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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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Web annexEvidence Base

Abbreviations

aOR

adjusted odds ratio

CI

confidence interval

cRCT

cluster-randomized controlled trial

CTG

cardiotocography

EB

evidence base

GRADE

Grading of Recommendations Assessment, Development and Evaluation

IA

intermittent auscultation

IM

intramuscular

IV

intravenous

MD

mean difference

mMISS-21

modified 21-item Medical Interview Satisfaction Scale

n/a

not applicable

PCA

patient-controlled analgesia

PPH

postpartum haemorrhage

RCT

randomized controlled trial

RMC

respectful maternity care

RR

risk ratio

SMD

standardized mean difference

3.1. Care throughout labour and birth

EB Table 3.1.1: Respectful maternity care (RMC)

Comparison: RMC intervention compared with usual practice (no RMC intervention) (PDF, 108K)

Source: Downe S, Lawrie TA, Finlayson K, Oladapo OT. Effectiveness of respectful care policies for women using intrapartum care services. Reprod Health. 2018 (in press).

EB Table 3.1.2: Effective communication

Comparison: Effective communication by health care staff compared with usual practice (PDF, 139K)

Source: Chang YS, Coxon K, Portela AG, Furuta M, Bick D. Interventions to support effective communication between maternity care staff and women in labour: a mixed methods systematic review. Midwifery. 2017;59:4-16.

EB Table 3.1.3: Companionship during labour and childbirth

Comparison: Companionship during labour and childbirth compared with usual practice (PDF, 137K)

Source: Bohren MA, Hofmeyr G, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2017;(7):CD003766.

Companionship during labour and childbirth - subgroup analysis according to the type of support person (PDF, 141K)

3.2. First stage of labour

EB Table 3.2.3: Progress of the first stage of labour

i. Cervical dilatation patterns in women with normal perinatal outcomes - nulliparous women (PDF, 79K)

Source: Oladapo OT, Diaz V, Bonet M, Abalos E, Thwin SS, Souza H, et al. Cervical dilatation patterns of “low-risk" women with spontaneous labour and normal perinatal outcomes: a systematic review. BJOG. 2017. doi:10.1111/1471-0528.14930.

ii. Cervical dilatation patterns in women with normal perinatal outcomes - parous women (PDF, 63K)

Source: Oladapo OT, Diaz V, Bonet M, Abalos E, Thwin SS, Souza H, et al. Cervical dilatation patterns of “low-risk" women with spontaneous labour and normal perinatal outcomes: a systematic review. BJOG. 2017. doi:10.1111/1471-0528.14930.

EB Table 3.2.4: Labour ward admission policy

Comparison: delaying admission compared with direct admission to the labour ward (PDF, 73K)

Source: Kobayashi S, Hanada N, Matsuzaki M, Takehara K, Ota E, Sasaki H, Nagata C, Mori R. Assessment and support during early labour for improving birth outcomes. Cochrane Database Syst Rev. 2017;(4):CD011516.

EB Table 3.2.5: Clinical pelvimetry on admission

Comparison: Routine clinical pelvimetry compared with no pelvimetry (PDF, 58K)

Source: Pattinson RC, Cuthbert A, Vannevel V. Pelvimetry for fetal cephalic presentations at or near term for deciding on mode of delivery. Cochrane Database Syst Rev. 2017;(3):CD000161.

EB Table 3.2.6: Routine assessment of fetal wellbeing on labour admission

Comparison: Cardiotocography (CTG) compared with auscultation on labour admission (PDF, 86K)

Source: Devane D, Lalor JG, Daly S, McGuire W, Smith V. Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing. Cochrane Database Syst Rev. 2012;(2):CD005122.

EB Table 3.2.10: Continuous cardiotocography (CTG) during labour

Comparison: Continuous cardiotocography (CTG) compared with intermittent auscultation (IA) (PDF, 116K)

Source: Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev. 2017;(2):CD006066.

EB Table 3.2.11: Intermittent fetal heart rate auscultation

Comparison 1: Intermittent monitoring with Doppler ultrasound device compared with routine Pinard fetal stethoscope (PDF, 85K)

Source: Martis R, Emilia O, Nurdiati DS, Brown J. Intermittent auscultation (IA) of fetal heart rate in labour for fetal well-being. Cochrane Database Syst Rev. 2017;(2):CD008680.

Comparison 2: Intermittent cardiotocography (CTG) compared with routine Pinard fetal stethoscope (PDF, 69K)

Source: Martis R, Emilia O, Nurdiati DS, Brown J. Intermittent auscultation (IA) of fetal heart rate in labour for fetal well-being. Cochrane Database Syst Rev. 2017;(2):CD008680.

Comparison 3: “Strict” (or intensive) monitoring compared with “routine” monitoring with Pinard fetal stethoscope (PDF, 114K)

Source: Martis R, Emilia O, Nurdiati DS, Brown J. Intermittent auscultation (IA) of fetal heart rate in labour for fetal well-being. Cochrane Database Syst Rev. 2017;(2):CD008680.

EB Table 3.2.12: Epidural analgesia for pain relief

Comparison 1: Any epidural analgesia compared with placebo or no epidural analgesia (PDF, 137K)

Source:† Anim-Somuah M, Smyth RM, Jones L. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev. 2011;(12):CD000331.

Comparison 2: Epidural analgesia compared with parenteral opioid analgesia (PDF, 132K)

Source:† Anim-Somuah M, Smyth RM, Jones L. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev. 2011;(12):CD000331.

EB Table 3.2.13: Opioid analgesia for pain relief

Comparison 1: Parenteral opioids compared with placebo or no opioids (PDF, 91K)

Comparison 1.a. Pethidine intramuscular (IM) compared with placebo

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 1.b. Pethidine (intravenous [IV]) compared with placebo (PDF, 59K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 1.c. Pentazocine intramuscular (IM) compared with placebo (PDF, 58K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 1.d. Tramadol intramuscular (IM) compared with no analgesia (PDF, 56K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2: Parenteral opioids (various types) compared with pethidine (PDF, 85K)

Comparison 2.a. Meptazinol intramuscular (IM) compared with pethidine (IM)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.b. Tramadol intramuscular (IM) compared with pethidine (IM) (PDF, 74K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.c. Tramadol intramuscular (IM) with triflupromazine compared with pethidine (IM) with triflupromazine (PDF, 56K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.d(i). Morphine or diamorphine intramuscular (IM) compared with pethidine (IM) (PDF, 117K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.d(ii). Diamorphine intramuscular (IM) plus prochlorperazine compared with pethidine (IM) plus prochlorperazine (PDF, 72K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.e. Dihydrocodeine intramuscular (IM) compared with pethidine (IM) (PDF, 57K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.f. Pentazocine intramuscular (IM) compared with pethidine (IM) (PDF, 80K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.g. Nalbuphine intramuscular (IM) compared with pethidine (IM) (PDF, 80K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.h. Phenazocine intramuscular (IM) compared with pethidine (IM) (PDF, 56K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.i. Butorphanol intramuscular (IM) compared with pethidine (IM) (PDF, 59K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.j. Fentanyl intravenous (IV) compared with pethidine (IV) (PDF, 73K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.k. Nalbuphine intravenous (IV) compared with pethidine (IV) (PDF, 56K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.l. Phenazocine intravenous (IV) compared with pethidine (IV) (PDF, 57K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.m. Butorphanol intravenous (IV) compared with pethidine (IV) (PDF, 66K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.n. Morphine intravenous (IV) compared with pethidine (IV) (PDF, 57K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.o. Alphaprodine intravenous (IV) compared with pethidine (IV) (PDF, 55K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.p. Patient-controlled analgesia (PCA) pentazocine compared with PCA pethidine (PDF, 68K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.q. Patient-controlled analgesia (PCA) remifentanil compared with PCA pethidine (PDF, 73K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.r. Patient-controlled analgesia (PCA) nalbuphine compared with PCA pethidine (PDF, 62K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.s. Patient-controlled analgesia (PCA) fentanyl compared with PCA pethidine (PDF, 68K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

Comparison 2.t. Patient-controlled analgesia (PCA) (intramuscular [IM]) meptazinol compared with PCA (IM) pethidine (PDF, 61K)

Source:† Ullman R, Smith LA, Burns E, Mori R, Dowswell T. Parenteral opioids for maternal pain management in labour. Cochrane Database Syst Rev. 2010;(9):CD007396.

EB Table 3.2.14: Relaxation techniques for pain management

Comparison 1: General relaxation techniques compared with usual care (no relaxation techniques) (PDF, 87K)

Source:† Smith CA, Levett KM, Collins CT, Crowther CA. Relaxation techniques for pain management in labour. Cochrane Database Syst Rev. 2011;(12):CD009514.

Comparison 2: Yoga techniques compared with control (no yoga techniques) (PDF, 62K)

Source:† Smith CA, Levett KM, Collins CT, Crowther CA. Relaxation techniques for pain management in labour. Cochrane Database Syst Rev. 2011;(12):CD009514.

Comparison 3: Music compared with usual care (no music) (PDF, 62K)

Source:† Smith CA, Levett KM, Collins CT, Crowther CA. Relaxation techniques for pain management in labour. Cochrane Database Syst Rev. 2011;(12):CD009514.

Comparison 4: Audio-analgesia compared with control (PDF, 54K)

Source:† Smith CA, Levett KM, Collins CT, Crowther CA. Relaxation techniques for pain management in labour. Cochrane Database Syst Rev. 2011;(12):CD009514.

Comparison 5: Mindfulness training compared with control (no mindfulness training) (PDF, 60K)

Source: Smith CA, Levett KM, Collins CT, Crowther CA. Relaxation techniques for pain management in labour. Cochrane Database Syst Rev. 2011;(12):CD009514.

EB Table 3.2.15: Manual techniques for pain management

Comparison 1: Massage techniques compared with usual care (no massage) (PDF, 91K)

Source: Smith CA, Levett KM, Collins CT, Dahlen HG, Ee CC, Suganuma M. Massage, reflexology and other manual methods for pain management in labour. Cochrane Database Syst Rev. 2018:CD009290 (in press).

Comparison 2: Warm pack compared with usual care (no warm packs) (PDF, 56K)

Source: Smith CA, Levett KM, Collins CT, Dahlen HG, Ee CC, Suganuma M. Massage, reflexology and other manual methods for pain management in labour. Cochrane Database Syst Rev. 2018:CD009290 (in press).

3.3. Second stage of labour

EB Table 3.3.2: Birth position for women without epidural analgesia

Comparison: Upright position compared with recumbent position in the second stage of labour without epidural analgesia (PDF, 97K)

Source: Gupta JK, Sood A, Hofmeyr G, Vogel JP. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev. 2017;(5):CD002006.

EB Table 3.3.3: Birth position for women with epidural analgesia

Comparison: Upright position compared with recumbent position in the second stage of labour for women with epidural analgesia (PDF, 90K)

Source: Kibuka M, Thornton JG. Position in the second stage of labour for women with epidural anaesthesia. Cochrane Database Syst Rev. 2017;(2):CD008070.

EB Table 3.3.4: Method of pushing

Comparison: Spontaneous pushing compared with directed pushing (PDF, 87K)

Source: Lemos A, Amorim MM, Dornelas de Andrade A, de Souza AI, Cabral Filho JE, Correia JB. Pushing/bearing down methods for the second stage of labour. Cochrane Database Syst Rev. 2017;(10):CD009124.

EB Table 3.3.5: Method of pushing for women with epidural analgesia

Comparison: Delaying pushing compared with immediate pushing in women with epidural analgesia (PDF, 89K)

Source: Lemos A, Amorim MM, Dornelas de Andrade A, de Souza AI, Cabral Filho JE, Correia JB. Pushing/bearing down methods for the second stage of labour. Cochrane Database Syst Rev. 2017;(10):CD009124.

EB Table 3.3.6: Techniques for preventing perineal trauma

Comparison 1: Perineal massage compared with control (“hands off” or usual care) (PDF, 75K)

Source: Aasheim V, Nilsen A, Reinar L, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev. 2017;(6):CD006672.

Comparison 2: Warm perineal compress compared with control (“hands off” or usual care) (PDF, 61K)

Source: Aasheim V, Nilsen A, Reinar L, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev. 2017;(6):CD006672.

Comparison 3: “Hands-off” compared with “hands-on” perineum approach (PDF, 60K)

Source: Aasheim V, Nilsen A, Reinar L, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev. 2017;(6):CD006672.

Comparison 4: Ritgen's manoeuvre compared with usual practice (“hands-on” approach) (PDF, 60K)

Source: Aasheim V, Nilsen A, Reinar L, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev. 2017;(6):CD006672.

EB Table 3.3.7: Episiotomy policy

Comparison: Policy of selective/restrictive compared with routine or liberal use of episiotomy (PDF, 98K)

Source: Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev 2017;(2):CD000081.

EB Table 3.3.8: Fundal pressure

Comparison: Manual fundal pressure compared with no fundal pressure (PDF, 90K)

Source: Hofmeyr G, Vogel JP, Cuthbert A, Singata M. Fundal pressure during the second stage of labour. Cochrane Database Syst Rev. 2017;(3):CD006067.

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