevention
of delay in labor in women receiving epidural analgesia.(3)
(Strong
recommendation, moderate-quality evidence)
5.2.8 We recommend against routine vaginal cleansing
with chlorhexidine during labor for the purpose of preventing infectious
morbidities.(2, 3)
(Strong
recommendation, moderate- quality evidence)
Justification
Application of slow-yet-normal cervical dilatation patterns as the benchmark for
managing the first stage of labor might be cost-effective as it has the
potential to reduce the use of interventions to accelerate labor and birth
(e.g. caesarean section, oxytocin augmentation) and linked interventions (e.g.
continuous cardiotocography, pain relief, antibiotics). In certain middle- and
high-income country settings where physicians attend to all women in labor, the
use of slow-yet-normal dilatation patterns for managing labor is likely to
result in increases in health care resource use.(3)
It is likely that facilitating slow-yet-normal labors would lead to
increased bed costs for vaginal births due to longer labor ward stays for
women. The estimated cost of a facility bed per day varies widely across
regions, as shown by the WHO-CHOICE example estimates (2007–2008).(38)
Increases in bed costs associated with longer labors might have less
impact on health care costs in LMICs than in HICs, where bed costs form a
larger proportion of costs for childbirth services. On the other hand, if the
use of oxytocin augmentation is reduced and fewer caesarean sections are
performed as a result of facilitation of slow-yet-normal cervical dilatation
patterns, the overall bed costs and health care resource use could be reduced
due to shorter postnatal stays.(3)
The most common indication for oxytocin augmentation and primary caesarean
section is “failure of labor to progress”, based on the expectation that normal
labor progression is at least 1 cm/hour during the active phase, which
traditionally starts from 4 cm.(39) However, unnecessary augmentation of labor and caesarean
section are highly inequitable interventions as they are unlikely to be
promptly received by disadvantaged women even when indicated. Application of
slow-yet-normal dilatation patterns to labor management for all women has the
potential to reduce inequity that is associated with overmedicalization of
childbirth.(3)
Findings from a review of qualitative studies looking at what matters to
women during intrapartum care(28) indicate that most women want a normal childbirth with
good outcomes for mother and baby, and do not appreciate unnecessary medical
interventions, including additional vaginal examinations that the test strategy
may warrant (high confidence in the evidence).
5.3
Ongoing
care during active phase of first stage
5.3.1 Digital vaginal examination (VE)
5.3.1.1 Minimize VE: VE at intervals of two hours is
recommended for routine assessment of active first stage of labor in low-risk
women.
5.3.1.2 Offer additional VE if:
· At
time of ROM
· Suspected
second stage
(GPS, Consensus-based)
5.3.2 Advice the woman to pass urine regularly to avoid
full bladder.
(GPS, Consensus-based)
5.3.3 Maternal mobility and position:
5.3.3.1 There is little evidence that any one position is
optimal in labor
5.3.3.2 Avoid supine position as it is associated with
adverse effects including:
· Supine
hypotension
· Abnormal FHR.(3)
(Strong
recommendation, low-quality evidence)
Justification
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 labor). The GDG acknowledged that the frequency of vaginal
examinations is dependent on the context of care and the progress of labor. The
group agreed that vaginal examinations at intervals more frequent may be
warranted by the condition of the mother or the baby.(3)
Evidence relating
to mobility and upright position compared with bed care for women in labor was
extracted from a Cochrane systematic review of 25 trials (> 5000 women).(26)
The review
included both randomized and quasi-randomized controlled trials. Most of the
women recruited into the trials were at full term with no pregnancy
complications. About half of the included trials recruited only nulliparous
women and a subgroup analysis by parity was performed. The trials examined two
different comparisons: upright and ambulant care versus bed care for women with
(seven trials) and without (18 trials) epidural analgesia at the point of
randomization.(26)
A very broad
range of interventions was considered in this review; upright and ambulant
positions ranged from women sitting, kneeling, squatting and walking, through
to taking up other positions either on or off the bed. For both comparisons, the quality of the
evidence was graded as low or very low for most outcomes, and due to the low
event rates for most of the neonatal outcomes many of the effect estimates
relating to the condition of the newborn were imprecise.(26)
5.4
Fetal
heart assessment
5.4.1 We recommend against the use of continuous
cardiotocography for assessment of fetal well-being in normal labor.(1, 3)
(Strong
recommendation, moderate-quality evidence)
5.4.2 Intermittent fetal heart rate monitoring: Intermittent auscultation of the fetal heart rate with
either a Doppler ultrasound device (e.g. Doptone® or SonicAid®) or a Pinard
fetal stethoscope is recommended for normal labor.
5.4.3 Interval: Auscultate every
15–30 minutes in active first stage of labor, and every 5 minutes in the second
stage of labor.
5.4.4 Duration: Each
auscultation should last for at least 1 minute; if the FHR is not always in the
normal range (i.e. 110–160 bpm), auscultation should be prolonged to cover at
least three uterine contractions.
5.4.5 Timing: Auscultate
during a uterine contraction and continue for at least 30 seconds after the
contraction.
5.4.6 Recording: Record the
baseline FHR (as a single counted number in beats per minute) and the presence
or absence of accelerations and decelerations.(1, 3)
(Strong
recommendation, moderate-quality evidence)
Justification
The evidence was derived from a Cochrane systematic
review comparing continuous CTG versus intermittent auscultation (IA) for
assessment of fetal well-being during labor.(12) For the purposes of
this guideline, only evidence derived from the low-risk subgroup of the review
was included. The method of IA varied across trials to include auscultation
using a Pinard fetal stethoscope and/or Doppler ultrasound device.
Summary estimates suggest little or
no difference in effect on perinatal mortality, cerebral palsy, cord blood
acidosis, hypoxic-ischemic encephalopathy (HIE), oxytocin augmentation and
epidural analgesia, among others. Very few clinically relevant neonatal
outcomes were reported consistently in the trials.(12) In addition, as
long-term follow-up was not performed, the long-term effects of the reported
neonatal seizures are not known.(3)
5.5
Partogram
5.5.1 Start using the partogram when active labor is
confirmed for documentation and providing a visual overview of progress.
5.5.2 Record the following observations during the
first stage of labor in the partogram:
5.5.2.1
half-hourly
documentation of frequency of contractions
5.5.2.2
hourly
pulse
5.5.2.3
4-hourly
temperature, blood pressure and respiratory rate as a minimum; in addition to
other observations according to situation.(1)
(Strong
recommendation, moderate-quality evidence)
Justification
Commence when active labor is
confirmed.(40) Although quality of
evidence for clinical benefit is low(3), it Provides a pictorial overview of progress,
facilitates timely transfer of care and may assist in the detection of
prolonged labor.
5.6
Maternal
and fetal warning signs
5.6.1 If any of the warning signs are present or
developed during labor, consult a specialist care:
– pulse
over 120 beats/minute on 2 occasions 15 to 30 minutes apart
– a
single reading of either raised diastolic blood pressure of 110 mmHg or more or
raised systolic blood pressure of 160 mmHg or more
– either
raised diastolic blood pressure of 90 mmHg or more or raised systolic blood
pressure of 140 mmHg or more on 2 consecutive readings taken 15 to 30 minutes
apart
– a
reading of 2+ of protein on urinalysis and a single reading of either
– raised
diastolic blood pressure (90 mmHg or more) or raised systolic blood pressure
(140 mmHg or more)
– respiratory
rate of less than 9 or more than 21 breaths per minute on 2 occasions 15 to 30
minutes apart
– temperature
of 38°C or above on a single reading, or 37.5°C or above on 2 consecutive
occasions 1 hour apart; for advice on intrapartum antibiotics
– fresh
red bleeding or blood-stained liquor
– the
new appearance of meconium
– pain
reported by the woman that differs from the pain normally associated with
contractions
– confirmed
delay in the first stage of labor
– obstetric
emergency, including antepartum hemorrhage, cord prolapse, maternal seizure or
collapse, or a need for advanced neonatal resuscitation
– any
non-cephalic presentation, including cord presentation
– high
(4/5 to 5/5 palpable) or free-floating head in a nulliparous woman
– suspected
fetal growth restriction or macrosomia
– suspected
anhydramnios or polyhydramnios
– any alarming fetal heart rate pattern.(1-3)
(Strong
recommendation, moderate-quality evidence)
5.7
Delayed
progress in active first stage (protracted labor)
5.7.1 If delayed progress in the established first
stage is suspected, assess:
– cervical
dilatation of less than 2 cm in 4 hours
– descent
and rotation of the baby's head
– strength,
duration and frequency of uterine contraction
– condition
of fetal membranes.(1)
(Strong
recommendation, moderate-quality evidence)
5.7.2 Offer the woman support, hydration, and
appropriate and effective pain relief.(1)
(Strong
recommendation, moderate-quality evidence)
5.8
Management
of delayed/protracted first stage or arrest of labor
5.8.1 Discuss the findings and the options available
with the woman, and support her decision.(1-3)
(Strong
recommendation, low-quality evidence)
5.8.2 For women with intact membranes in whom delay in
the established first stage of labor is confirmed:
– consider amniotomy if membranes are intact
– oxytocin if inertia was diagnosed and
– repeat vaginal examination 2 hours later.(1)
(GPS,
low-quality evidence)
Justification
Multiple studies have investigated the use of amniotomy
compared with no intervention, other interventions, or adjunctive to other
interventions during spontaneous labor and induction of labor.
A 2020 systematic review published by the Agency for
Healthcare Research and Quality included five randomized controlled trials from
2007 to 2010 investigating amniotomy in pregnant women undergoing spontaneous
labor compared with various control treatments.
The review determined that amniotomy in spontaneous labor decreased the
total duration of time in labor for nulliparous individuals without increasing
the risk for cesarean delivery, maternal infection, hemorrhage, or trauma to
the pelvic floor. Neonatal outcomes were not routinely evaluated in all of the
included trials, but no significant differences were noted. None of the
randomized controlled trials demonstrated an increased risk of cord prolapse
with amniotomy.(41)
5.8.3 If available, offer the woman an epidural
analgesia before oxytocin is started or if she requests it later.(1)
(Conditional
recommendation, moderate-quality evidence)
5.8.4 If oxytocin is used in the first stage of labor,
ensure that the time between increments of the dose is no more frequent than
every 30 minutes. Increase oxytocin until there are 3 to 4 contractions in 10
minutes.(1)
(Strong
recommendation, moderate-quality evidence)
5.8.5 Oxytocin must be discontinued immediately if
there is abnormality in fetal heart rate is observed.(1)
(Strong recommendation,
moderate-quality evidence)
5.8.6 Consider restarting oxytocin in the first stage
of labor if:
– Obstetric
review has been carried out and the FHR is no longer abnormal.
– Base
the dose when restarting on a full clinical assessment, taking into consideration
the previous dose.(1)
(Conditional
recommendation, low-quality evidence)
5.8.7 Perform vaginal examination 2 hourly after the
oxytocin infusion has led to regular contractions: If cervical dilatation has
increased by less than 2 cm after 4 hours of oxytocin, or there is arrest of
labor, further obstetric review is needed by a senior obstetrician to assess
whether a caesarean birth is advisable.(1)
(Strong
recommendation, moderate-quality evidence)
Justification
Several studies have evaluated the optimal duration of
oxytocin augmentation in the face of labor protraction or arrest. A prospective
study of 319 pregnant women with dysfunctional labor found that, with 4
additional hours of oxytocin, 50.7% of nulliparous individuals and 41.7% of
multiparous individuals delivered vaginally. In nulliparous patients, a period
of 8 hours of augmentation resulted in an 18% cesarean delivery rate. In
contrast, if the period of augmentation had been limited to 4 hours, the
cesarean delivery rate would have been almost twice as high at 35.5%.(42) Thus, a slow but progressive active phase of labor
demonstrating cervical change at least every 4 hours in the setting of
reassuring maternal and fetal status should not be an indication for cesarean
delivery.
6. Second stage of labor
6.1
Assessment
of women during the second stage of labor
6.1.1 Continue with observations of the woman and baby,
and assessment of risk as described for the first stage of labor and, but be
aware that the frequency of fetal monitoring should increase.
6.1.2 Increase Frequency of observations if clinically
indicated.(1, 2)
(Strong
recommendation, moderate-quality evidence)
6.2
Vaginal
examination
6.2.1 To assess progress, the vaginal examination
should include:
– position
of the head
– descent
– caput and molding.(1)
(GPS, Consensus-based)
6.3
Fundal
pressure
6.3.1 Application of manual fundal pressure to
facilitate childbirth during the second stage of labor is not recommended.(3)
(Strong
recommendation, moderate quality evidence)
Justification
The evidence was derived from a Cochrane systematic
review that included nine trials involving 3948 women.(43) Manual fundal
pressure was applied according to the Kristeller manoeuvre in four trials, and
as “gentle assisted pushing” in one small trial (120 women); two of these
trials recruited primigravid women only. One trial limited the application of
fundal pressure to three attempts. Most of the included trials had design
limitations.
Concerns relating to the practice of fundal pressure are
due to the possibility that serious harm might arise in the mother or the baby
from the application of excessive uncontrolled force,(44, 45) including uterine and
other organ rupture, and maternal and perinatal death; however, these
occurrences might not often be reported in the literature.
6.4
Techniques
for preventing perineal trauma
6.4.1 For women in the second stage of labor,
techniques to reduce perineal trauma and facilitate spontaneous birth
(including perineal massage, warm compresses and a “hands on” guarding of the
perineum) are recommended.(3)
(Strong
recommendation, moderate-quality evidence)
Justification
The
evidence is derived from a Cochrane systematic review that included 22
individual RCTs.(46) Twenty trials involving 15 181 women
contributed data. Perineal techniques
performed in the second stage of labor that are included in this framework are:
perineal
massage compared with a “hands-off” approach or usual care;
a
“hands-off” compared with a “hands-on” approach;
a
warm compress compared with a “hands-off” approach or no warm compress; and
Ritgen’s
maneuver compared with usual practice.
Perineal/vaginal
trauma: Low-certainty evidence suggests that perineal massage may increase the
likelihood of having an intact perineum after giving birth (6 trials, 2618
women, RR 1.74, 95% CI 1.11–2.73). The absolute effect is estimated as 168 more
women having an intact perineum per 1000 (from 25 to 393 more).
High-certainty
evidence indicates that perineal massage reduces third- or fourth-degree
perineal tears (5 trials, 2477 women, RR 0.49, 95% CI 0.25– 0.94). The absolute
effect is estimated as 5 fewer per 1000 (from 2 to 22 fewer). Evidence on
first- and second-degree tears, episiotomy and the need for perineal suturing
is of very low certainty. The review found no evidence on long-term outcomes,
maternal satisfaction or other outcomes related to birth experience.(3, 46)
6.5
Episiotomy
policy
6.5.1 Routine or liberal use of episiotomy is not
recommended for women undergoing spontaneous vaginal birth.(3)
(Strong
recommendation, moderate-quality evidence)
6.5.2 If an episiotomy is performed, the recommended
technique is a mediolateral episiotomy originating at the vaginal fourchette
and usually directed to the right side. The angle to the vertical axis should
be between 45 and 60 degrees at the time of the episiotomy.(1)
(Strong
recommendation, moderate-quality evidence)
6.5.3 Perform an episiotomy if there is a clinical
need, such as birth with forceps or ventouse or suspected fetal compromise.
6.5.4 Provide tested, effective analgesia before
carrying out an episiotomy, except in an emergency because of acute fetal
compromise.(1)
(Strong recommendation, moderate-quality evidence)
Justification
The evidence was derived from a Cochrane systematic review that included 12 RCTs (168). In 11 trials, participants were women in labor for whom a vaginal birth was anticipated. Differences in episiotomy rates between the study groups in the trials varied from 21% to 91%, with three trials reporting a difference of less than 30%. In the selective episiotomy groups, episiotomy rates ranged from 8% to 59% (median 32%), and in the routine or liberal episiotomy groups they ranged from 51% to 100% (median 83%).(46)
Low-certainty evidence suggests that a policy of selective/restrictive episiotomy may reduce severe perineal/vaginal trauma (mainly third- and fourth-degree tears) compared with routine or liberal episiotomy (11 trials, 6177 women, RR 0.70, 95% CI 0.52–0.94). Subgroup analysis by parity suggests that the episiotomy policy might not make a difference to perineal/vaginal trauma in multigravid women, but the evidence is very uncertain. A selective/restrictive episiotomy policy may reduce the need for perineal suturing (excluding episiotomy repair) (6 trials, 4333 women, RR 0.68, 95% CI 0.58–0.78); however, the data in some trials may have included episiotomy repair, making the evidence uncertain.(46)
Low-certainty evidence suggests that selective/ restrictive episiotomy may have little or no effect on perineal infection (3 trials, 1467 women, RR 0.90, 95% CI 0.45–1.82). Evidence on relative blood loss at birth is very uncertain.
For long-term morbidity at 6 months or more after childbirth, low-certainty evidence suggests there may be little or no effect of selective/restrictive versus routine or liberal episiotomy on dyspareunia (pain during intercourse) (3 trials, 1107 women, RR 1.14, 95% CI 0.84–1.53). Evidence on other long-term morbidity is sparse and very uncertain (urinary incontinence, genital prolapse), or lacking (fecal incontinence, sexual dysfunction).(46)
Evidence on low Apgar scores (< 7 at 5 minutes) is of very low certainty, mainly because the sample size is small (2 trials, 511 babies) and no events occurred in either comparison group.(3, 46)
6.6
Shortening
of the 2nd stage(1)
6.6.1 Delay in active second stage is diagnosed when:
– In nulliparous woman (any of): either
insufficient flexion/rotation/descent within 1 hour or the second stage
duration is > 2 hours.
– In multiparous woman (any of): either
insufficient flexion/rotation/descent within 30 minutes or the second
stage duration is > 1 hour.
– Longer durations may be appropriate where
maternal and fetal condition is optimal.
(GPS, very low-quality evidence)
6.6.2 A specific absolute maximum length of second
stage (passive plus active) has not been identified. Rather than rigid time limits,
base decision-making on continuing assessment of:
– Maternal physical and emotional condition
– Fetal condition
– Progress of labor
–
Maternal
preferences.(5)
(Strong recommendation, moderate-quality evidence)
6.6.3 Operative vaginal delivery in second stage of
labor by experienced and well-trained physicians should be considered safe,
acceptable alternative to cesarean delivery. Training in, and ongoing
maintenance of, practical skills related to operative vaginal delivery should
be encouraged.(47-51)
6.6.4 Training in, and ongoing maintenance of,
practical skills related to operative vaginal delivery should be encouraged.
(Strong
recommendation, moderate-quality evidence)
7. Third stage of labor
7.1
Management
of third stage of labor
7.1.1 The use of uterotonics for prevention of PPH
during the third stage of labor is recommended for all births.(52, 53)
(Strong
recommendation, high-quality evidence)
7.1.2 Cord clamping:
7.1.2.1 Late cord clamping (performed approximately 1 to 3 minutes
after birth) is recommended for all births while initiating simultaneous
essential newborn care.(54)
(Strong
recommendation, moderate-quality evidence)
7.1.2.2 Early
cord clamping (<1 minute after birth) is not recommended unless the neonate
is asphyxiated and needs to be moved immediately for resuscitation.(54)
(Strong recommendation, moderate-quality evidence)
Justification
The evidence base for recommendations for the timing of cord clamping includes both vaginal and caesarean births. Delayed clamping should be performed during the provision of essential newborn care.(55) The recommendations for the timing of cord clamping apply equally to preterm and term births. The GDG considers the benefits of delayed clamping for preterm infants to be particularly important.
Some health professionals working in areas of high HIV prevalence have expressed concern regarding delayed cord clamping as part of management of the third stage of labor. These professionals are concerned that during placental separation, a partially detached placenta could be exposed to maternal blood and this could lead to a micro-transfusion of maternal blood to the baby. It has been demonstrated that the potential for maternal-to-child transmission of HIV can take place at three different points in time: micro-transfusions of maternal blood to the fetus during pregnancy (intra-uterine HIV transmission), exposure to maternal blood and vaginal secretions when the fetus passes through the birth canal in vaginal deliveries (intra-partum transmission), and during breastfeeding (postnatal infection).
For this reason, the main intervention to reduce the maternal-to-child transmission is the reduction of maternal viral load through the use of antiretroviral drugs during pregnancy, childbirth and postnatal period. There is no evidence that delaying the cord clamping increases the possibility of HIV transmission from the mother to the newborn. Maternal blood percolates through the placental intervillous space throughout pregnancy with a relatively low risk of maternal fetal transmission before delivery. It is highly un likely that separation of the placenta increases exposure to maternal blood, and is highly unlikely that it disrupts the fetal placental circulation (i.e. it is unlikely that during placenta separation the newborn circulation is exposed to maternal blood). Thus, the proven benefits of a 1 – 3 minutes delay at least in clamping the cord outweigh the theoretical, and unproven, harms. Late cord clamping is recommended even among women living with HIV or women with unknown HIV status.