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WHO recommendations: Intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018.

Cover of WHO recommendations: Intrapartum care for a positive childbirth experience

WHO recommendations: Intrapartum care for a positive childbirth experience.

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Annex 4Implementation considerations specific to individual recommendationsa

3.1 CARE THROUGHOUT LABOUR AND BIRTH
3.1.1
Respectful maternity care (RMC)
  • Multifaceted RMC interventions are most likely to be effective, and policy-makers should ensure that key stakeholders are engaged in RMC programmes, including facility administrators, training institutions, professional societies, providers and 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
  • Successful RMC programmes should be documented to inform the development of guidelines and protocols for better quality maternity care in different settings.
  • Policy-makers should ensure compliance with the 2017 Joint WHO/United Nations statement on ending discrimination in health care settings.d
3.1.2
Effective communication
  • Including effective communication training routinely in all pre-service and in-service professional training interventions could be the most feasible way to implement effective communication interventions.
  • Health care facilities should ensure there is an up-to-date, written policy that outlines clear goals, operational plans and monitoring mechanisms to promote the interpersonal communication and counselling skills of health care staff.
  • Potential barriers to implementation at individual, health care facility and health system levels will need to be identified and addressed. Some barriers (e.g. high workload) may be common across settings, while other barriers (e.g. cultural attitudes to disadvantaged women) might be setting-specific.
  • Changes to system infrastructure (e.g. increased staff, reorganization of staffing, skill mix, workload capacity, promotion of multidisciplinary team working, clinical leadership) could facilitate effective communication interventions and make them more sustainable.
  • Easily understood health education materials, in an accessible written or pictorial format, should be made available in the languages of the communities served by the health care facility.
  • Culturally appropriate 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 effective communication and (ii) the existence of a mechanism for raising and addressing complaints related to their maternity care.
3.1.3
Companionship during labour and childbirth
  • Policy-makers should consider how to provide a companionship service for women during labour and birth that meets the needs of the population. One approach could be to encourage women to bring their own companion wherever possible, but if a woman does not bring/have a companion, the health service would offer to provide someone to support her.
  • In settings where women are unfamiliar with the concept or the benefits of companionship during labour and childbirth, the organization of community-based groups of volunteer companions, antenatal care education and counselling groups, women's groups, hospital open days, and other promotional activities could help to promote demand for and use of companionship.
  • Policy-makers should develop culturally sensitive training programmes for companions, and consider ways of registering, retaining and incentivizing them.
  • Prior to implementation, to reduce resistance to change among health care providers, implementers might want to consider training them on the benefits of companionship during labour and childbirth, as well as how companions can be integrated into the woman's support team.
  • Labour companions should have clearly designated roles and responsibilities, to ensure that their presence is beneficial to both the woman and her health care providers, and to reduce the risk of being “in the way”.
  • Infection control measures should be considered for companions, such as access to sanitation, hygiene measures and protective clothing as necessary.
  • 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
Definitions of the latent and active first stages of labour
  • Guidance and protocols for health care facilities without availability of caesarean section will need to be developed that are context- and situation-specific.
  • Introduction of these new definitions and concepts should involve pre-service training institutions and professional bodies, so that training curricula for intrapartum care can be updated as quickly and smoothly as possible.
  • Labour monitoring tools will need to be updated and/or developed to facilitate the new approach.
  • Practice manuals and labour ward protocols will need to be updated and disseminated.
3.2.2
Duration of the first stage of labour
3.2.3
Progress of the first stage of labour
3.2.4
Labour ward admission policy
  • This recommendation requires a well functioning health system with a sufficient number of trained health care professionals.
  • 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
Clinical pelvimetry on admission
  • In settings where clinical pelvimetry is routinely performed among healthy pregnant women on admission in labour, health care providers need to be aware that there is insufficient evidence to support this practice.
3.2.6
Routine assessment of fetal well-being on labour admission
  • In settings where cardiotocography (CTG) is performed routinely on admission for labouring women with no risk factors for adverse outcomes, it is important to inform health care professionals and other stakeholders that this practice is not evidencebased and increases the risk of unnecessary medical interventions.
  • 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
Continuous cardiotocography during labour
  • The GDG panel is aware that in some countries and settings, continuous CTG is used to protect against litigation. In such settings, health care professionals and women should be advised that this practice is not evidence-based and does not 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.
3.2.11
Intermittent fetal heart rate auscultation during labour
  • Policy-makers should consider what method(s) is/are most feasible in their settings. In low-resource settings, Pinard fetal stethoscope would be the most feasible method for intermittent auscultation (IA) as it is not associated with ongoing costs related to supplies and equipment maintenance, and has no infrastructural requirements (e.g. power supply).
  • A practical approach in low-resource settings might be to firstly ensure widespread availability and competence of health care providers to conduct IA with the Pinard fetal stethoscope. Then, as resources become available, the Doppler ultrasound device could be introduced with appropriate pre-service and in-service training.
  • In settings with a high prevalence of litigation, policy-makers and relevant stakeholders need to consider whether records from non-electronic fetal monitoring (and IA in general) would be valid in the defence against potential litigation claims.
3.2.12
Epidural analgesia for pain relief
  • Policy-makers need to determine which pain relief measures are most feasible and acceptable in their settings.
  • Facilities offering epidural analgesia need to have staff with the appropriate specialist skills (anaesthetists, obstetricians) as well as equipment and systems in place to monitor, detect and manage any undesirable effects of the procedure during and after labour to ensure the safety of mother and baby. Epidural analgesia should not be introduced in settings where these resources are not consistently available.
  • Systems should be in place to ensure adherence to standardized protocols for epidural analgesia, including correct drugs, doses, techniques, staffing levels and other resource requirements.
  • Oxygen, resuscitation equipment and appropriate drugs for resuscitation should be readily available in labour and postnatal wards where women who have undergone epidural analgesia are cared for.
  • Health care providers and women should be aware that epidural analgesia is a significant procedure that can lead to serious complications. The benefits and risks associated with epidural analgesia should be clearly explained to women considering this method of pain relief.
  • Signed informed consent is necessary for all women undergoing epidural analgesia.
  • 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 professionals should communicate to women the pain relief options available for labour and birth at their facility, and should discuss the advantages and disadvantages of these options, as part of antenatal care education and counselling. A woman's choice of pain relief during labour, if pain relief is required, should be confirmed on admission in labour. In addition, she should be free to change her mind about the type of pain relief she would like if she feels the need to do so.
  • Health care facilities providing pharmacological options for pain relief, including epidural 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 necessary drugs are kept in stock and can be dispensed when needed.
  • Health care facilities offering epidural analgesia during labour should conduct regular audit and feedback procedures to ensure adherence to clinical protocols and to monitor complications.
3.2.13
Opioid analgesia for pain relief
  • Policy-makers need to determine which pain relief measures are most appropriate (feasible and acceptable) in their settings, in consultation with health care 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
Relaxation techniques for pain management
3.2.15
Manual techniques for pain management
  • 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 early as possible in labour, and ideally as part of antenatal care education and counselling.
  • Training institutions could cover these techniques in health care professionals’ pre-service and in-service training. For lay companions, basic training in these techniques could be facilitated during the antenatal period.
3.3 SECOND STAGE OF LABOUR
3.3.1
Definition and duration of the second stage of labour
  • Same as considerations for 3.2.1–3.2.3.
3.3.2
Birth position (for women without epidural analgesia)
  • In settings where women usually give birth in recumbent positions, policy-makers should ensure that (i) health care professionals receive in-service training on how to support women to give birth in upright positions and (ii) the necessary facilities that can be used to support alternative upright positions for women are provided.
  • 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.
3.3.3
Birth position (for women with epidural analgesia)		Same implementation considerations as for item 3.3.2 (previous row).
3.3.4
Method of pushing
  • In settings where health care professionals are accustomed to using directed pushing techniques, clinical protocols, pre-service and in-service training content should be updated to support spontaneous pushing.
3.3.5
Method of pushing (for women with epidural analgesia)
  • Clinical protocols, pre-service and in-service training content should be updated to support delayed pushing in the second stage of labour for women with epidural analgesia.
3.3.6
Techniques for preventing perineal trauma
  • Policy-makers should liaise with professional bodies, societies and training institutions to ensure that pre-service training of health care professionals includes training in techniques for preventing perineal trauma.
  • Professional bodies, societies and health care facilities should update their training and guidance on supporting women in the second stage of labour to include these different options for preventing perineal trauma: perineal massage, warm compresses and a “hands-on” guarding approach.
  • Stakeholders can consider which techniques are most feasible in their settings.
  • Health care professionals should communicate to women the different options available for preventing perineal trauma; this should be done during antenatal care contacts as part of BPCR counselling, and the woman's preferences for her care during the second stage of labour should be noted.
3.3.7
Episiotomy policy
  • To secure broad support and to ensure that health workers receive appropriate training and support, policy-makers should include representatives of training facilities and professional bodies in participatory processes.
  • Guidelines of professional societies and health care facility protocols should be updated to reflect the recommendation that episiotomy is not to be used liberally and that only selective use of episiotomy is permissible.
  • In settings where routine or liberal use of episiotomy has been employed, and in settings with low utilization of health care facilities for childbirth, women and health care providers should be informed that the use of episiotomy is now restricted.
  • All stakeholders should be aware of the need for a woman to give informed consent for episiotomy.
  • Episiotomy indications and protocols should be clearly displayed in maternity facilities.
  • Policy-makers, health care managers and administrators for both public and private health care facilities should ensure that any financial and other incentives to perform episiotomy are removed.
3.3.8
Fundal pressure
  • Health care providers should be made aware that this practice is not recommended and can lead to adverse birth outcomes.
  • Stakeholders could consider undertaking implementation research to determine how best to reduce unnecessary childbirth practices in their settings.

Footnotes

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.

d

Joint United Nations statement on ending discrimination in health care settings. Joint WHO/UN statement. 27 June 2017 (http://www​.who.int/mediacentre​/news/statements​/2017/discrimination-in-health-care/en/).

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