Alliance for the Improvement of Maternity Services (AIMS)

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The WORLD HEALTH ORGANIZATION report, "CARE IN NORMAL BIRTH: A Practical Guide" Following are the recommendations appearing on pages 34-37 of the Report:

CLASSIFICATION OF PRACTICES IN NORMAL BIRTH, WHO

This chapter classifies the practices common in the conduct of normal childbirth into four categories, dependent on their usefulness, effectiveness and harmfulness. The classification reflects the views of the Technical Working Group on Normal Birth. Arguments for this classification are not given here; the reader is referred to the preceding chapters, which are the outcome of the reflection and debates of the Working Group, based on the best currently available evidence (numbers of chapters between brackets).

CATEGORY A:

6.1 Practices which are Demonstrably Useful and Should be Encouraged

1. A personal plan determining where and by whom birth will be attended, made with the woman during pregnancy and made known to her husband/partner and, if applicable, to the family (1.3).

2. Risk assessment of pregnancy during prenatal care, reevaluated at each contact with the health system and at the time of the first contact with the caregiver during labour, and throughout labour (1.3).

3. Monitoring the woman's physical and emotional well-being throughout labour and delivery, and at the conclusion of the birth process (2.1).

4. Offering oral fluids during labour and delivery (2.3).

5. Respecting women's informed choice of place of birth (2.4).

6. Providing care in labour and delivery at the most peripheral level where birth is feasible and safe and where the woman feels safe and confident (2.4, 2.5).

7. Respecting the right of women to privacy in the birthing place (2.5).

8. Empathic support by caregivers during labour and birth (2.5).

9. Respecting women's choice of companions during labour and birth (2.5).

10. Giving women as much information and explanation as they desire (2.5).

11. Non-invasive, non-pharmacological methods of pain relief during labour, such as massage and relaxation techniques (2.6).

12. Fetal monitoring with intermittent auscultation (2.7).

13. Single use of disposable materials and appropriate decontamination of reusable materials throughout labour and delivery (2.8).

14. Use of gloves in vaginal examination, during delivery of the baby and in handling the placenta (2.8).

15. Freedom in position and movement throughout labour (3.2).

16. Encouragement of non-supine position in labour (3.2, 4.6).

17. Careful monitoring of the progress of labour, for instance by the use of the WHO partograph (3.4).

18. Prophylactic oxytocin in the third stage of labour in women with a risk of postpartum haemorrhage, or endangered by even a small amount of blood loss (5.2, 5.4).

19. Sterility in the cutting of the cord (5.6).

20. Prevention of hypothermia of the baby (5.6).

21. Early skin-to-skin contact between mother and child and support of the initiation of breast-feeding within 1 hour postpartum in accordance with the WHO guidelines on breast-feeding (5.6).

22. Routine examination of the placenta and the membranes (5.7).

CATEGORY B:

6.2 Practices which are Clearly Harmful or Ineffective and Should be Eliminated

1. Routine use of enema (2.2).

2. Routine use of pubic shaving (2.2).

3. Routine intravenous infusion in labour (2.3).

4. Routine prophylactic insertion of intravenous cannula (2.3).

5. Routine use of the supine position during labour (3.2, 4.6).

6. Rectal examination (3.3).

7. Use of X-ray pelvimetry (3.4).

8. Administration of oxytocics at any time before delivery in such a way that their effect cannot be controlled (3.5).

9. Routine use of lithotomy position with or without stirrups during labour (4.6).

10. Sustained, directed bearing down efforts (Valsalva manoeuvre) during the second stage of labour (4.4).

11. Massaging and stretching the perineum during the second stage of labour (4.7).

12. Use of oral tablets of ergometrine in the third stage of labour to prevent or control hemorrhage (5.2, 5.4).

13. Routine use of parenteral ergometrine in the third stage of labour (5.2).

14. Routine lavage of the uterus after delivery (5.7).

15. Routine revision (manual exploration) of the uterus after delivery (5.7).

CATEGORY C:

6.3 Practices for which Insufficient Evidence Exists to Support a Clear Recommendation and which Should be Used with Caution while Further Research Clarifies the Issue

1. Non-pharmacological methods of pain relief during labour, such as herbs, immersion in water and nerve stimulation (2.6).

2. Routine early amniotomy in the first stage of labour (3.5).

3. Fundal pressure during labour (4.4).

4. Manoeuvres related to protecting the perineum and the management of the fetal head at the moment of birth (4.7).

5. Active manipulation of the fetus at the moment of birth(4.7).

6. Routine oxytocin, controlled cord traction, or combination of the two during the third stage of labour (5.2, 5.3, 5.4).

7. Early clamping of the umbilical cord (5.5).

8. Nipple stimulation to increase uterine contractions during the third stage of labour (5.6).

CATEGORY D:

6.4 Practices which are Frequently Used Inappropriately

1. Restriction of food and fluids during labour (2.3).

2. Pain control by systemic agents (2.6).

3. Pain control by epidural analgesia (2.6).

4. Electronic fetal monitoring (2.7).

5. Wearing masks and sterile gowns during labour attendance (2.8).

6. Repeated or frequent vaginal examinations especially by more than one caregiver (3.3).

7. Oxytocin augmentation (3.5).

8. Routinely moving the labouring woman to a different room at the onset of the second stage (4.2).

9. Bladder catheterization (4.3).

10. Encouraging the woman to push when full dilatation or nearly full dilatation of the cervix has been diagnosed, before the woman feels the urge to bear down herself (4.3).

11. Rigid adherence to a stipulated duration of the second stage of labour, such as 1 hour, if maternal and fetal conditions are good and if there is progress of labour (4.5).

12. Operative delivery (4.5).

13. Liberal or routine use of episiotomy (4.7).

14. Manual exploration of the uterus after delivery (5.7).

PLEASE NOTE: The WORLD HEALTH ORGANIZATION report, "CARE IN NORMAL BIRTH: A Practical Guide" can be ordered from WHO Publications Center USA, 49 Sheridan Ave, Albany, N.Y. 12210 Tel: (518) 436-9686 (ask for publications) or Fax: (518) 436-7433. Cost: $9. plus $5 shipping. To use credit card send name, card name and card number with order.