Clinical Guidelines Endorse Physiologic Care in Labor

The Lancet has devoted an issue to maternal health that includes a systematic review of maternity care practice guidelines entitled: “Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.” It joins a growing list of documents published over the years that pretty much say the same thing about ways to improve outcomes. (See the end of this post.) Follow the link to view or download the review for free. Here, for your viewing pleasure, are recommendations aligned with principles of physiologic care:

Recommended Practices

• “Offer women the possibility of being cared for by a midwife; provide one-on-one continuous supportive care”
• “Consider the psychological and emotional needs of the woman.”
• “Offer intermittent auscultation of the fetal heart rate to women in established first stage of labour in all birth settings”
• “Encourage women to adopt any upright position they find comfortable throughout labour”
• “Advise women that breathing exercises, immersion in water, and massage might reduce pain during first stage of labour, and that breathing exercises and massage might reduce pain during second stage of labour”
• “Inform women about risks and benefits and potential implications of epidural analgesia during labour”
• “Allow and encourage women to drink water, juice, or isotonic drinks, and eat light meals or snacks during labour”
• “Encourage and help women to move and adopt any position they find most comfortable throughout labour and childbirth, except supine or semi-supine”
• “Inform women that in the second stage they should be guided by their own urge to push”
• “Delayed cord clamping (done 1-3 min after birth) is recommended for all births while initiating essential newborn care”
• “Encourage women to have skin-to-skin contact with their babies as soon as possible after birth”
• “Avoid woman-baby separation before the first hour following birth, unless at the mother’s request; delay postnatal routine procedures (eg, weighing, bathing, and measuring); monitor the neonate’s condition during skin-to-skin contact”
• “Encourage and support breastfeeding initiation within first hour”
• “Facilitate rooming-in (mother and baby should stay in the same room 24 h a day)
• “Promote exclusive breastfeeding from birth until 6 months of age”

Practices Not Recommended

• “Routine involvement of obstetricians or gynaecologists in the care of women with normal course of pregnancy is not recommended for improvement of perinatal results”
• “Do not perform cardiotocography on admission for low-risk women in suspected or established labour in any birth setting as part of the initial assessment”
• “Do not offer or advise clinical intervention if labour is progressing normally and the woman and baby are well (including amniotomy [breaking the bag of waters] and oxytocin augmentation, even in women with epidural analgesia)”
• “Discourage the woman from lying supine or semi-supine in the second stage [pushing phase] of labour”
• “Do not carry out a routine episiotomy during spontaneous vaginal birth”

It’s always good to see authoritative documents that endorse physiologic care, but one wonders when maternity care experts will no longer need to re-invent this particular wheel because providers and institutions will finally put a set of them on a vehicle and drive it off the lot. Until that happy day arrives, the Lancet review provides maternity care reformers and consumers one more impeccable resource to point to in support of policies and practices that produce the best outcomes while minimizing use of medical intervention.

Optimal Care Leverage Documents

American College of Nurse-Midwives, Midwives Alliance North America, National Association of Certified Professional Midwives. Supporting healthy and normal physiologic childbirth: a consensus statement by ACNM, MANA, and NACPM; 2012. (http://www.nacpm.org/documents/Normal-Physiologic-Birth-Statement.pdf)

California Maternal Quality Care Collaborative. Toolkit to Support Vaginal Birth and Reduce Primary Cesareans: A Quality Improvement Toolkit. Stanford, CA: California Maternal Quality Care Collaborative; 2016. (https://www.cmqcc.org/VBirthToolkit)

Childbirth Connection. 2020 Vision for a High-Quality, High-Value Maternity Care System. 2010. (http://transform.childbirthconnection.org/vision/)

Coalition for Improving Maternity Services. The Mother-Friendly Childbirth Initiative. 1996. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2409133)

International Federation of Gynecology and Obstetrics, International Confederation of Midwives, White Ribbon Alliance, et al. Mother-baby friendly birthing facilities. Int J Gynaecol Obstet 2015;128(2):95-9. (https://www.whiteribbonalliance.org/wp-content/uploads/2017/11/MBFBF-guidelines.pdf)

International MotherBaby Childbirth Organization. The International MotherBaby Childbirth Initiative. (http://imbco.weebly.com/uploads/8/0/2/6/8026178/imbci__final_04-05-08.pdf)

Lamaze International. Healthy Birth Practices. (http://www.lamaze.org/HealthyBirthPractices)

Maternity Care Working Party. Making normal birth a reality. Consensus statement from the Maternity Care Working Party – our shared views about the need to recognise, facilitate and audit normal birth. Normal Birth Consensus Statement: Royal College of Obstetricians and Gynaecologists; 2007. (http://mothersnaturally.org/pdfs/UKNormalBirthDocument.pdf)

Sakala C, Corry MP. Evidence-Based Maternity Care: What It Is and What It Can Achieve. New York: Milbank Memorial Fund; 2008. (http://www.milbank.org/uploads/documents/0809MaternityCare/0809MaternityCare.html)

World Health Organization. WHO Recommendations. Intrapartum Care for a Positive Childbirth Experience. Geneva: World Health Organization; 2018. (http://apps.who.int/iris/bitstream/10665/260178/1/9789241550215-eng.pdf)