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slidedoc February 24, Prepared by:
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TABLE OF CONTENTS
EXECUTIVE
SUMMARY 01 02 03 04
Background Methods Recommendations Implementation
Pages 1–7 Pages 8–9 Pages 10–18 Pages 19–167 Pages 168–170
+ Childbirth and the + Guideline + Care Throughout + Putting the

2030 Agenda for Contributors Labour and Birth Guideline in
Sustainable Context
Development + Priority + First Stage of
Questions: Labour + WHO
+ Medicalization of Focusing on What Intrapartum Care
Childbirth Matters to + Second Stage of Model
Women Labour
+ Labour + Considerations
Progression: + Confidence in the + Third Stage of Specific to
What’s Normal? Evidence: The Labour Individual
GRADE Approach Recommendations
+ Guideline Scope: + Care of the
Who & What? + Making of the Woman and
Recommendations Newborn After
Birth
© Duarte, Inc. 2014 2

TABLE OF CONTENTS
05 06 07 08
Research Dissemination Applicability Updating the
Implications Issues Guideline
Pages 171–172 Page 173 Page 174 Page 175
+ Underlying + Global Launch + Potential Barriers + Living Guidelines

Principles With Press to Implementation Approach
Release
+ Priority Research + Organization of + New Guideline
Worth the + WHO Web Care : What Questions?
Investment Resources Needs to Change
+ Connecting With
+ Top Three + Social Media + Monitoring and WHO
Research Impact
Priorities + Translations Evaluation
+ Conferences
+ Implementation
Tools

Background
01
+ Childbirth and the 2030 Agenda for Sustainable
Development
+ Medicalization of Childbirth
+ Labour Progression: What’s Normal?
+ Guideline Scope: Who & What?

CHILDBIRTH AND THE 2030 AGENDA FOR SUSTAINABLE DEVELOPMENT
Globally, approximately 140 million births Global agendas are expanding

occur every year.
their focus to ensure that
The type and degree of risk related to women and their babies not
labour and childbirth, and the early weeks
of life differ between countries and
only survive labour
settings. complications if they occur but
also that they thrive and reach
Majority of births occur
their full potential for health
among pregnant women with
and well-being.
no identified risk factors for
complications, either for Improving the quality of care around the
themselves or their babies, at time of birth has been identified as the
most impactful strategy for reducing
the beginning and throughout stillbirths, maternal and newborn deaths,
labour. compared with antenatal or postpartum
care strategies.
Nevertheless, the time of birth is critical to
the survival of mothers and their babies,
as the risk of morbidity and mortality could
increase considerably if complications
arise.
MEDICALIZATION OF CHILDBIRTH
Despite years of research, the concept of Over-medicalization of

“normality” in labour and childbirth is not
universal or standardized.
childbirth processes tends to
undermine the woman’s own
The predominant model of care in many
parts of the world, is the one where a
capability to give birth and
health provider controls the birthing negatively impacts her
process. childbirth experience.
There has been a substantial
Healthy pregnant women continue to be
increase over the last two subjected to ineffective and potentially
decades in the application of a harmful routine labour interventions such
as perineal shaving, enema, amniotomy,
range of labour practices to intravenous fluids, antispasmodics, and
initiate, accelerate, terminate, antibiotics for uncomplicated vaginal
regulate or monitor the births.
process of labour.
 LINK: INCREASING TREND IN CS RATES There is evidence that a substantial

 LINK: WITHIN COUNTRY INEQUALITY IN CS proportion of women undergo at least one
obstetric intervention during labour and
 LINK: INTERVENTIONS IN LOW-RISK WOMEN
childbirth.
LABOUR PROGRESSION: WHAT’S NORMAL?
The validity of one of the most The question of whether the current
cervicograph design can safely and
important components of the unequivocally identify healthy labouring
partograph, the alert and women at risk of adverse outcomes has
action lines, has been called become critical to clinical guidance on
intrapartum care.
into question in the last
decade, as findings of several
studies suggest that labour
can indeed be slower than the
To safely monitor labour and childbirth, a
limits proposed in the 1950s clear understanding of what constitutes
by Emmanuel Friedman. normal labour onset and progress is
essential.
Consensus around the definitions of the

onset and duration of the different phases
and stages of normal labour is lacking.
 LINK: S/REVIEW OF LABOUR PROGRESSION In practice, there are considerable

 LINK: PERFORMANCE OF THE “ALERT LINE”
variations in how normal labour progress
is defined in terms of cervical dilatation Cervical dilatation patterns (grey lines) in
women with normal birth outcomes versus
pattern and safe time limits. alert line (dashed line).

LABOUR PROGRESSION PROFILES OF ≈10,000 WOMEN VERSUS ALERT LINE
SOURCE: SOUZA ET AL. BJOG. 2018

8 © Duarte, Inc. 2014 8
LABOUR PROGRESSION PROFILES OF ≈10,000 WOMEN VERSUS ALERT LINE
Good outcome Bad outcome
SOURCE: SOUZA ET AL. BJOG 2018

9 © Duarte, Inc. 2014 9
GUIDELINE SCOPE: WHO & WHAT?
This guideline focuses on the care of all healthy

pregnant women and their babies during
labour and childbirth in any health care
setting. “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.
The management of pregnant women who develop labour

complications and those with high-risk pregnancies who require
specialized intrapartum care is outside the scope of this
guideline.
The guideline covers essential care that should be provided

throughout labour and childbirth, and interventions specific to the
first, second, and third stages of labour.

©Photoshare
Methods
02
+ Guideline Contributors
+ Priority Questions: Focusing on What Matters to Women
+ Confidence in Evidence: The GRADE Approach
+ Making of the Recommendations

GUIDELINE CONTRIBUTORS
WHO Steering Group

This comprises staff members from the
WHO Departments of Reproductive Health
and Research (RHR); Maternal, Newborn,
Child and Adolescent Health (MCA), who
managed the guideline development
process.
Guideline Development Group

This consists of external experts and
stakeholders from the six WHO regions .
Members were identified in a way that

ensured geographic representation and
gender balance, and they had no
important conflicts of interest.
Photo: Olufemi Oladapo
The group examined and interpreted the
evidence and formulated the final The GDG is a diverse group of individuals with expertise in research, clinical
recommendations at two face-to-face practice, policy and programmes, and guideline development methods
relating to intrapartum care practices and service delivery.
meetings in May and September 2017.
. © Duarte, Inc. 2014 12

GUIDELINE CONTRIBUTORS
Technical Working Group

This comprises guideline methodologists
and systematic review team leads, who
worked closely with WHO Steering group
to synthesize the evidence and other
considerations for development of the
recommendations.
External Review Group

These are external experts and
stakeholders from the six WHO regions,
who peer-reviewed the final guideline
document to identify any factual errors and
comment on clarity of the language,
contextual issues and implications for
implementation.
Photo: Olufemi Oladapo
Observers The GDG is a diverse group of individuals with expertise in research, clinical
practice, policy and programmes, and guideline development methods
Representatives of FIGO; ICM; RCOG; relating to intrapartum care practices and service delivery.
UNFPA; and USAID

PRIORITY QUESTIONS: FOCUSING ON WHAT MATTERS TO WOMEN
The guideline focus was based on a

scoping process that identified woman- .
centred interventions and outcomes for
Normal birth
intrapartum care. This included a
systematic qualitative review to
(without
understand what women want, need and
intervention)
A healthy
value during childbirth. The findings show
Photo: WHO mother and
that:
baby
Support
Women want a positive
from a birth
childbirth experience that companion
fulfils or exceeds their prior Desire to be
personal and sociocultural in control
beliefs and expectations. Sensitive,
caring, kind,
Therefore, WHO used a consultative respectful
process to identify priority questions staff
related to the effectiveness of clinical and
non-clinical practices aimed at helping Here are some
of the views shared by
women achieve their expectations of
women included in the
childbirth.
systematic review.
Two bottom photos: iStock by Getty Images. All rights reserved

CONFIDENCE IN THE EVIDENCE:
THE GRADE APPROACH
Systematic Reviews of Systematic Reviews of Resource Implications and

Quantitative Evidence Qualitative Evidence Cost-Effectiveness Reviews
“What are the desirable and undesirable “Is there important uncertainty or variability “What are the resources associated with
effects of the intervention?” and “What is in how much women value the outcomes the intervention?” and “Is the
the certainty of the evidence on effects?”. associated with the intervention?”, “Is the intervention/option cost-effective?”
intervention acceptable and feasible to
implement by women, health care
providers, relevant stakeholders?”, and
“What is the anticipated impact of the
intervention on equity?” © Duarte, Inc. 2014 15
CONFIDENCE IN THE EVIDENCE:
THE GRADE APPROACH GRADE Evidence-to-Decision
(EtD) Frameworks
These include explicit and systematic
consideration of evidence on prioritized
interventions in terms of effects, values,
resources, equity, acceptability and
feasibility.
Systematic Reviews of Systematic Reviews of Resource Implications and

Quantitative Evidence Qualitative Evidence Cost-Effectiveness Reviews
“What are the desirable and undesirable “Is there important uncertainty or variability “What are the resources associated with
effects of the intervention?” and “What is in how much women value the outcomes the intervention?” and “Is the
the certainty of the evidence on effects?”. associated with the intervention?”, “Is the intervention/option cost-effective?”
intervention acceptable and feasible to
implement by women, health care
providers, relevant stakeholders?”, and
“What is the anticipated impact of the
intervention on equity?” © Duarte, Inc. 2014 16
MAKING OF THE RECOMMENDATIONS
Two GDG meetings were held to reach

consensus on each recommendation, including
its direction and in some instances the specific
context, based on EtD frameworks, GRADE
evidence profiles and evidence summaries.
Consensus was defined as the agreement by three quarters or

more of the GDG, provided that those who disagreed did not feel
strongly about their position.
In line with other recently published WHO guidelines using EtD

frameworks, the GDG classified each recommendation into one
of four categories.


evidence profiles and evidence summaries.


of four categories.


evidence profiles and evidence summaries. Recommended


of four categories.


evidence profiles and evidence summaries. Not
Recommended


of four categories.


in specific
context


of four categories.


in rigorous
research


of four categories.

Recommendations
03
+ Care Throughout Labour and Birth
+ First Stage of Labour
+ Second Stage of Labour
+ Third Stage of Labour
+ Care of the Woman and Newborn After Birth

56 RECOMMENDATIONS IN TOTAL…
This guideline includes 26 new recommendations adopted

by the GDG at the 2017 meetings, and 30 existing
recommendations from previously published WHO
guidelines.
Recommendations are grouped and presented according

to the timing of the practice ranging from labour onset
through to the immediate postnatal period.
Additional remarks are included where needed to ensure that recommendations
are correctly understood and applied in practice.
The full guideline and the supporting GRADE evidence profiles
are available here.

RESPECTFUL MATERNITY CARE
Respectful maternity care – which 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 labour and childbirth – is
recommended.
Photo: Global Health Project
Supportive care throughout

labour and birth © Duarte, Inc. 2014 25

women in a manner that maintains their
dignity, privacy and confidentiality, ensures
freedom from harm and mistreatment, and RMC is for everyone
enables informed choice and continuous • Regardless of:
support during labour and childbirth – is • The risk status for labour complications - ‘low’
recommended. or ‘high’
• Birth settings – home or hospital
• Cadres of health care provider
• Country income level – high, middle, or low


dignity, privacy and confidentiality…
women in a manner that maintains their • In accordance with a human-rights-based
dignity, privacy and confidentiality, ensures approach to reducing maternal morbidity and
freedom from harm and mistreatment, and mortality
• Requires interventions at the interpersonal
enables informed choice and continuous
level between a woman and her health care
support during labour and childbirth – is providers
recommended. • Interventions should aim to ensure a
respectful and dignified working
environment for those providing care

EFFECTIVE COMMUNICATION
Effective communication between maternity

care providers and women in labour, using
simple and culturally acceptable methods, is
recommended.

EFFECTIVE COMMUNICATION
Effective communication should include:
• Introducing themselves to the woman and her

companion and addressing the woman by her
Effective communication between maternity name
care providers and women in labour, using

• Offering the woman and her family the
simple and culturally acceptable methods, is information they need in a clear and concise
recommended. manner, avoiding medical jargon, and using
pictorial and graphic materials
• Responding to the woman’s needs, preferences

and questions with a positive attitude
• Ensuring that procedures are explained to the

woman, and that verbal and, when appropriate,
written informed consent for pelvic examinations
and other procedures is obtained from the
woman
COMPANIONSHIP DURING LABOUR AND CHILDBIRTH
A companion of choice is recommended for

all women throughout labour and childbirth.

COMPANIONSHIP DURING LABOUR AND CHILDBIRTH
Who is a companion in this context?

• Any person chosen by the woman to provide her
with continuous support during labour and
childbirth and may be someone from the
A companion of choice is recommended for woman’s family or social network, such as:
all women throughout labour and childbirth. • Spouse/partner
• Female friend or relative
• Community member (such as a female
community leader, health worker or traditional
birth attendant)
• Doula
• It is important that women’s wishes are
respected, including those who prefer not to have
a companion.

DEFINITION AND DURATION OF THE LATENT AND ACTIVE FIRST STAGES
OF LABOUR
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 labours
Care during the first stage

OF LABOUR
… and how long does this stage

usually take?
The latent first stage is a period of time Women should be informed that a
characterized by painful uterine standard duration of the latent first
contractions and variable changes of the stage has not been established and
can vary widely from one woman to
cervix, including some degree of effacement
another.
and slower progression of dilatation up to 5
cm for first and subsequent labours.

OF LABOUR
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 labours

OF LABOUR
… and how long does this stage

usually take?
The active first stage is a period of time The duration of active first stage
characterized by regular painful uterine usually does not extend beyond 12
contractions, a substantial degree of cervical hours in first labours, and usually
does not extend beyond 10 hours in
effacement and more rapid cervical
subsequent labours.
dilatation from 5 cm until full dilatation for
first and subsequent labours.

PROGRESS OF THE FIRST STAGE OF LABOUR
There is insufficient evidence to support the use of the partograph alert line as a classifier to
detect women at risk of adverse birth outcomes.
1 cm per hour rule inaccurate < 1 cm/hour ≠ obstetric intervention Every birth is unique
For pregnant women with A minimum cervical dilatation rate of Labour may not naturally accelerate
spontaneous labour onset, the 1 cm/hour throughout active first until a cervical dilatation threshold of
cervical dilatation rate threshold of stage is unrealistically fast for some 5 cm is reached. Therefore the use
1 cm/hour during active first stage women and is therefore not of medical interventions to
(as depicted by the partograph alert recommended for identification of accelerate labour and birth (such as
line) is inaccurate to identify women at normal labour progression. A slower oxytocin augmentation or caesarean
risk of adverse birth outcomes and is than 1-cm/hour cervical dilatation section) before this threshold is not
therefore not recommended for this rate alone should not be a routine recommended, provided fetal and
purpose. indication for obstetric intervention. maternal conditions are reassuring.

ROUTINE ASSESSMENT OF FETAL WELL-BEING
Routine cardiotocography is not

recommended for the assessment of fetal
well-being on labour admission or during
labour in healthy pregnant women
undergoing spontaneous labour.

But why?
• The GDG placed its emphasis on evidence that

suggests that both admission and continuous
Routine cardiotocography is not cardiotocography increase the risk of caesarean
recommended for the assessment of fetal section and other medical interventions
without improving substantive birth outcomes.
well-being on labour admission or during
labour in healthy pregnant women • Continuous cardiotocography restricts other
undergoing spontaneous labour. beneficial interventions during labour, such as
having a choice of labour and birth positions,
and being able to walk around freely, and can
be stressful for women.

Auscultation of the fetal heart rate with

either a handheld Doppler ultrasound device
or a Pinard fetal stethoscope is
recommended for healthy pregnant women
in labour.

Standard protocol for intermittent auscultation?

• No evidence of comparative benefits of
different protocols
• Interval: Every 15–30 minutes in active first
stage of labour, and every 5 minutes in the
Auscultation of the fetal heart rate with second stage of labour
either a handheld Doppler ultrasound device • Duration: Each auscultation should last for
at least 1 minute
or a Pinard fetal stethoscope is
recommended for healthy pregnant women • Timing: During a uterine contraction and for
at least 30 seconds thereafter
in labour.
• Recording: Record the baseline as a single
counted number in beats per minute, and
acceleration or deceleration

PAIN RELIEF DURING LABOUR
It is likely that the care context and the type of care provision and care provider have a strong
effect on the need for labour pain relief, and on the choices women make in relation to this need.
Relaxation and Massage Epidural Analgesia Parenteral Opioids

Techniques
Epidural analgesia appears to be the more Despite being widely available and used,
Most women desire some form of pain effective pain relief option but compared pethidine is not the preferred opioid
relief during labour, and qualitative with opioid analgesia it also requires more option, as shorter-acting opioids tend to
evidence indicates that relaxation resources to implement and to manage its have fewer undesirable side-effects
techniques can reduce labour discomfort, adverse effects, which are more common
with epidural analgesia. Before use, health care providers should
relieve pain and enhance the maternal
counsel women about the potential side-
birth experience.
effects of opioids, including maternal
drowsiness, nausea and vomiting, and
neonatal respiratory depression, and
about the alternative pain relief options
available.
DEFINITION AND DURATION OF THE SECOND STAGE OF LABOUR
The second stage is the period of time

between full cervical dilatation and birth of
the baby, during which the woman has an
involuntary urge to bear down, as a result of
expulsive uterine contractions.
Care during the second stage

DEFINITION AND DURATION OF THE SECOND STAGE OF LABOUR
The second stage is the period of time

between full cervical dilatation and birth of
the baby, during which the woman has an
involuntary urge to bear down, as a result of … and how long does this stage
usually take?
expulsive uterine contractions.
• Women should be informed that the
duration of the second stage varies from
one woman to another. In first labours,
birth is usually completed within 3 hours
whereas in subsequent labours, birth is
usually completed within 2 hours.

BIRTH POSITIONS
For women with or without epidural

analgesia, encouraging the adoption of a
birth position of the individual woman’s
choice, including upright positions, is
recommended.

BIRTH POSITIONS
Individual woman’s choice means…
• Any particular position is not forced on the

woman and that she is encouraged and
For women with or without epidural
supported to adopt any position that she finds
analgesia, encouraging the adoption of a most comfortable.
choice, including upright positions, is • The health care professional should ensure that
the well-being of the baby is adequately
recommended.
monitored in the woman’s chosen position.
Should a change in position be necessary to
ensure adequate fetal monitoring, the reason
should be clearly communicated to the woman.

BIRTH POSITIONS
And when she is ready to push…
Women in the expulsive phase of the second

For women with or without epidural stage of labour should be encouraged and
analgesia, encouraging the adoption of a supported to follow their own urge to push.
choice, including upright positions, is
recommended.

EPISIOTOMY POLICY
Routine or liberal use of episiotomy is not

recommended for women undergoing
spontaneous vaginal birth.

FUNDAL PRESSURE
Application of manual fundal pressure to

facilitate childbirth during the second stage
of labour is not recommended.

THIRD STAGE OF LABOUR RECOMMENDATIONS
Recommendations on selected essential practices during the third stage of labour were
integrated from the 2012 WHO recommendations for the prevention and treatment of PPH.
Recommended When oxytocin is Timing of umbilical Controlled cord Uterine massage

uterotonics for PPH not available cord clamping traction Sustained uterine
The use of uterotonics In settings where Delayed umbilical cord In settings where skilled massage is not
for the prevention of oxytocin is unavailable, clamping (not earlier birth attendants are recommended as an
postpartum the use of other than 1 minute after birth) available, controlled intervention to prevent
haemorrhage (PPH) injectable uterotonics (if is recommended for cord traction (CCT) is postpartum
during the third stage of appropriate, improved maternal and recommended for haemorrhage (PPH) in
labour is recommended ergometrine/methylergo infant health and vaginal births if the care women who have
for all births. Oxytocin metrine, or the fixed nutrition outcomes. provider and the received prophylactic
(10 IU, IM/IV) is the drug combination of parturient woman regard oxytocin
recommended oxytocin and a small reduction in
uterotonic drug for the ergometrine) or oral blood loss and a small
prevention of misoprostol (600 μg) is reduction in the duration
postpartum recommended. of the third stage of
haemorrhage. labour as important.
Third stage of labour

CARE OF THE NEWBORN
Newborns without complications should be

kept in skin-to-skin contact (SSC) with their
mothers during the first hour after birth to
prevent hypothermia and promote
breastfeeding.
This recommendation has been integrated from the WHO

recommendations for management of common childhood
conditions: evidence for technical update of pocket book
recommendations, in which the GDG for that guideline
determined it to be a strong recommendation based on low-
quality evidence.
The evidence supporting this recommendation can be found in

the source guideline document, which is available here.
Care of the newborn

CARE OF THE NEWBORN
All newborns, including low-birth-weight

(LBW) babies who are able to breastfeed,
should be put to the breast as soon as possible
after birth when they are clinically stable, and
the mother and baby are ready.

recommendations on newborn health. The evidence supporting
this recommendation can be found in the WHO guidelines on
optimal infant feeding for low birth weight infants in low- and
middle-income countries. This recommendation was determined
to be a strong recommendation based on low-quality evidence.
The source and the evidence supporting this recommendation

can be found here and there:
Care of the newborn

CARE OF THE NEWBORN
All newborns should be given 1 mg of vitamin

K intramuscularly after birth (i.e. after the
first hour by which the infant should be in
skin-to-skin contact with the mother and
breastfeeding should be initiated).

Recommendations for management of common childhood
conditions: evidence for technical update of pocket book
recommendations, in which the GDG for that guideline
determined it to be a strong recommendation based on
moderate-quality evidence.
Photo: World Bank

Care of the newborn

CARE OF THE WOMAN AFTER BIRTH
Routine antibiotic prophylaxis is not

recommended for women with uncomplicated
vaginal birth. And likewise for women with
episiotomy.
The GDG was concerned about the potential public health

implications of the high rate of routine use of antibiotics following
vaginal birth without any specific risk factors in some settings.
The group places emphasis on the negative impact of such
routine use on the global efforts to contain antimicrobial
resistance and, therefore, made a strong recommendation
against routine antibiotic prophylaxis.
Photo: UNICEF/Christine Nesbitt
Care of the woman after birth

Implementation
04
+ Putting the Guideline into Context
+ WHO Intrapartum Care Model
+ Considerations Specific to Individual Recommendations

GENERAL IMPLEMENTATION CONSIDERATIONS
Update clinical Equip health Support behaviour

guidance facilities change
Develop or revise existing Ensure necessary physical Obtain technical support for
clinical guidelines, protocols or resources, supplies, equipment implementation, engage
job aids for intrapartum care and staff to deliver recommended stakeholders and partners, and
practices provide training
Putting the guideline into

context © Duarte, Inc. 2014 55
INTRODUCING THE WHO INTRAPARTUM CARE MODEL
The recommendations should be implemented as a package of care in all

facility-based settings, by kind, competent and motivated health care
professionals who have access to the essential physical resources.
The principles guiding the 2018 guideline

that includes 56 evidence-based
recommendations include the following:
 Labour and childbirth should be

individualized and woman-centred
 No intervention should be implemented

without a clear medical indication
 Only interventions that serve an

immediate purpose and proven to be
beneficial should be promoted
 A clear objective that a positive

childbirth experience for the woman,
the newborn and her family should be
at the forefront of labour and childbirth
care at all times
WHO intrapartum care model

CONSIDERATIONS SPECIFIC TO INDIVIDUAL RECOMMENDATIONS
In addition to the overarching WHO model of intrapartum care,

implementation considerations that are peculiar to selected practices
are presented as an annex.
Respectful Care Definitions, Duration, and

Mechanisms should be put in place to
Progress of First Stage
ensure that all women are made aware Introduction of these new definitions
of their right to RMC and the existence of and concepts should involve pre-
a mechanism for raising and addressing service training institutions and
complaints. RMC policies should be professional bodies, so that training
tailored to ensure that vulnerable curricula for intrapartum care can be
subgroups of women are not excluded. updated as quickly and smoothly as
possible.
Effective Communication Labour Companionship

Routine inclusion of communication Policy-makers should develop
training in all pre-service and in- culturally sensitive training
service professional training programmes for companions, and
interventions is the most feasible consider ways of registering, retaining
way to implement. and incentivizing them.

Research gaps
05
+ Underlying Principles
+ Priority Research Worth the Investment
+ Top Three Research Priorities

TOP THREE RESEARCH PRIORITIES
Ideal paper-based
or digital tool
for labour
Delaying versus monitoring and Comparative
direct labour ward clinical decision- effects of different
admission for making. intermittent
health pregnant auscultation
women. protocols.
Key research gaps are

related to admission policy
and labour monitoring: 1 2 3
Out of the 29 priority research During the guideline development improvements in the childbirth experience
process, the Guideline Development of women, be likely to promote equity, and
questions identified, the GDG Group (GDG) identified important be feasible to implement.
considered 3 questions as knowledge gaps that need to be
Research gaps were only discussed and
urgent to support addressed through primary research.
presented for new recommendations in
implementation of specific Where the certainty of available evidence the guideline.
recommendations. was rated as “low” or “very low”, the GDG
considered whether further research
should be prioritized, based on whether
such research would contribute to

Dissemination
06
+ Global Launch With Press Release
+ International Conferences
+ WHO Web Resources
+ Social Media
+ Translations

DISSEMINATION CHANNELS
WHO and other partners will support national and subnational working groups to adapt and
implement this guideline.
Press release FAQs Web stories & Translations

Commentaries
Infographics Additional info Conferences Implementation tools

Applicability issues
07
+ Potential Barriers at Country Level
+ Organization of Care : What Needs to Change
+ Monitoring and Impact Evaluation

ANTICIPATED IMPACT ON ORGANIZATION OF CARE
Effective implementation of the

recommendations in this guideline may
Human
require reorganization of care and
resources
redistribution of health care resources.
The potential barriers to implementation include:
① Lack of human resources with the necessary expertise and

skills to implement, supervise and support recommended
practices.
Reorganized
② Lack of infrastructure to effectively support recommended intrapartum care
practices (e.g. comfortable waiting rooms for women in early
labour or physical space for labour companions. Closely
linked is the lack of essential equipment (e.g. Doppler
Health
ultrasound device and Pinard fetal stethoscope), supplies Infrastructure
information
and medicine.
③ Lack of health information management systems designed to

document and monitor recommended practices.

MONITORING AND IMPACT EVALUATION
How do we track the performance

and improve results?
The implementation and impact of these regional-level implementation of the
recommendations should be monitored at recommendations in the short to medium
the health-service, regional and country term to assess their impact on national
levels. policies of individual WHO Member
States.
The WHO publication Standards for
improving quality of maternal and newborn
care in health facilities provides lists of
prioritized input, output and outcome
measures, that can be used to define
quality of care criteria and indicators with
locally agreed targets.
The Monitoring & Evaluation teams of the

WHO Departments of Reproductive Health
and Research; and Maternal, Newborn,
Child and Adolescent Health, will be
collect and evaluate data on country- and

Updating the
guideline
08
+ Living Guidelines Approach
+ New Guideline Questions?
+ Connecting With WHO

A NEW APPROACH TO GUIDELINE UPDATE
A systematic and continuous process of surveillance, identification,

and bridging of evidence gaps following guideline
implementation will be employed.
Prioritize Review Update

recommendation evidence base recommendation
Living guidelines approach
The WHO Steering Group will continue to monitor the research developments in the
area of intrapartum care, particularly for those questions that are supported by low-
quality evidence, where new recommendations or a change in the published
recommendations may be warranted.
WHO welcomes suggestions regarding additional questions for inclusion in future

updates of this guideline; suggestions can be addressed to the WHO Department of
Reproductive Health and Research through this email address.

“
We want women to give birth in a safe
environment with skilled birth attendants
in well-equipped facilities. However, the
increasing medicalization of normal
childbirth processes are undermining a
woman’s own capability to give birth and
negatively impacting her birth experience.
We encourage health care providers to

adopt and adapt the recommendations in
this guideline, which provide a sound
foundation for the provision of person-
centred, evidence-based and
”
comprehensive care for women and their
newborn babies.
– Princess Nothemba Simelela

ADG, Family, Women’s and Children’s Health
(FWC) Cluster
Photo: Copyright 2018 World Health Organization © Duarte, Inc. 2014 67

MANY THANKS TO…
WHO Steering Group External Review Group
Ana Pilar Betrán, Mercedes Bonet, Maurice Bucagu, Blami Dao, Justus Hofmeyr, Caroline Homer,
A. Metin Gülmezoglu, Olufemi Oladapo, Anayda Vanora Hundley, and Ashraf Nabhan
Portela, João Paulo Souza, and Joshua Vogel
Technical Working Group

WHO Regional Advisors
Edgardo Abalos, Debra Bick, Meghan Bohren,
Mavjuda Babamuradova, Karima Gholbzouri, Monica Chamillard, Virginia Diaz, Soo Downe,
Bremen De Mucio, Mari Nagai, and Leopold Therese Dowswell, Kenneth Finlayson, Frances
Ouedraogo Kellie, Theresa Lawrie, Julia Pasquale, Elham
Shakibazadeh and Gill Thomson
Guideline Development Group Observers

Diogo Ayres-de-Campos [FIGO]); Mechthild M.
Hany Abdel-Aleem, Fernando Althabe, Melania
Gross [ICM]); Petra ten Hoope-Bender [UNFPA];
Amorim, Michel Boulvain, Aparajita Gogoi, Tina
Mary Ellen Stanton [USAID], and Alison Wright
Lavender, Pisake Lumbiganon, Silke Mader, Suellen
[RCOG]
Miller, Rintaro Mori, James Neilson, Hiromi Obara,
Oladapo Olayemi, Robert Pattinson, Harshad
Sanghvi, Mandisa Singata-Madliki, Jorge E. Tolosa,
Funders
and Hayfaa Wahabi
USAID; HRP
68 © Duarte, Inc. 2014 68

CONTACT US
If you want to contact WHO: If you want to contact

Dr Olufemi Oladapo:
Email:
oladapoo@who.int
Facebook:
Email: Twitter:
World Health Twitter:
Department of @HRPresearch
Organization @oladapo_olufemi
Reproductive Health
and Research
LinkedIn:
Femi Oladapo

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+ Childbirth and the + Guideline + Care Throughout + Putting the

© Duarte, Inc. 2014 2

+ Underlying + Global Launch + Potential Barriers + Living Guidelines

© Duarte, Inc. 2014 3

© Duarte, Inc. 2014 4

Globally, approximately 140 million births Global agendas are expanding

Despite years of research, the concept of Over-medicalization of

 LINK: INCREASING TREND IN CS RATES There is evidence that a substantial

Consensus around the definitions of the

 LINK: S/REVIEW OF LABOUR PROGRESSION In practice, there are considerable

© Duarte, Inc. 2014 7

SOURCE: SOUZA ET AL. BJOG. 2018

Good outcome Bad outcome

SOURCE: SOUZA ET AL. BJOG 2018

This guideline focuses on the care of all healthy

The management of pregnant women who develop labour

The guideline covers essential care that should be provided

© Duarte, Inc. 2014 10

© Duarte, Inc. 2014 11

WHO Steering Group

Guideline Development Group

Members were identified in a way that

. © Duarte, Inc. 2014 12

Technical Working Group

External Review Group

© Duarte, Inc. 2014 13

The guideline focus was based on a

© Duarte, Inc. 2014 14

Systematic Reviews of Systematic Reviews of Resource Implications and

Systematic Reviews of Systematic Reviews of Resource Implications and

Two GDG meetings were held to reach

Consensus was defined as the agreement by three quarters or

In line with other recently published WHO guidelines using EtD

© Duarte, Inc. 2014 17

Two GDG meetings were held to reach

Consensus was defined as the agreement by three quarters or

In line with other recently published WHO guidelines using EtD

© Duarte, Inc. 2014 18

Two GDG meetings were held to reach

Consensus was defined as the agreement by three quarters or

In line with other recently published WHO guidelines using EtD

© Duarte, Inc. 2014 19

Two GDG meetings were held to reach

Consensus was defined as the agreement by three quarters or

In line with other recently published WHO guidelines using EtD

© Duarte, Inc. 2014 20

Two GDG meetings were held to reach

Consensus was defined as the agreement by three quarters or

In line with other recently published WHO guidelines using EtD

© Duarte, Inc. 2014 21

Two GDG meetings were held to reach

Consensus was defined as the agreement by three quarters or

In line with other recently published WHO guidelines using EtD

© Duarte, Inc. 2014 22

© Duarte, Inc. 2014 23

This guideline includes 26 new recommendations adopted

Recommendations are grouped and presented according

© Duarte, Inc. 2014 24

Respectful maternity care – which refers to

Supportive care throughout