WHO recommendation on techniques for preventing perineal trauma during labour

WHO recommendation on techniques for preventing perineal trauma during labour

 

Recommendation

For women in the second stage of labour, techniques to reduce perineal trauma and facilitate spontaneous birth (including perineal massage, warm compresses and a “hands on” guarding of the perineum) are recommended, based on a woman’s preferences and available options.

(Recommended)

 

Publication history

First published: February 2018

Updated: No update planned

Assessed as up-to-date: February 2018

 

Remarks

  • Evidence suggests that perineal massage may increase the chance of the keeping the perineum intact and reduces the risk of serious perineal tears, that warm perineal compresses reduce third- and fourth-degree perineal tears, and that a “hands-on” approach (guarding) probably reduces firstdegree perineal tears. Most women accept these low-cost preventative perineal techniques and highly value the outcomes that they impact. 
  • Evidence on Ritgen’s manoeuvre (using one hand to pull the fetal chin from between the maternal anus and the coccyx, and the other hand placed on the fetal occiput to control speed of birth) is very uncertain; therefore, this technique is not recommended.

 

Background

Globally, approximately 140 million births occur every year (1). The majority of these are vaginal births among pregnant women with no identified risk factors for complications, either for themselves or their babies, at the onset of labour (2, 3). However, in situations where complications arise during labour, the risk of serious morbidity and death increases for both the woman and baby. Over a third of maternal deaths and a substantial proportion of pregnancy-related life-threatening conditions are attributed to complications that arise during labour, childbirth or the immediate postpartum period, often as result of haemorrhage, obstructed labour or sepsis (4, 5). Similarly, approximately half of all stillbirths and a quarter of neonatal deaths result from complications during labour and childbirth (6). The burden of maternal and perinatal deaths is disproportionately higher in low- and middle-income countries (LMICs) compared to high-income countries (HICs). Therefore, improving the quality of care around the time of birth, especially in LMICs, has been identified as the most impactful strategy for reducing stillbirths, maternal and newborn deaths, compared with antenatal or postpartum care strategies (7).

Over the last two decades, women have been encouraged to give birth in health care facilities to ensure access to skilled health care professionals and timely referral should the need for additional care arise. However, accessing labour and childbirth care in health care facilities may not guarantee good quality care. Disrespectful and undignified care is prevalent in many facility settings globally, particularly for underprivileged populations, and this not only violates their human rights but is also a significant barrier to accessing intrapartum care services (8). In addition, the prevailing model of intrapartum care in many parts of the world, which enables the health care provider to control the birthing process, may expose apparently healthy pregnant women to unnecessary medical interventions that interfere with the physiological process of childbirth.

As highlighted in the World Health Organization (WHO) framework for improving quality of care for pregnant women during childbirth, experience of care is as important as clinical care provision in achieving the desired person-centred outcomes (9).

This up-to-date, comprehensive and consolidated guideline on intrapartum care for healthy pregnant women and their babies brings together new and existing WHO recommendations that, when delivered as a package of care, will ensure good quality and evidence-based care in all country settings. In addition to establishing essential clinical and non-clinical practices that support a positive childbirth experience, the guideline highlights unnecessary, non-evidence-based and potentially harmful intrapartum care practices that weaken women’s innate childbirth capabilities, waste resources and reduce equity.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

 

Methods

These recommendations were developed using standard operating procedures in accordance with the process described in the WHO handbook for guideline development (10). Briefly, these procedures include: (i) identification of priority questions and outcomes; (ii) evidence retrieval and synthesis; (iii) assessment of the evidence; (iv) formulation of the recommendations; and (v) planning for implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (11) and Confidence in the Evidence from Reviews of Qualitative research (CERQual) (12) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions.

The GRADE evidence-to-decision (EtD) framework (13), an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at two technical consultations in May and September 2017. In addition, relevant recommendations from existing WHO guidelines approved by the Guidelines Review Committee (GRC) were systematically identified and integrated into this guideline for the purpose of providing a comprehensive document for end-users.

 

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following questions:

  • For women in the second stage of labour (P), does any perineal technique (e.g. massage, warm compress or guiding) used for preventing perineal trauma (I), compared with no perineal technique or usual practice (C), improve birth outcomes (O)?

 

Evidence summary

The evidence is derived from a Cochrane systematic review that included 22 individual RCTs (14).

Twenty trials involving 15181 women contributed data. The trials were conducted in Australia (2 trials), Austria (1 trial), Brazil (2 trials), Denmark (1 trial), Iran (8 trials), Israel (1 trial), Spain (1 trial), Sweden (2 trials), the United Kingdom (1 trial) and the USA (1 trial). Perineal techniques performed in the second stage of labour 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 manoeuvre compared with usual practice. Other interventions assessed in the review that were associated with very limited evidence included cold compresses, delivery of the posterior shoulder first compared with the anterior shoulder, the application of petroleum jelly, enriched oil compared with liquid wax, and a perineal protection device. These interventions are not evaluated in this framework.

 

Comparison 1: Perineal massage compared with control (“hands off” approach or usual care)

Seven studies (2684 participants) from Australia, Iran and the USA contributed data to this comparison. In these studies, perineal massage in the second stage of labour was performed with a lubricant. It generally involved the midwife inserting two fingers into the vagina and applying mild, downward pressure to the vagina towards the rectum, while moving the fingers with steady strokes from side to side. Massage in some studies was performed only during contractions in the second stage and in others was continued during and between pushes.

Maternal outcomes

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.

Long-term morbidity: The review found no evidence on long-term outcomes. Birth experience: The review found no evidence on maternal satisfaction or other outcomes related to birth experience.

Fetal and neonatal outcomes

Perinatal hypoxia-ischaemia: The review found no evidence on Apgar scores less than 7 at 5 minutes.

Birth trauma: The review did not include birth trauma as an outcome.

Values

Findings from a review of qualitative studies looking at what matters to women during intrapartum care (15) indicate that most women want a normal childbirth with good outcomes for mother and baby (high confidence in the evidence). Findings also suggest that women are aware of the unpredictability of labour and childbirth and are fearful of potentially traumatic events (including medical interventions and maternal and fetal morbidities) that can occur during the birthing process (high confidence in the evidence). It is therefore likely that women will value any technique that may limit perineal trauma, particularly if it is offered by kind, competent health care professionals who are sensitive to their needs (high confidence in the evidence). Qualitative evidence also shows that, 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) (15).

Additional considerations

Findings from a meta-synthesis of women’s experiences of perineal trauma suggest that women may feel devalued, dismissed, depressed and have a sense of failure when their perineum is damaged following childbirth (16).

Resources

No review evidence was found.

Additional considerations: Perineal techniques are a low-cost intervention for which in-service training would be the main cost. If perineal massage increases the proportion of women with an intact perineum after childbirth and reduces third- and fourth-degree tears, it would logically be more cost-effective than usual care by reducing the costs associated with suturing supplies (e.g. suture materials, local anaesthetics, swabs) and health care professional time required to suture. A 2002 study from Argentina reported an average provider cost saving of US$ 20.21 per birth with a change in episiotomy policy that led to fewer episiotomies being performed and a reduced need for suturing (17), which gives an indirect indication of possible cost savings that might occur per birth with reduced third- and fourth-degree tears and an increase in intact perineum.

Equity

No evidence on perineal techniques and equity was found.

Additional considerations

If health care professionals could contribute to preserving the integrity of the perineum in the second stage of labour through simple perineal techniques, women in LMICs might be more inclined to use facility-based birth services, which could have a positive impact on equity.

Acceptability

A qualitative systematic review of women’s experiences of labour and childbirth found no direct evidence relating to women’s views on perineal massage techniques (18). Indirect evidence from this review suggests that, in certain contexts, some women may appreciate techniques that limit perineal trauma, provided they are applied by kind and sensitive health care professionals (low confidence in the evidence). In other contexts, women may find these techniques painful, uncomfortable or embarrassing (very low confidence in the evidence). The qualitative systematic review also found no direct evidence on health care professionals’ views on perineal techniques to prevent perineal trauma (18).

Additional considerations: In a Canadian survey of women’s views of prenatal perineal massage (n = 684), the authors found that women held positive views of the technique and would use it again in a subsequent pregnancy (19). It is likely that women would appreciate any of the perineal techniques if there was evidence to suggest they might help or limit any of the potential long-term consequences of a damaged perineum (dyspareunia, sexual dysfunction, urinary or faecal incontinence).

Feasibility

A qualitative systematic review of women’s experiences of labour and childbirth found no direct evidence relating to women’s views on perineal techniques (18). Indirect evidence from this review would suggest that there are unlikely to be any concerns around feasibility. The qualitative systematic review also found no direct evidence on health care professionals’ views relating to perineal techniques (18). Indirect evidence would suggest that health care professionals in certain contexts may lack the training and/or experience to use some or all of the perineal techniques described (very low confidence in the evidence).

Additional considerations: In a small survey of 54 Australian midwives taking part in an RCT on perineal massage during labour (20), the author found that midwives did not always apply the intervention for a variety of reasons, including: (i) women found it uncomfortable; (ii) labour progressed too quickly; (iii) there was fetal distress; (iv) they didn’t have time and (v) they felt it was intrusive. After the trial, the number of midwives who felt the technique was “definitely beneficial” increased from 8 to 15.

 

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

Four studies (1799 participants) from Australia, Iran, Spain and the USA contributed data to this comparison. In one study (717 participants), warm perineal compresses were provided as pads soaked in warm sterile water (heated to between 45° and 59 °C) and applied during contractions once the baby’s head distended the perineum. The pad was re-soaked between contractions to maintain warmth. In another study (808 participants), warm compresses were applied continually, during and between contractions in the second stage. The warm compresses provided in the other two studies were not described in detail in the review.

Maternal outcomes

Perineal/vaginal trauma: High-certainty evidence suggests that warm compresses make little or no difference to having an intact perineum after giving birth (4 trials, 1799 women, RR 1.02, 95% CI 0.85–1.21). High-certainty evidence indicates that warm compresses reduce the incidence of third- or fourth-degree perineal tears (4 trials, 1799 women, RR 0.46, 95% CI 0.27–0.79). The absolute effect on third- or fourth-degree tears is estimated as 24 fewer per 1000 (from 9 to 33 fewer). Moderate-certainty evidence suggests that warm compresses probably make little or no difference to episiotomy (4 trials, 1799 women, RR 0.86, 95% CI 0.60–1.23). Evidence on first- and second-degree tears and the need for perineal suturing is of very low certainty.

Long-term morbidity: The review found no evidence on long-term outcomes.

Birth experience: The review found no evidence on maternal satisfaction or other outcomes related to birth experience.

Fetal and neonatal outcomes

Perinatal hypoxia-ischaemia: The review found no evidence on Apgar scores less than 7 at 5 minutes.

Birth trauma: The review did not include birth trauma as an outcome.

Additional considerations

The review also included a separate analysis of cold compresses compared with a control group (1 study, 64 women) for which the resulting evidence was assessed as being largely very uncertain.

Values

Findings from a review of qualitative studies looking at what matters to women during intrapartum care indicate that most women want a normal childbirth with good outcomes for mother and baby (high confidence in the evidence) (15). Findings also suggest that women are aware of the unpredictability of labour and childbirth and are fearful of potentially traumatic events (including medical interventions and maternal and fetal morbidities) that can occur during the birthing process (high confidence in the evidence). It is therefore likely that women will value any technique that may limit perineal trauma, particularly if it is offered by kind, competent health care professionals who are sensitive to their needs (high confidence in the evidence). Qualitative evidence also shows that, 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).

Additional considerations: Findings from a meta-synthesis of women’s experiences of perineal trauma suggest that women may feel devalued, dismissed, depressed and have a sense of failure when their perineum is damaged following childbirth (16).

Resources

No review evidence was found.

Additional considerations: Warm compresses are a low-cost intervention for which supplies of pads/packs and in-service training would be the main cost. However, sterile water was used in at least one of the included trials, and this would have additional cost implications. Health care providers would need access to clean warm water, which may not be possible in some low-resource settings. As warm compresses reduce third- and fourth-degree tears, this practice should be more cost-effective than usual care, as costs associated with suturing supplies (e.g. suture materials, local anaesthetics, swabs) and health care professional time required to suture should be reduced. A 2002 study from Argentina reported an average provider cost saving of US$ 20.21 per birth with a change in episiotomy policy that led to fewer episiotomies being performed and a reduced need for suturing (17), which gives an indirect indication of possible cost savings that might occur per birth with reduced third- and fourth-degree tears.

Equity

No evidence on perineal techniques and equity was found.

Additional considerations: If health care professionals could contribute to preserving the integrity of the perineum in the second stage of labour through simple perineal techniques, women in LMICs might be more inclined to use facility-based birth services, which could have a positive impact on equity.

Acceptability

A qualitative systematic review of women’s experiences of labour and childbirth found no direct evidence relating to women’s views on perineal techniques (18) Indirect evidence from this review suggests that, in certain contexts, some women may appreciate techniques that limit perineal trauma, provided they are applied by kind and sensitive health care professionals (low confidence in the evidence). In other contexts, women may find these techniques painful, uncomfortable or embarrassing (very low confidence in the evidence). The qualitative systematic review also found no direct evidence relating to health care professionals’ views on perineal techniques to prevent perineal trauma (18).

Additional considerations: It is likely that women would appreciate any perineal techniques if there was evidence to suggest they might help or limit any of the potential long-term consequences of a damaged perineum (dyspareunia, sexual dysfunction, urinary or faecal incontinence). Women might plausibly perceive warm compresses as less uncomfortable and embarrassing than perineal massage, but no evidence on this was found.

Feasibility

A qualitative systematic review of women’s experiences of labour and childbirth found no direct evidence relating to women’s views on perineal techniques (18). Indirect evidence from this review would suggest that there are unlikely to be any concerns around feasibility. The qualitative systematic review also found no direct evidence on health care professionals’ views relating to perineal techniques (18).

Additional considerations: Although it is a low-cost intervention, warm compresses might be less feasible to implement in settings where resources are limited, particularly if warm running tap water is not available in delivery rooms.

 

Comparison 3: “Hands-off” compared with “hands-on” perineum approach

Five studies (7317 participants) from Austria, Brazil, Iran and the United Kingdom contributed data to this comparison. The hands-off (or poised) approach was generally expectant and observational to the extent that light pressure could be applied to the baby’s head in case of rapid expulsion, with the plan not to touch the head or perineum otherwise, and to allow spontaneous birth of the shoulders. A hands-on approach (or guarding) involved the midwife supporting the anterior and posterior perineum with both hands to protect/guard the perineum and maintain flexion of, and control, the expulsion of the fetal head.

Maternal outcomes

Perineal/vaginal trauma: Moderate-certainty evidence suggests that use of the hands-off compared with the hands-on approach probably makes little or no difference to the likelihood of having an intact perineum after giving birth (2 trials, 6547 women, RR 1.03, 95% CI 0.95–1.12). Low-certainty evidence suggests that the hands-off approach may increase first-degree tears compared with the hands-on approach (2 trials, 700 participants, RR 1.32, 95% CI 0.99–1.77), however, the estimate of effect includes the possibility of no difference. The absolute effect is estimated as 58 more per 1000 (from 2 fewer to 139 more). Evidence on third- and fourth-degree tears, second-degree tears and episiotomy is of very low certainty.

Long-term morbidity: The review found no evidence on long-term outcomes.

Birth experience: The review found no evidence on maternal satisfaction or other outcomes related to childbirth experience.

Fetal and neonatal outcomes

Perinatal hypoxia-ischaemia: The review found no evidence on Apgar scores less than 7 at 5 minutes.

Birth trauma: The review did not include birth trauma as an outcome.

Values

Findings from a review of qualitative studies looking at what matters to women during intrapartum care (15) indicate that most women want a normal childbirth with good outcomes for mother and baby (high confidence in the evidence). Findings also suggest that women are aware of the unpredictability of labour and childbirth and are fearful of potentially traumatic events (including medical interventions and maternal and fetal morbidities) that can occur during the birthing process (high confidence in the evidence). It is therefore likely that women will value any technique that may limit perineal trauma, particularly if it is offered by kind, competent health care professionals who are sensitive to their needs (high confidence in the evidence). Qualitative evidence also shows that, 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).

Additional considerations: Findings from a meta-synthesis of women’s experiences of perineal trauma suggest that women may feel devalued, dismissed and depressed and may have a sense of failure when their perineum is damaged following childbirth (16). The quantitative evidence suggests that there may be little difference between these approaches; however, the possibility of more first-degree tears with the hands-off approach might incline some women to prefer the hands-on approach.

Resources

No review evidence was found.

Additional considerations: Perineal techniques are low-cost interventions for which in-service training would be the main cost. Although the evidence suggests that the hands-off approach might increase first-degree perineal tears, these do not usually require suturing and are not associated with other poor outcomes, therefore this may not have cost implications.

Equity

No evidence on perineal techniques and equity was found.

Additional considerations: If health care professionals could contribute to preserving the integrity of the perineum in the second stage of labour through simple perineal techniques, women in LMICs might be more inclined to use facility-based birth services, which could have a positive impact on equity. However, from the evidence on effects, it is not clear whether these perineal techniques reduce perineal trauma.

Acceptability

A qualitative systematic review of women’s experiences of labour and childbirth found no direct evidence relating to women’s views on perineal techniques (18). Indirect evidence from this review suggests that, in certain contexts, some women may appreciate techniques that limit perineal trauma, provided they are applied by kind and sensitive health care professionals (low confidence in the evidence). In other contexts, women may find these techniques painful, uncomfortable or embarrassing (very low confidence in the evidence). The qualitative systematic review also found no direct evidence on health care professionals’ views relating to perineal techniques to prevent perineal trauma (18).

Additional considerations: It is likely that women would appreciate any of the perineal techniques if there was evidence to suggest they might help or limit any of the potential long-term consequences of a damaged perineum (dyspareunia, sexual dysfunction, urinary or faecal incontinence).

Feasibility

A qualitative systematic review of women’s experiences of labour and childbirth found no direct evidence relating to women’s views on perineal techniques (18). Indirect evidence from this review would suggest that there are unlikely to be any concerns around feasibility. The qualitative systematic review also found no direct evidence on health care professionals’ views relating to perineal techniques (18). Indirect evidence would suggest that health care professionals in certain contexts may lack the training and/or experience to use some or all of the perineal techniques described (very low confidence in the evidence).

 

Comparison 4: Ritgen’s manoeuvre compared with usual practice (“hands-on” approach)

Two studies (1489 participants) from Iran and Sweden contributed data to this comparison. A modified Ritgen’s manoeuvre was performed in the second stage of labour in the largest study (1423 participants). This involved “using one hand to pull the fetal chin from between the maternal anus and the coccyx, and the other (hand placed) on the fetal occiput to control speed of birth”. In this study, the manoeuvre was considered to be modified as it was used during a uterine contraction instead of between contractions. The “standard practice” arm comprised using one hand to support the perineum and the other hand to control the expulsion of the fetal head. Standard practice was also to perform selective episiotomy for certain indications not described in the review.

Maternal outcomes

Perineal/vaginal trauma: Low-certainty evidence suggests that Ritgen’s manoeuvre may have little or no impact on third- and fourth-degree perineal tears (1 trial, 1423 participants, RR 1.24, 95% CI 0.78– 1.96) and episiotomy (2 trials, 1489 participants, RR 0.81, 95% CI 0.63–1.03). The evidence on the likelihood of having an intact perineum and other perineal outcomes is of very low certainty.

Long-term morbidity: The review found no evidence on long-term outcomes.

Birth experience: The review found no evidence on maternal satisfaction or other outcomes related to birth experience.

Fetal and neonatal outcomes

Apgar scores: The review found no evidence on Apgar scores less than 7 at 5 minutes.

Birth trauma: The review did not include birth trauma as an outcome.

Additional considerations

The review also included a comparison of another type of guiding procedure: delivery of the posterior shoulder first compared with delivery of the anterior shoulder first; however, data for the review outcomes were limited and the resulting evidence was of very low certainty.

Values

Findings from a review of qualitative studies looking at what matters to women during intrapartum care indicate that most women want a normal childbirth with good outcomes for mother and baby (high confidence in the evidence) (15). Findings also suggest that women are aware of the unpredictability of labour and childbirth and are fearful of potentially traumatic events (including medical interventions and maternal and fetal morbidities) that can occur during the birthing process (high confidence in the evidence). It is therefore likely that women will value any technique that may limit perineal trauma, particularly if it is offered by kind, competent health care professionals who are sensitive to their needs (high confidence in the evidence). Qualitative evidence also shows that, 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).

Resources No review evidence was found.

Additional considerations: Perineal techniques are a low-cost intervention for which in-service training would be the main cost.

Equity

No evidence on perineal techniques and equity was found

Additional considerations: If health care professionals could contribute to preserving the integrity of the perineum in the second stage of labour through simple perineal techniques, women in LMICs might be more inclined to use facility-based birth services, which could have a positive impact on equity. However, the effects evidence on Ritgen’s manoeuvre is very uncertain.

Acceptability A qualitative systematic review of women’s experiences of labour and childbirth found no direct evidence relating to women’s views on perineal massage techniques (18). Indirect evidence from this review suggests that, in certain contexts, some women may appreciate techniques that limit perineal trauma provided they are applied by kind and sensitive health care professionals (low confidence in the evidence). In other contexts, women may find these techniques painful, uncomfortable or embarrassing (very low confidence in the evidence). The qualitative systematic review also found no direct evidence relating to health care professionals’ views on perineal techniques to prevent perineal trauma (18).

Additional considerations: It is likely that women would appreciate any perineal technique if there was evidence to suggest they might help or limit any of the potential long-term consequences of a damaged perineum (dyspareunia, sexual dysfunction, urinary or faecal incontinence). Ritgen’s manoeuvre might plausibly be less comfortable for women than other perineal techniques, such as warm compresses.

Feasibility

A qualitative systematic review of women’s experiences of labour and childbirth found no direct evidence relating to women’s views on perineal techniques (18). The qualitative systematic review also found no direct evidence on health care professionals’ views relating to perineal techniques (18). Indirect evidence would suggest that health care professionals in certain contexts may lack the training and/or experience to use some or all of the perineal techniques described (very low confidence in the evidence).

Additional considerations: Appropriate application of the technique demands a reasonable level of midwifery or obstetric expertise to understand the anatomy of the fetal head.

 

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:

http://apps.who.int/iris/bitstream/10665/250796/8/9789241549912-websupplement-eng.pdf?ua=1

http://apps.who.int/iris/bitstream/handle/10665/260178/9789241550215-eng.pdf;jsessionid=7E800B590A164DC7FC879E73B480D6FC?sequence=1

 

Implementation considerations

The successful introduction of evidence-based policies related to intrapartum care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.

The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.

An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.

Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.

Health policy considerations 

  • A firm government commitment to increasing coverage of maternity care for all pregnant women giving birth in health care facilities is needed, irrespective of social, economic, ethnic, racial or other factors. National support must be secured for the whole package of recommendations, not just for specific components.
  • To set the policy agenda, to secure broad anchoring and to ensure progress in policy formulation and decision-making, representatives of training facilities and professional societies should be included in participatory processes at all stages. 
  • To facilitate negotiations and planning, situation-specific information on the expected impact of the new intrapartum care model on service users, providers and costs should be compiled and disseminated.
  • To be able to adequately ensure access for all women to quality maternity care, in the context of universal health coverage (UHC), strategies for raising public funding for health care will need revision. In low-income countries, donors could play a significant role in scaling up implementation.

 

Organizational or health-system-level considerations 

  • Long-term planning is needed for resource generation and budget allocation to address the shortage of skilled midwives, to improve facility infrastructure and referral pathways, and to strengthen and sustain good-quality maternity services.
  • Introduction of the model should involve training institutions and professional bodies so that preservice and in-service training curricula can be updated as quickly and smoothly as possible. 
  • Standardized labour monitoring tools, including a revised partograph, will need to be developed to ensure that all health care providers (i) understand the key concepts around what constitutes normal and abnormal labour and labour progress, and the appropriate support required, and (ii) apply the standardized tools.
  • The national Essential Medicines Lists will need to be updated (e.g. to include medicines to be available for pain relief during labour). 
  • Development or revision of national guidelines and/or facility-based protocols based on the WHO intrapartum care model is needed. For health care facilities without availability of caesarean section, context- or situation-specific guidance will need to be developed (e.g. taking into account travel time to the higher-level facility) to ensure timely and appropriate referral and transfer to a higher level of care if intrapartum complications develop. 
  • Good-quality supervision, communication and transport links between primary and higher-level facilities need to be established to ensure that referral pathways are efficient. 
  • Strategies will need to be devised to improve supply chain management according to local requirements, such as developing protocols for obtaining and maintaining stock of supplies. 
  • Consideration should be given to care provision at alternative maternity care facilities (e.g. on-site midwife-led birthing units) to facilitate the WHO intrapartum care model and reduce exposure of healthy pregnant women to unnecessary interventions prevalent in higher-level facilities. 
  • Behaviour change strategies aimed at health care providers and other stakeholders could be required in settings where non-evidence-based intrapartum care practices are entrenched. 
  • Successful implementation strategies should be documented and shared as examples of best practice for other implementers. User-level considerations 

 

Community-level sensitization activities should be undertaken to disseminate information about: 

  • respectful maternity care (RMC) as a fundamental human right of pregnant women and babies in facilities; 
  • facility-based practices that lead to improvements in women’s childbirth experience (e.g. RMC, labour and birth companionship, effective communication, choice of birth position, choice of pain relief method);
  • and unnecessary birth practices that are not recommended for healthy pregnant women and that are no longer practised in facilities (e.g. liberal use of episiotomy, fundal pressure, routine amniotomy).

 

Research implications

The GDG did not identify any priority question related to this recommendation.

 

Related links

WHO recommendations on intrapartum care for a positive childbirth experience

(2018) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

 

References

  1. The state of the world’s children 2016: a fair chance for every child. New York (NY): United Nations Children’s Fund; 2016 (https://www.unicef.org/ publications/files/UNICEF_SOWC_2016.pdf, accessed 20 October 2017).
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Citation: WHO Reproductive Health Library. WHO recommendation on techniques for preventing perineal trauma in second stage of labour (February 2018). The WHO Reproductive Health Library; Geneva: World Health Organization.