World Health Organization Releases New Intrapartum Care Guidelines and They ROCK!

WHO Guidelines banner.jpg

The World Health Organization just released updated guidelines "WHO recommendations: Intrapartum care for a positive childbirth experience" and it is an important 212-page tome.  Right off the bat, I appreciated the title which recognizes that some birth experiences can be less than positive.  Hearing this news may bring back memories of ACOG's release of "Approaches to Limit Interventions During Labor and Birth" which came out this time last year. Science & Sensibility covered this here and here.

Maternal-infant health organizations worldwide recognize that there is a lot of room for improvement in the standard care that most people receive during labor and birth.  In the words of Dr. Neel Shah – we are challenged with doing "too much, too soon or too little, too late."  The purpose of this newly released document is to establish standards of care for healthy low-risk. pregnancies and reduce intrapartum interventions.

Dr. Princess Nothemba Simelela, WHO Assistant Director-General for Family, Women, Children, and Adolescents states "We want women to give birth in a safe environment with skilled birth attendants in well-equipped facilities. However, the increasing medicalization of normal childbirth processes are undermining a woman’s own capability to give birth and negatively impacting her birth experience.  “If labour is progressing normally, and the woman and her baby are in good condition, they do not need to receive additional interventions to accelerate labour."  

Sidenote: I encourage you to read Dr. Simelela's commentary "A 'good birth' goes beyond having a healthy baby."  I could not agree with her more.

There are 56 recommendations in these new guidelines that confirm that childbirth is a normal physiological process with all the variations that one might expect and advises health care providers to recognize these variations and have the patience to let the process unfold. WHO also recognizes that childbirth should be a positive, life-changing experience and currently that is not the case for all those who give birth.  There are many physical and emotional reasons why starting off parenting a newborn would benefit from a healthy, positive birth. All of the recommendations are based on current evidence-based principals and take a human rights approach to childbirth.

Some of the selected current recommendations include:

  • 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
  • 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.
  • 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 rst and subsequent labours.
  • A minimum cervical dilatation rate of 1 cm/hour throughout active 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.
  • Intermittent auscultation of the fetal heart rate with either a Doppler ultrasound device or Pinard fetal stethoscope is recommended for healthy pregnant women in labour.
  • 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
  • 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.
  • The use of amniotomy alone 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.
  • 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.
  • 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 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.
  • Routine or liberal use of episiotomy is not recommended for women undergoing spontaneous vaginal birth.
  • Delayed umbilical cord clamping (not earlier than 1 minute after birth) is recommended for improved maternal and infant health and nutrition outcomes.
  • Newborns without complications should be kept in skin-to-skin contact (SSC) with their mothers during the rst hour after birth to prevent hypothermia and promote breastfeeding.
  • 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.

I encourage you to read (or try to, it is 212 pages long, but there is a wonderful summary table at the beginning) this new WHO publication for all the details and supporting documents.

who logo guidelines.jpgThe first thing that came to my mind, and maybe yours too, was how similar these recommendations are to Lamaze International's Six Healthy Birth Practices. How strange and sad that NO interventions are now being debated and finally recommended when that was the way things were "before".  To have to now recommend "doing nothing" unless needed is crazy to think about.  The Institute of Medicine states that it takes 17 years for information to go from research to practice - or as is commonly noted, "from lab bench to bedside."  How long will it take for world practices to change and people begin to be the recipients of this evidence-based, low intervention appropriate care?

One thing we can do as childbirth educators and other birth professionals is to inform the families of what current best practice recommendations are.  When they know what the research shows, they can ask for those practices to be applied to their care.  If discussions with their health care provider do not assure them that they will be receiving this evidence-based care, then they can make a change to receive care elsewhere.  I recognize that ability to change providers is a sign of privilege and we need to make this option available to everyone and remove any barriers that exist.

I have long been facilitating discussions and activities focused on the Six Healthy Birth Practices (and then later, the ACOG recommendations) and will now include the information from the WHO in my childbirth classroom learning.  I applaud the WHO for clearly stating what good maternity care looks like and making this information available in many different languages and in many different formats.  These recommendations can only help to improve maternal-infant health worldwide for years to come.  How will you incorporate this new information into your childbirth classes?  Are you seeing these recommendations already in practice in the hospital facilities in your community?  Please share your thoughts in the comments below.


Recommendation #41

February 15, 2018 02:45 PM by Denise Brigitte Georges, LCCE

What is everyones thoughts on recommendation #41 that the use of uterotonics to prevent PPH is recommended for ALL births. ?? This has stumped me. For a low-risk woman who has a normal, intervention free birth with a healthy baby, why is skin-to-skin, and breastfeeding not enough?

Also, they define active labour as starting at 5cm.... Do we now avise our students that active labour is 5-6cm?



Denise (australia)

Recommendation #41

February 19, 2018 12:00 AM by Ann Rosia Roberts, Antenatal Educator

In the UK - the NICE guidelines conclude that using syntocinon or syntometrine statistically reduces blood loss and major PPH. However, that is probably more relevant to labours and births where there has been intervention - on our MLUs physiological third stage without oxytocics is often the norm.
My question would be about the need for hats for all newborns. Maybe babies born compromised in theatre and needing to kept warm, but not all babies - surely. 

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