It has been more than two decades since the World Health Organization (WHO) issued technical guidance dedicated to the care of healthy pregnant women and their babies – Care in normal birth: a practical guide. The global landscape for maternity services has changed considerably since that guidance was issued. More women are now giving birth in health care facilities in many parts of the world, and yet suboptimal quality of care continues to impede attainment of the desired health outcomes. While in some settings too few interventions are being provided too late to women, in other settings women are receiving too many interventions that they do not need too soon. WHO has released several recommendations to address specific aspects of labor management and the leading causes of maternal and newborn mortality and morbidity. The focus of the global agenda has expanded beyond the survival of women and their babies, to include ensuring that they thrive and achieve their full potential for health and well-being.
The recommendations in this guideline are intended to inform the development of relevant national- and local-level health policies and clinical protocols. Therefore, the target audience includes national and local public health policy-makers, implementers and managers of maternal and child health programs, health care facility managers, nongovernmental organizations (NGOs), professional societies involved in the planning and management of maternal and child health services, health care professionals (including nurses, midwives, general medical practitioners and obstetricians) and academic staff involved in training health care professionals.
Guideline development methods
Throughout this guideline, the term “healthy pregnant women” is used to describe pregnant women and adolescent girls who have no identified risk factors for themselves or their babies, and who otherwise appear healthy.
list of recommendations on intrapartum care for a positive childbirth experience: Respectful maternity care – refers to care organized for and provided to all women in a manner that maintains their dignity, privacy and confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during labor and childbirth – is recommended.
- Recommended Effective communication
Effective communication between maternity care providers and women in labor, using simple and culturally acceptable methods, is recommended.
- Recommended Companionship during labor and childbirth
A companion of choice is recommended for all women throughout labor and childbirth.
- Recommended Continuity of care
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 programs.
- Definitions of Stages of Labor
The use of the following definitions of the latent and active first stages of labor is recommended for practice. — The latent first stage is a period of time characterized by [painful] uterine contractions and variable changes of the cervix, including some degree of effacement and slower progression of dilatation up to 5 cm for first and subsequent labors. — 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 first and subsequent labors.
- Recommended Duration of the first stage of labor
Women should be informed that a standard duration of the latent first stage has not been established and can vary widely from one woman to another. However, the duration of active first stage (from 5 cm until full cervical dilatation) usually does not extend beyond 12 hours in first labors, and usually does not extend beyond 10 hours in subsequent labors.
- Recommended Progress of the first stage of labor
For pregnant women with spontaneous labor onset, the cervical dilatation rate threshold of 1 cm/hour during active first stage is inaccurate to identify women at risk of adverse birth outcomes and is therefore not recommended for this purpose.
- Rate of Dilation and Obstetric Intervention
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 labor progression. A slower than 1-cm/hour cervical dilatation rate alone should not be a routine indication for obstetric intervention.
- Intervention before 5 cm dilation
Labor may not naturally accelerate until a cervical dilatation threshold of 5 cm is reached. Therefore the use of medical interventions to accelerate labor and birth (such as oxytocin augmentation or caesarean section) before this threshold is not recommended, provided fetal and maternal conditions are reassuring.
RECOMMENDED: Respect, privacy, communication in maternal care.
RECOMMENDED: Labor Support Companion
RECOMMENDED: Midwifery Model of Care (continuity of care).
DEFINITIONS: Stages of Labor: Early First Stage = 0-5 cm.
Active First Stage = 6-10 cm.
Time frames widely variable. Average Early stage is up to 12 hours in first-time moms.
NOT RECOMMENDED: Friedman Curve Theory of 1 cm per hour for any stage of labor
NOT RECOMMENDED: accelerating labor via Pitocin (or c-section) before 5 cm