Population: Pregnant women undergoing normal spontaneous labor.

Organizations

NICE 2022, ACOG 2021, WHO 2018

Recommendations

–Allow mother to choose her birth setting (eg, home, midwifery unit, or hospital obstetric unit). Home birth has a small increase (1 in 250) in serious medical problems for the newborn vs. birth in a midwifery unit or hospital. (NICE)

–Encourage support from birth companion(s). Communicate clearly and respectfully.

–Suggest relaxation techniques such as mindfulness, breathing exercises, water immersion, and massage for pain control during latent labor. Encourage mobility and an upright position unless high risk.

–Avoid continuous external fetal monitoring (EFM) in routine/low-risk situations.¹ Offer continuous EFM (and, transfer to obstetrics-led care if not already there) if any of the following:

• Maternal HR >120 or BP >160/110 (or >140/90 ×2).

• Maternal urine protein ≥2+ with BP >140/90 ×1.

• Vaginal bleeding.

• ROM >24 prior to labor.

• Meconium.

• Atypical pain.

• High-risk maternal comorbidities.

• Fetal abnormal lie.

• High or free-floating head in nulliparous woman.

• Suspected fetal growth restriction or macrosomia.

• Suspected oligonydramnios or polyhydramnios.

• FHR <110 or >160.

• Fetal deceleration heard on intermittent auscultation.

• Reduced fetal movement.

–During labor, support maternal choice for breathing/relaxation techniques, massage, immersion in water and music.

–Offer nitrous oxide for analgesia.

–Offer opioids for anesthesia (limited pain relief; may cause drowsiness/nausea/vomiting in mom and respiratory depression and drowsiness in baby).

–If receiving care in an obstetric unit, offer epidural (no increase in first stage of labor or cesarean birth; longer second stage of labor and increased vaginal instrumental birth; more intense monitoring and reduced mobility).

–The first stage of labor typically progresses at 1-cm dilation per hour, but do not intervene solely for a progression rate at <1 cm/h (WHO).

–Do not routinely perform amniotomy to expedite labor (WHO).

–Second stage of labor: suspect labor dystocia after 2 h in nulliparous woman and 1 h in multiparous woman; ensure availability of operative vaginal birth, unless delivery is imminent.

–Consider use of oxytocin to augment second stage of labor.

–Reduce perineal trauma using either “hands on” (guarding perineum and flexing baby’s head) or “hands poised” (hands off perineum and baby’s head but in readiness) technique. Avoid perineal massage, lidocaine spray, and routine episiotomy.

–Manage third stage of labor:

• Administer 10 IU oxytocin immediately after birth of anterior shoulder.

• Clamp and cut cord after 1 min (unless FHR <60) but before 5 min.

• Use controlled cord traction until delivery of placenta.

• Remove the placenta actively if hemorrhage or placenta not delivered within 1 h.

Sources

–www.nice.org.uk/guidance/cg190

–WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO.

–Obstet Gynecol. 2019;133(2):e164.