Philippine Obstetrical and

Gynecological Society (POGS), Foundation, Inc.

Second Edition, November 2009




Task Force on Clinical Practice Guideline
In the Management of Normal Labor
and Delivery

CLI NI CAL PRACTI CE GUI DELI NES
on
NORMAL LABOR and DELI VERY

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Philippine Obstetrical and
Gynecological Society (POGS), Foundation,
Inc.















Second Edition, November 2009



Task Force on Clinical Practice Guideline
In the Management of Normal Labor
and Delivery

CLINICAL PRACTICE GUIDELINES
on
NORMAL LABOR and DELIVERY






























LOURDES B. CAPITO, MD
President
Philippine Obstetrical and Gynecological Society (Foundation), Inc. (POGS), 2009


I have envisioned and have implemented to completion the publication of a series of
Clinical Practice Guidelines on the major procedures and topics of Obstetrics and Gynecology.
This is in consonance with the theme of my Presidency, Babae, Kalusugan Mo, Katungkulan
Natin. This is the Clinical Practice Guidelines on Normal Labor and Delivery and is the Second
Edition of this Publication, 2009.

In the role of the POGS to provide its members with updates, current and standard
practice recommendations and guidelines, this publication will fulfill the objective of continuing
education and implementation of refinements in Obstetrics and Gynecology. In keeping with the
highest standards of care, the Level and Grades of Clinical Practice/Recommendation have
been adopted for every recommendation that is completed and decided.

In the process of the formulation of the guideline/recommendation, the entire
membership of the POGS was consulted. I take special effort to thank the AdHoc Committee on
Clinical Practice Guidelines, headed by its Chair, Dr. Efren J. Domingo for the unceasing
tireless effort to complete this publication. I also gratefully acknowledge the Chairs and Training
Officers of the Residency-Accredited Hospitals, the Technical Working Group, and the CME
Committee.

It becomes easy, dignified and scientific to conduct the practice of Obstetrics and
Gynecology specifically on Normal Labor and Delivery. Now, the Clinical Practice Guidelines on
Normal Labor and Delivery will hope to update and make the practice current and responsive to
world-class standards and make the patients under our care deserving of the trust and
confidence that we, Obstetricians, impart with utmost care and compassion.



LOURDES BLANCO-CAPITO, MD

FOREWORD




































EFREN J. DOMINGO, MD, PhD
Chair, AdHoc Committee on the Clinical Practice Guidelines, 2009



The Clinical Practice Guidelines on Normal Labor and Delivery is the Second Edition of
this Publication, 2009. The Philippine Obstetrical and Gynecological Society, (Foundation), Inc.
(POGS), through the AdHoc Committee on Clinical Practice Guidelines initiated and led to
completion the publication of this manual in plenary consultation with the Residency Accredited
Training Hospitals Chairs and Training Officers, The Regional Board of Directors, The Board of
Trustees, The Task Force on the Mangement of Normal Labor and Delivery and the Committee
on Continuing Medical Education.

This publication represents the collective effort of the POGS in updating the clinical
practice of Obstetrics and Gynecology, specifically on Normal Labor and Delivery, and making it
responsive to the most current and acceptable standard in this procedure. A greater part of the
inputs incorporated in this edition are the contributions originating from the day-to-day academic
interactions from the faculty of the different Residency-Accredited Hospitals in Obstetrics and
Gynecology in the country.

This Clinical Practice Guideline on Normal Labor and Delivery is envisioned to become
the handy companion of the Obstetrician-Gynecologist in his/her day-to-day rendition of quality
care and decision making in managing the Obstetric patient. This is also envisioned to provide
the academic institutions in the country and in Southeast Asia updated information and Normal
Labor and Delivery treatments being practiced in the Philippines.

Profound gratitude is extended to all the members of the POGS, the Chairs and Training
Officers of the Residency-Training Accredited Institutions, the Regional Directors, The Task
Force on Normal Labor and Delivery Reviewers/Contributors, The CME Committee members,
the 2009 POGS Board of Trustees and the educational grant provided by Sheeling Pharma.



EFREN J. DOMINGO, MD, PhD

INTRODUCTION






BOARD OF TRUSTEES 2009


OFFICERS

Lourdes B. Capito, MD
President

Regta L. Pichay, MD
Vice President

Ma. Carmen H. Quevedo, MD
Secretary

Ditas Christina D. Decena, MD
Treasurer

Christia S. Padolina, MD
Public Relations Officer


BOARD OF TRUSTEES
Mayumi S. Bismarck, MD
Virgilio B. Castro, MD
Efren J. Domingo, MD, PhD
Gil S. Gonzales, MD
Diosdado V. Mariano, MD
Ma. Socorro M. Solis, MD





ADHOC COMMITTEE ON CLINICAL PRACTICE GUIDELINES ON
NORMAL LABOR AND DELIVERY

Efren J. Domingo, MD, PhD
Chair

MEMBERS
Jennifer T. Co, MD
Jericho Thaddeus P. Luna, MD
Josephine M. Lumitao, MD
Lisa Teresa P. Jabson, MD
Noel E. Raymundo, MD
Elisa O. Tiu, MD

FELLOWS
Rachelle U. delos Reyes, MD Ana Victoria V. Dy Echo, MD
May Nueva-Hipolito, MD Michelle R. Ong, MD
Renee Vina G. Sicam, MD

TECHNICAL STAFF ASSISTANTS
Ms. Emiliana C. Enriquez
Ms. Jhasmin G. De Guzman


TASK FORCE REVIEWERS AND PLENARY REVIEWERS

Rainerio S. Abad, MD Rommel Z. Dueas, MD Patria P. Punsalan, MD
Imelda O. Andres, MD Joseline A. Ferrolino, MD Ma. Carmen H. Quevedo, MD
Cecilia Joyce M. Bascarra, MD Ma. Corazon N. Gamilla, MD Rebecca M. Ramos, MD
Mayumi S. Bismark, MD Erlinda G. Germar, MD Cristina C. Raymundo, MD
Ricardo R. Braganza, MD Ma. Antonia E. Habana, MD Rosendo R. Roque, MD
Sylvia A. Carnero, MD Myrna R. Habaa, MD Marilyn D. Ruaro, MD
Virgilio B. Castro, MD Bernardita B. Javier, MD Ma. Socorro M. Solis, MD
Lyra Ruth Clemente-Chua, MD Milagros T. Jocson, MD Sherri Ann L. Suplido, MD
Maria Lourdes B. Coloma, MD Lilia P. Luna, MD Walfrido W. Sumpaico, MD
Godofreda V. Dalmacion, MD Augusto M. Manalo, MD Carmencita B. Tongco, MD
Ditas Cristina D. Decena, MD Diosdado V. Mariano, MD Ma. Victoria Torres, MD
Santiago A. del Rosario, MD Jocelyn Z. Mariano, MD Milagros P. Torres, MD
Rey H. Delos Reyes, MD Christia S. Padolina, MD Ma. Trinidad R. Vera, MD
Virginia R. de Jesus, MD Mildred N. Pareja, MD Ma. Guadalupe N. Villanueva, MD
Arcangel N. Diamante, MD Wilhelmina Pineda, MD

Regional Directors
Ellen A. Manzano, MD (Region 1) Evelyn R. Lacson, MD (Region 6)
Melchor C. dela Cruz, MD (Region 2) Belinda N. Paares, MD (Region 7)
Concepcion P. Aronza, MD (Region 3) Realino G. Molina, MD (Region 8)
Ernesto S. Naval, MD (Region 4) Suzette S. Montuno, MD (Region 9)
Rowena M. Auxillos, MD (Region 4A) Jana Joy R. Tusalem, MD (Region 10)
Cecilia Valdes-Neptuno, MD (Region 5) Amelia A. Vega, MD (Region 11)




DISCLAIMER, RELEASE AND WAIVER OF RESPONSIBILITY


This is the Clinical Practice Guidelines (CPG) on Normal Labor and Delivery, Second Edition,
November 2009.
This is the publication of the Philippine Obstetrical and Gynecological Society, (Foundation), Inc.
(POGS).
This is the ownership of the POGS, its officers, and its entire membership.
The obstetrician gynecologist, the general practitioner, the patient, the student, the allied medical
practitioner, or for that matter, any capacity of the person or individual who may read, quote, cite,
refer to, or acknowledge, any, or part, or the entirety of any topic, subject matter, diagnostic condition
or idea/s willfully release and waive all the liabilities and responsibilities of the POGS, its officers
and general membership, as well as the AdHoc Commiittee on the Clinical Practice Guidelines and its
Editorial Staff in any or all clinical or other disputes, disagreements, conference audits/controversies,
case discussions/criticquing.
The reader is encouraged to deal with each clinical case as a distinct and unique clinical condition
which will never fit into an exact location if reference is made into any or all part/s of this CPG.
The intention and objective of this CPG is to serve as a guide, to clarify, to make clear the distinction.
It is not the intention or objective of this CPG to serve as the exact and precise answer, solution and
treatment for clinical conditions and situations. It is always encouraged to refer to the individual
clinical case as the one and only answer to the case in question, not this CPG.
It is hoped that with the CPG at hand, the clinician will find a handy guide that leads to the a clue, to a
valauable pathway that leads to the discovery of clinical tests leading to clinical treatments and
eventually recovery.
In behalf of the POGS, its Board of Trustees, the Adhoc Committee on The Clinical Practice
Guidelines, 2009, this CPG is meant to make each one of us a perfect image of Christ, the Healer.




















CPG ON NORMAL LABOR AND DELIVERY
CONTENTS, AUTHOR/S, REVIEWER/S

I. Definition of labor .. 1
Dr. Rainerio Abad / Dr. Trinidad Vera
II. First stage of labor
A. Monitoring of fetal well being during labor (monitoring of progress of labor,
first stage labor) .........
Dr. Josephine Lumitao / Dr. Virgilio Castro
B. Induction of labor .
Dr. Guadalupe Villanueva / Dr. Sherri Ann Suplido
C. Intrapartum nutrition
Dr. Bernardita Javier / Dr. Rebecca Ramos
D. Enema during labor .
Dr. Sylvia Carnero / Dr. Lilia Luna
E. Monitoring progress of labor ..
Dr. Rommel Duenas / Dr. Jennifer Co
F. Maternal position during the first stage of labor
Dr. Pura Caisip / Dr. Maria Lourdes Coloma
G. Analgesia and anesthesia during labor .
Dr. Concepcion Cruz / Dr. Minerva Calimag
H. Amniotomy .
Dr. Elisa Tiu / Dr. Cecilia Joyce Bascara
I. Continuous support during labor ..
Dr. Lisa Jabson / Dr. Anna Marie Madamba-Burgos
III. Second stage of labor
A. Routine perineal shaving during delivery .
Dr. Imelda Andres / Dr. Mayumi Bismark
B. Maternal position during the second stage of labor
Dr. Mildred Pareja / Dr. Virginia de Jesus
C. Alternative methods of bearing down .
Dr. Godofreda Dalmacion / Dr. Ma. Antonia Habana
D. Perineal support : hands poised versus hands on ....
Dr. Santiago Del Rosario / Dr. Diosdado Mariano
E. Instrumental vaginal delivery ......
Dr. Lyra Clemente-Chua
IV. Third stage of labor
A. Use of episiotomy and repair ..
Dr. Zaida Gamilla / Dr. Patria Punsalan
B. Suture materials for episiorraphy ..
Dr. Milagros Torres / Dr. Wilhelmina Pineda
C. Management of the third stage of labor .
Dr Walfrido Sumpaico / Dr. Ma. Victoria Torres
D. Drugs in the third stage of labor ..
Dr. Erlinda Germar / Dr. Milagros Jocson
V. Fourth stage of labor
Early breastfeeding ....
Dr. Arcangel Diamante / Dr. Carmencita Tongco











































I. DEFINITION OF LABOR

o In Latin, the word labor means a troublesome effort or suffering. Another term for
labor is parturition which comes from the Latin Parturire to be ready to bear young and
is related to partus to produce. To labor in this sense is to produce.
o Labor is a physiologic process that begins with the onset of rhythmic contractions which
bring about changes in the biochemical connective tissue resulting in gradual effacement
and dilatation of the cervix and end with the expulsion of the product of conception.
o The contractions are characterized by a progressive increase in frequency, intensity and
duration.
o Labor is a clinical diagnosis.
o Cervical dilatation in the absence of uterine contractions suggests cervical incompetence,
whereas uterine contractions without cervical changes does not meet the definition of
labor.
o The criteria for the diagnosis of labor include:
1. Uterine contractions (at least 1 in 10 minutes or 4 in 20 minutes) by direct
observation or electronically using a cardiotocogram
2. Documented progressive changes in cervical dilatation and effacement as observed by
one observer
3. Cervical effacement of > 70-80%
4. Cervical dilatation > 3cm
o The diagnosis of labor is traditionally based on clinical findings and it is particularly
difficult to make with confidence especially to those presenting in the early stage of
labor.
o A serious digital cervical examination must be done in a patient with persistent uterine
contractions.
o The majority of reported criteria for labor in literature agree that there must be cervical
changes brought about by regular uterine contractions. However, they differ in the
number of observed contractions, the cervical dilatation and the start of labor, and the
degree of cervical change necessary for the diagnosis.


References
1. Cheng Y, Caughey AB. eMedicine Specialties> Obstetrics and Gynecology> Labor and Delivery,
Updated April 15, 2009.
2. Norwitz ER, Robinson JN, Repke JT. Labor and delivery In: Gabbe SG, Niebyl JR; eds
Obstetrics; Normal and problematic pregnancies 3
rd
ed New York Churchill Livingstone 2003.
3. Kurjak.Textbook of Perinatal Medicine and from Gonik and Creasy. AJOG, 1986.
























































II. FIRST STAGE OF LABOR


A. MONITORING OF FETAL WELL-BEING DURING NORMAL LABOR

o The monitoring of the fetal heart rate in labor aims to identify hypoxia before it is
sufficient to lead to long term poor neurological outcome for babies.
o Auscultation of the fetal heart rate during labor was the predominant method of
assessment since the start of the 20
th
century. Auscultation is done at regular intervals
using a hand held Doppler device, Pinard (special trumpet shaped device) or fetal
stethoscope.
o Since the introduction of the electronic fetal heart rate monitoring in the 1960s, the idea
of receiving continuous data by electronic fetal monitoring (EFM) was thought to be
superior to intermittent auscultation. Its use though is limited to institutional births.


Recommendations:
o Royal College of Gynaecologists (RCOG) / National Institute for Health and Clinical
Excellence (NICE) Guidelines recommend that intermittent auscultation be undertaken
every 15-30 minutes in the 1
st
stage of labor and every 5 minutes in the 2
nd
stage of labor
at least 30 seconds after each contraction.
o Intermittent auscultation is recommended as a minimum for women who at the onset of
labor are identified as having low risk of developing fetal compromise. (Grade A)
o Admission cardiotocography (CTG) is not recommended for healthy women at term in
labor in the absence of risk factors for adverse perinatal outcome, as there is no evident
benefit. (Grade A)
o Continuous EFM should be recommended when either risk factors for fetal compromise
have been identified antenatally, at the onset or during labor. (Grade A)
o There is universal acceptance that the fetus in labor is at particular risk from hypoxic
damage. It is therefore the goal of intrapartum fetal surveillance to detect potential fetal
decompensation and to allow timely and effective intervention to prevent
perinatal/neonatal morbidity and mortality.



B. INDUCTION OF LABOR

Definition:

o Induction of labor is defined as an intervention designed to artificially initiate uterine
contractions leading to progressive dilatation and effacement of the cervix and birth of
the baby (RCOG, 2001).




Recommendations:

General
o Assessment with documentation prior to starting the induction should include:
! confirmation of parity
! confirmation of gestational age











! presentation
! Bishops score

Table 1. Bishops Preinduction Cervical Score System

uterine activity
! nonstress test

o Induction of labor is a major intervention and should only be implemented on a valid
indication. (Level I, Grade C).
The indication for induction should be documented.







Confirmation of Term Gestation
(ACOG Practice Bulletin #230, November 1996)

Fetal heart tones have been documented for 20 weeks by nonelectronic
fetoscope or for 30 weeks by Doppler
The passage of 36 weeks since a serum or urine human chorionic
gonadotropin (HCG) pregnancy test was found to be positive
Ultrasound measurement of the crown-rump length at 6-11 weeks
gestational age (GA) that support a current GA equal =/> 39 weeks
Ultrasound measurements at 13-20 weeks GA that supports a clinically
determined GA equal =/> 39 weeks.
SCORE FACTOR
0 1 2 3
Cervical Dilatation
(in cm)
closed 1-2 3-4 !5
Cervical Effacement
(%)
0-30 40-50 60-70 >80
Station -3 -2 -1 +1,+2
Cervical Consistency Firm Medium Soft
Cervical Position Posterior Midposition Anterior








o Assess cervical ripening with the use of Bishops preinduction score system (Table 1).
o The induction of labor should be administered only in a hospital setting, particularly in a
labor room under the responsibility of an obstetrician. It should also be monitored by a
physician familiar with the effects of induction agents and able to detect and respond to
maternal and fetal complications.

Methods of Induction of Labor
OXYTOCIN
o Oxytocin augmentation is a major intervention and should only be implemented on a
valid indication. (Level I, Grade C).
o Cervical dilation, parity, and gestational age are predictors of the dose response to
oxytocin for labor stimulation (Level 4).
o Women in whom labor induction is indicated may be managed by either a low or high
dose oxytocin regimen. (ACOG, Grade A).
o The purpose of oxytocin administration is to effect uterine activity that is sufficient to
Induction is indicated when the continuance of pregnancy may no longer be
advisable in the following clinical circumstances:
1. Gestational hypertension
2. Preeclampsia, eclampsia
3. Prelabor rupture of membranes
4. Maternal medical conditions (e.g., diabetes mellitus, renal disease, chronic
hypertension)
5. Gestation ! 41 + 1/7 weeks
6. Evidence of fetal compromise (eg, severe fetal growth restriction,
isoimmunization)
7. Intraamnionic infection
8. Fetal demise
9. Logistic factors for term pregnancy (e.g., history of rapid labor, distance
from hospital, psychosocial indications)
Contraindications for Labor Induction

1. Malpresentations (e.g., transverse, breech)
2. Absolute cephalopelvic disproportion
3. Placenta previa
4. Previous major uterine surgery or classical cesarean section
5. Invasive carcinoma of the cervix
6. Cord presentation
7. Active genital herpes
8. Gynecological, obstetrical, or medical conditions that preclude vaginal
birth
9. Obstetricians convenience

produce cervical change and fetal descent while avoiding uterine hyperstimulation and
fetal compromise.
o It is recommended that oxytocin be ordered and recorded in milliunits (mU)/minute.
o Oxytocin should be delivered through a secondary intravenous (IV), piggy-backed to the
main IV line as close to the venipuncture site as possible.
o When induction of labor is undertaken with oxytocin, the recommended regimen is a
starting dose of 1-2 mU/minute and is increased at intervals of 30 minutes or more. The
minimum dose should be used and this should be titrated against uterine contractions
aiming for a maximum of 3 to 4 contractions every 10 minutes (RCOG, Grade C).
o Adequate contractions may be established at 12 mU/min and the licensed maximum dose
is 20 mU/min (RCOG, Grade C). If higher doses are used, the maximum dose used
should not exceed 32 mU/min (RCOG, Grade C).
o To reduce error, a standard dilution should always be used (for example, 30 IU in 500 mL
of normal saline; hence 1 mL/hour =1 mU/minute (RCOG, Grade C).
o Regular observations of uterine contractions and fetal heart rate should be recorded every
15 to 30 minutes and with each incremental increase of oxytocin.
o Continuous intrapartum electronic fetal monitoring is recommended when oxytocin is
being used for induction of labor.
o If fetal heart rate abnormalities or tetanic contractions develop, the infusion should be
stopped, intrauterine resuscitation measures initiated and the situation re-evaluated before
restarting the infusion.
o If restarting the oxytocin, it may be necessary to lower the dosage and lengthen the
interval between subsequent increases.











o If intrauterine resuscitation is successful, oxytocin may be restarted at 1/2 the last dose
o Should uterine hyperstimulation occur without evidence of fetal compromise, then
decrease the oxytocin infusion rate and re-evaluate situation.

Signs and symptoms of hyperstimulation include:

Five contractions in 10 minutes or more than 10 contractions in 20 minutes
Hypertonus contraction(s) lasting more than 120 seconds
Excessive uterine activity with an atypical or abnormal fetal heart rate
Oxytocin should not be continued or rate increased in the presence of
atypical or abnormal fetal heart rate and/or tetanic contractions

Intrauterine Resuscitation Measures

Stop oxytocin infusion
Reposition to left lateral decibitus
Continue or initiate EFM
Give oxygen mask at 10 L/min
Notify responsible physician
Administer a tocolytic agent
Prepare for possible cesarean delivery if fetal pattern remains abnormal

MEMBRANE SWEEPING / STRIPPING

o Sweeping of the membranes, also named stripping of the membranes, is a relatively
simple technique usually performed without admission to hospital. During vaginal
examination, the clinician's finger is introduced into the cervical os. Then, the inferior
pole of the membranes is detached from the lower uterine segment by a circular
movement of the examining finger. This intervention has the potential to initiate labor by
increasing local production of prostaglandins and, thus, reduce pregnancy duration or
pre-empt formal induction of labor with either oxytocin or amniotomy.
o Sweeping the membranes during a cervical examination is done to bring in labor women
at term.
o The review of trials found that sweeping brings on labor and is generally safe where there
are no other complications. Sweeping reduces the need for other methods of labor
induction such as oxytocin. The review also found that sweeping can cause discomfort
during the procedure, some bleeding and irregular contractions.
o Before formal induction of labor, women should be offered sweeping of the
membranes
19
, and when this is proposed, discussion between the physician and the
patient should include information that membrane sweeping is not associated with
increase in maternal or neonatal infection, and that it may be associated with increased
levels of discomfort and bleeding during the procedure (RCOG, Grade A).
o At the 40
th
and 41
st
week of antenatal visit of nulliparous women, and at the 41
st
week
antenatal visit of parous women, patient should be offered a vaginal examination for
membrane sweeping.
19

o When a vaginal examination is carried out to assess the cervix, the opportunity should be
taken to offer the woman a membrane sweep. Additional sweeping may be offered if
labor does not occur spontaneously.
19


AMNIOTOMY (see also Chapter in Amniotomy)

o Artificial rupture of the membranes may be used as a method of labor induction,
especially if the condition of the cervix is favorable.
o Used alone for inducing labor, amniotomy can be associated with unpredictable and
sometimes long intervals before the onset of contractions.


FAILED INDUCTION: DEFINITION

A failed induction of labor may be diagnosed in women whose continued lack of
progression into the active phase makes it unlikely that they would safely proceed to a vaginal
delivery. A group suggested that nulliparous women could safely remain in the latent phase for
up to 12 hours, whereas women who remained in the latent phase for longer periods had a low
chance (13%) of subsequent vaginal delivery. It is not unreasonable to allow up to 18 hours of
latent labor before recommending a cesarean for a failed induction.
20




References
1. Royal College of Obstetricians and Gynaecologists; RCOG Clinical Effectiveness Support
Unit. Induction of labour. Evidence-based Clinical Guideline Number 9. London: RCOG Press;
2001.
2. American College of Obstetricians and Gynecologists. Assessment of fetal lung maturity (ACOG
Practice Bulletin # 230) . November 1996.
3. American College of Obstetricians and Gynecologists. Induction of Labor (ACOG Practice
Bulletin # 10). November 1999.
4. Satin AJ, Leveno KJ, Sherman ML, McIntire DD. Factors affecting the dose response to oxytocin
for labor stimulation. American Journal of Obstetrics and Gynecology 1992; 166:1260-1261.
5. Society of Obstetricians and Gynecologists of Canada. Fetal Health Surveillance in Labour.
Number 112, April 2002.
6. Allott HA, Palmer CR. Sweeping the membranes: a valid procedure in stimulating the onset of
labour. British Journal of Obstetrics and Gynecology 1993; 100:898-903.
7. Boulvain M, Stan C, Irion O. Membrane sweeping for induction of labour. Cochrane Database of
Systematic Reviews 2005, Issue 1.
8. Read JA, Miller FC, Paul RH. Randomized trial of ambulation vs oxytocin for labor
inhancement: a preliminary report. American Journal of Obstetrics and Gynecology 1981;
139:669-672.
9. Hemminki E, Lenck M, Saarikoski S, Henriksson L. Ambulation vs oxytocin in protracted labor:
a pilot study. European Journal of Obstetrics and Gynecology and Reproducitve Biology 1985;
20:199-208.
10. Bidgood KA, Steer PJ. A randomized control study of oxytocin augmentation of labor . British
Journal of Obstetrics and Gynaecology 1987; 94:512-17.
11. Cohen GR, OBrien WF, Lewis L, Knuppel RA. A prospective randomized study of the
aggressive management of early labor. American Journal of Obstetrics and Gynecology
1987;157:1174-77.
12. Lopez-Zeno JA, Peaceman Am, Adashek JA, Socol ML. A controlled trial of a program for the
active management of early labor. North Englan Journal of Medicine 1992;326:450-54.
13. Tannirandorn Y. Jumrustanasan T. A comparative study of membrane stripping and nonstripping
for induction of labor in uncomplicated term pregnancy. Journal of Medical Association of
Thailand. 82(3):229-33, 1999 Mar.
14. Wiriyasirivaj B. Vutyavanich T. Ruangsri RA. A randomized controlled trial of membrane
stripping at term to promote labor. Obstetrics and Gynecology 1996; 87(5Pt 1):767-70.
15. Crowley P. Interventions for preventing or improving the outcome of delivery at or beyond term.
Cochrane Database of Systematic Reviews 2006, Issue 4.
16. Hofmeyr GJ, Glmezoglu AM. Vaginal misoprostol for cervical ripening and induction of labour.
Cochrane Database of Systematic Reviews 2003, Issue 1.
17. Kelly AJ, Tan BP. Intravenous oxytocin alone for cervical ripening and induction of labour.
Cochrane Database of Systematic Reviews 2001, Issue 3.
18. American College of Obstetricians and Gynecologists. ACOG Technical Bulletin Number 10:
Induction of Labor, 1999, Nov.
19. National Institute for Health and Clinical Excellence. NICE Clinical Guideline number 70, 2008,
July.
20. Phil. Journal of Obstetric and Gynecology 2009, Vol. 32 supplement





C. INTRAPARTUM NUTRITION
o The management of oral intake of parturients seeks to provide adequate hydration and
nutrition while maintaining safety for the mother and baby.
o Many obstetricians restrict oral food and fluid intake during active labor because of the
possible risk of aspirating gastric contents with the administration of anesthesia.
However, sources of energy need to be replenished during labor in order to ensure fetal
and maternal well-being.
o The incidence of aspiration of gastric contents has always been low and therefore plays a
very small role as a cause of maternal death.
11


Recommendations:
o For the normal, low-risk birth in any setting, there is no need for restriction of food,
except in situations where intervention is anticipated. (Level II-2, Grade B). Hence the
health status of the woman and the risk of surgical intervention should always be
adequately assessed.
o The Cochrane Pregnancy and Childbirth Group recommends a diet of easy-to-digest
foods and fluids during labor for women who wish to eat and drink.
o Isotonic calorific drinks consumed during labor reduce the incidence of maternal ketosis
without increasing gastric volumes (Level II; Level III-3).
o Routine intravenous infusions interfere with the natural birthing process and restrict
womens freedom to move. Even the prophylactic routine insertion of an intravenous line
can be considered unnecessary intervention.
o Intravenous infusion to treat or prevent dehydration, ketosis or electrolyte imbalance is
not as effective as allowing food and fluids in labor.
o The use of epidural anesthesia for intrapartum pain management in an otherwise normal
labor should not preclude oral intake.
o The correct approach for normal childbirth should include an assessment of the risk of
general anesthesia.

References
1. Crawford JS. Some aspects of obstetric anesthesia. Br J Anaesth 1956;28:146-158, 201-208.
2. Taylor G, Pryse-Davies J. The prophylactic use of antacids in the prevention of the acid-
pulmonary-aspiration syndrome (Mendelsons syndrome). Lancet 1966;1:288-291.
3. Tettambel MA. Preoperatvie use of antacids to prevent Mendelsons syndrome in caesarean
section, a pilot study. J Am Osteopath Assoc 1983;82:858-860.
4. McKay S, Mahan C. Modifying the stomach contents of labouring women: why, how, with what
success, and at what risk? How can aspiration of vomitus in obstetrics best be prevented? Birth
1988;15(4):213.
5. World Health Organization. Care in Normal Birth. Report of a Technical Working Group.
6. Dumoulin J, Foulkes J. Ketonuria during labor. Br J Obstet Gynaecol 1984;91:97-8.

7. Hazle N. Hydration in labor: is routine intravenous hydration necessary? J Nurse Midwifery
1986;31:171-176.
8. Newton N, Newton M, Broach J. Psychologic, physical, nutritional and technologic aspects of
intravenousinfusion during labor. Birth 1988;15:67-72.
9. Keppler AB. The use of intravenous fluids during labor. Birth 1988;15:75-9.
10. Baker C (1996) Nutrition and hydration in labour. British Journal of Midwifery Vol 4: 568-572 .
11. Johnson C, Keirse M, Enkin MJN, Chalmers I (1989) Nutrition and hydration in labour in
Chalmers I, Enkin M and Keirse MJN (eds). Effective care in pregnancy and childbirth. Vol 2.
Oxford: Oxford University Press: 827-832.
12. Broach J, Newton N (1988) Food and beverages in labour. Part II: the effects of cessation of oral
intake during labour. Birth 15: 88-92 .
13. Foulkes J, Dumoulin J (1985) The effects of ketonuria in labour. British Journal of Clinical
Practice 39: 59-62 .
14. Mendelson C (1946) The aspiration of stomach contents into the lungs during obstetric
anaesthesia. American Journal of Obstetrics and Gynecology 52: 191-205
15. Johnson C, Keirse M, Enkin MJN, Chalmers I (1989) Nutrition and hydration in labour in
Chalmers I, Enkin M and Keirse MJN (eds). Effective care in pregnancy and childbirth. Vol 2.
Oxford: Oxford University Press: 827-832
16. European Journal of Obstetrics & Gynecology and Reproductive Biology 2004;
117: 30-2
17. Australian and New Zealand College of Anesthetists Practice Guidelines
18. American Society of Anethesiologists Task Force in Obstetrics Anesthesia, Practice Guidelines
for Obstetric Anesthesia, An Update Report, 2007.
19. Royal College of Midwives, Evidence based Guidelines for Midwife led Care Labor, Jan 2005 .
20. American College of Nurses and Midwives, clinical Guidelines for Oral Nutrition during Labour,
2008 Journal of Midwifery & Womens Health.


D. ENEMA DURING LABOR

o Enemas are thought to decrease the risk of puerperal and neonatal infections, shorten the
duration of labor and make delivery cleaner for attending personnel.
o However, enemas are upsetting and humiliating for women in labor and may cause
increased pain.
o Enemas also cause watery stools and could theoretically increase contamination and
infection rates.


Recommendation:

o There is no evidence to support the routine use of enemas during labor. Although these
results cannot rule out a small clinical effect, it seems unlikely that enemas will improve
maternal and neonatal outcomes and provide an overall benefit. (Level 1, Grade A)




References
1. Reveiz L, Gaitan HG, Cuervo LG. Enemas During Labour. Cochrane Database of Systematic
Reviews 2007, Issue 4.
2. Cuervo LG, Bernal MP, Mendoza N. Effects of high volume saline enemas vs. no enema during
labor The N-Ma Randomized Controlled Trial. BMC Pregnancy Childbirth. 2006: 6 - 8.



E. MONITORING THE PROGRESS OF LABOR

o For monitoring the progress of labor, one may use the Friedmans labor curve (Figure 1),
or the WHO partogram (Figure 2). (Level 2, Grade B)

Figure 1: Friedmans Curve


















The labor curve is plotted as a function of cervical dilatation (cm) and fetal descent
(stations) versus time (usually in hours from onset of regular uterine contractions). The rate of
change of these two parameters is the measure of the efficiency of the labor process. The end of
labor takes place when there is expulsion of the fetus and the placenta.

There are 2 major events in Labor. (Figure 1, Friedmans Curve)
1. Cervical effacement and dilation (straight lines below)
2. Fetal descent through the birth canal
The Friedmans Curve
(Dilatational and Descent)

Cervical Effacement and Dilatation

DILATATION CURVE

1. Latent phase; up to 3-4 cm dilatation (approximately 8 hrs long)
2. Active Phase
a. Acceleration phase not always present
b. Phase of Maximum Slope (PMS)
- occurs at approximately 9 cm. dilatation
- fetus is considered fully descended as it falls one station below the ischial spine (+1)
c. Deceleration always present

Latent phase
Latent phase ends at 3-4 cm dilatation (approximately 8 hrs long)
Extends from the onset of labor, timed from the onset of the regular uterine contractions,
to the beginning of the active phase.
The duration of the latent phase is more variable and is sensitive to influences of
extraneous factors, sedation and myometrial stimulation.
Its duration does not have major influence over the subsequent course of labor.

Active Phase
The point in time when the rate of dilatation begins to change acutely, the curve
becoming more steeply inclined.
This phase ends at full cervical dilatation when the cervix is no longer palpable.
The active phase maybe further subdivided into three distinctive phases:

a. Acceleration phase
- This phase may not always be detected. In contrast to the latent phase, the
steepness of this part of the curve is reflective of labor outcome.
b. Phase of Maximum Slope (PMS)
- Since this is the time when cervical dilatation proceeds at its most rapid rate , this
phase of cervical dilatation is reflective of the overall efficiency of the contractile
machine (uterus).
c. Deceleration Phase
- This phase shows the feto-pelvic relationship and heralds entry into the pelvic
division of labor. This is the time wherein the classic cardinal movements of labor
take place.


Functional Divisions of Labor

1. Preparatory Division latent phase
Encompasses the latent and acceleration phase of cervical dilatation. At this time little
cervical dilatation takes place.



2. Dilatational divisions active phase
(when CERVICAL DILATATION occurs)
Encompasses the phase of maximum slope of the cervical dilatation. When the rate of
dilatation is fastest.

3. Pelvic Division concerned mostly with the descent aspect of delivery
Commences with the deceleration phase and second stage of labor. This is where the
classical cardinal movements of labor primarily occurs. The demarcation between this
and the dilatational division is clinically difficult to determine


Fetal Descent
o also shown in Friedmans curve

1. Latent phase no fetal descent occurs
- extends beyond dilatational phase of descent curve

2. Active Phase comes much later
a. Acceleration
b. Phase of maximum descent
- occurs at around 9 cm dilatation
- corresponds to the deceleration of dilatation
- fetus fully descended at +1 (station at the level of ischial spines)

o The pattern of descent follows a hyperbolic curve (station vs duration of labor). Like
cervical dilatation, it too has its phases as follows:

1. The Latent Phase of fetal head descent corresponds to the latent and acceleration
phase of cervical dilatation (the preparatory division of labor). At this time, little
if at all, fetal head descent takes place.

2. The Acceleration Phase of descent corresponds to the phase of maximum slope
(the dilatational division of labor) of cervical dilatation. This is the time that fetal
head descent ensues.

3. The Phase of Maximum Slope of descent encompasses the deceleration phase and
second stage of labor in cervical dilatation (pelvic division of labor). Especially in
nulliparas, increased rates of descent begins during this phase and progresses to a
maximum until the presenting part reaches the perineal floor. As this event
occurs, the cervix is expected to be at an advanced stage of dilatation (8-9 cm).

o In a vertex presentation, engagement occurs when the biparietal diameter has reached or
passed the pelvic inlet.
o Often, the leading edge is at or below the plane of the ischial spines.
o Station refers to the level of the leading edge of the presenting part in relation to the
interspinous plane.

o The level at which the biparietal diameter is at however, is not indicated by station.
o Station 0 is said to be reached when the lowermost part of the fetal head has reached the
ischial spines and has just engaged.
o Fetal head engagement usually occurs before labor in nulliparas.
o Its progress however occurs only late in labor. In multiparas, this event often occurs
during labor.

*+,-./ 01 23# 45.67,.58

WHO PARTOGRAPH

o If graph is located on the right side of the ALERT LINE: one should monitor the patient
closely.
o If graph reaches the ACTION LINE: should do cesarean section or forceps/vacuum
delivery.

The principles of the partograph include the following:
1. The active phase of labor commences at 3 cm dilatation.
2. The latent phase of labor should last no longer than 8 hours.
3. During the active phase, the rate of cervical dilatation should not be slower than 1
cm/hour.
4. A lag time of 4 hours between a slowing of labor and the need for intervention is
unlikely to compromise the fetus or mother and avoids unnecessary intervention.
5. Vaginal examinations should be performed as infrequently as is compatible with safe
practice (once every 4 hours is recommended).

o The partograph is intended for use in all maternity settings, but has a different level of
function depending on the level of health care provision.
o In a health center, the critical function is to give early warning that labor is likely to be
prolonged and transfer to hospital is mandated (alert line).
o In hospital, the right of the alert line is a warning for extra vigilance, but the action line is
the critical point which signals the need for specific interventional decisions. (Level 2b).

Parameters to record in the partograph
A. Patient information:
Fill out name, gravida, para, hospital number, date and time of admission and time of
ruptured membranes.

A. Fetal heart rate:
Record every half hour.

B. Amniotic fluid:
Record the color of amniotic fluid at every vaginal examination. The following codes are
used:
I: membranes intact
C: membranes ruptured, clear fluid
M: meconium-stained fluid
B: blood-stained fluid

C. Molding:
1: sutures apposed
2: sutures overlapped but reducible
3: sutures overlapped and not reducible



D. Cervical dilatation:
Assessed at every vaginal examination and marked with a cross (X). Begin plotting on
the partograph at 4 cm.

Alert line: A line starts at 4 cm of cervical dilatation to the point of expected full
dilatation at the rate of 1 cm per hour.

Action line: Parallel and 4 hours to the right of the alert line.

E. Descent assessed by abdominal palpation:
Refers to the part of the head (divided into 5 parts) palpable above the symphysis pubis;
recorded as a circle (O) at every vaginal examination. At 0/5, the sinciput (S) is at the
level of the symphysis pubis.

F. Hours:
Refers to the time elapsed since onset of active phase of labor (observed or extrapolated).

G. Time:
Record actual time.

H. Contractions:
Chart every half hour; palpate the number of contractions in 10 minutes and their
duration in seconds.
o Less than 20 seconds
o Between 20 and 40 seconds
o More than 40 seconds

J. Oxytocin:
Record the amount of oxytocin per volume IV fluids in drops per minute every 30
minutes when used.

K. Drugs given:
Record any additional drugs given.

L. Vital Signs:
Pulse: Record every 30 minutes and mark with a dot (").
Blood pressure: Record every 4 hours and mark with arrows.
Temperature: Record every 2 hours.

M. Protein, acetone and volume:
Record every time urine is passed.






POGS PARTOGRAM




















References

1. Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) a a form of electronic
fetal monitoring (EFM) for fetal assessment during labor.Cochrane Database of Systematic
Reviews 2006; Issue 3.
2. The Society of Obstetricians and Gynecologists of Canada. Fetal Health Surveillance:
Antepartum and Intrapartum Consensus Guideline. No. 197 September 2007.s25-49.
3. The Royal Australian and New Zealand College of Obstetricians and Gynecologists. Intrapartum
Fetal Surveillance Clinical Guidelines, 2
nd
Ed May 2006.
4. Thacker SB, Stroup DF, Chang M. Continuous electronic heart rate monitoring for fetal
assessment during labor. Cochrane Database of Systematic Reviews 2001; Issue 3.
5. Mires G, Williams F, Howie P, Goldbeck-wood S, Murray GD, Nesheim BI, Randomized control
trial of cardiotocography versus Doppler auscultation of fetal heart at admission in labor in low
risk obstsric population. British Medical Journal 2001; 322 (7300):1457-62.
6. Blix E, Reiner LM, Klovning A, Oian P. Prognostic value of the labor admission test and its
effectiveness compared with auscultation only: A systematic review. British Journal of Obstetrics
and Gynecology 2005;112(12):1595-604.



F. MATERNAL POSITION DURING THE FIRST STAGE OF LABOR

o There is evidence that walking and upright positions in the first stage of labor reduce the
length of labor and do not seem associated with increased intervention or negative effects
on mothers and babies well-being. Women should be encouraged to take up whatever
position they find most comfortable in the first stage of labor.


Reference

Lawrence A, Lewis L, Hofmeyr GJ, Droswell T Styles C. Maternal positions and mobility during the
first stage of labor. Cochrane Database of Systematic Reviews 2009, Issue 2.



G. ANALGESIA AND ANESTHESIA DURING LABOR

o The most ideal labor analgesia technique should adequately reduce pain of the first and
second stage of labor.
! Preferably, it should not interfere with the progress of labor.
! And most importantly it should be devoid of unwanted side effects on the mother,
allowing her to participate readily in the birthing process and should have no or
very minimal effect on the baby.

o Systemic opioids like meperidine are the most common medications used for labor pain
relief.

! Usually they are given intramuscularly and combined with a phenothiazine to
decrease the side effect of nausea and vomiting.
! Use of these drugs do not require the use of specialized equipment or personnel.
! They allow the parturient to better tolerate the pain of labor, but characteristically
do not provide adequate analgesia especially for the second stage of labor.
! More so, they cause a dose-dependent increase in unwanted side effects like
drowsiness, nausea and vomiting for the mother .
! And because these drugs easily cross the placenta, they are associated with risks
of respiratory depression and neurobehavioral changes in the newborn.

o Of all the methods of labor pain relief available in clinical practice, neuraxial analgesia
(epidural and spinal) are most effective methods of intrapartum pain relief.
! Administration of epidural analgesia traditionally involves an injection of local
anesthetic through a catheter positioned in the epidural space.
! Epidural solutions are administered either by bolus or infusion, or patient
controlled analgesia which permits analgesia to be maintained throughout labor.
! This technique offers the highest patient satisfaction and the least depressant
effects on the newborn compared with parenteral opioids.

o When neuraxial catheter techniques are used for analgesia during labor or vaginal
delivery, the primary goal is to provide adequate maternal analgesia with minimal
motor block which is achieved with the administration of local anesthetics at low
concentrations with or without opioids.
! Controversy exists though, with regards to its effect on the duration of first and
second stage labor, use of instrumental delivery, and the time of administration of
the epidural among others.
! Many care providers are concerned that epidural analgesia increases the risk of
caesarean section.

o Epidural analgesia should not be taken as a single entity. There are many variations of the
epidural which can be tailored to the patients obstetric needs.
! One of the more common variations is the combined spinal epidural analgesia
(CSE) which combine the advantages of both the spinal epidural techniques
including: faster onset, due to the spinal component and subsequent labor
analgesia via the epidural catheter.

o The other techniques for labor pain relief like the pudendal block, nitrous oxide
subanesthetic concentrations of inhalational gases provide less superior analgesia
compared with neuraxial blocks.


Recommendations:

o During labor, a parturients request for pain relief is a sufficient indication for its use.
When available and after sufficiently explaining the possible options for labor with their

corresponding advantages and disadvantages, all laboring mothers should be given the
option to choose which form of labor analgesia they prefer.

o Although meperidine is the most common parenteral opioid used, other opioids
(nalbuphine, butorphanol) are as comparable to meperidine and may be given
parenterally. (Level 1, Grade A)

o Note though that these systemic medications do not provide adequate pain relief
especially for the second stage of labor. Care should be taken in giving high doses as they
may cause side-effects of pruritus, nausea, vomiting, and drowsiness in the mother and
respiratory depression necessitating aggressive resuscitation in the newborn.

o When not contraindicated (e.g. hypovolemia, coagulopathy), neuraxial analgesia (spinal
or epidural) using local anesthetic with or without neuraxial opioids provides the most
effective pain relief for labor. (Level 1, Grade A).

o These techniques should be administered by a trained and skilled anesthesiologist in an
appropriate medical facility with appropriate resources for the treatment of complications
(e.g., hypotension, systemic toxicity, high spinal anesthesia) should be available.

! If a neuraxial opioid is added, treatments for related complications (e.g., pruritus,
nausea, respiratory depression) should be available.

o The following varieties of neuraxial analgesia provide satisfactory analgesia for labor and
delivery and may be used according to patients and providers preference and availability
of resources: (Level 1, Grade A)

a. Epidural analgesia using intermittent boluses or continuous infusion
b. Combined spinalepidural (CSE) may be used to provide rapid and effective
onset of analgesia for labor.
c. Patient-controlled epidural analgesia (PCEA) may be used to provide an effective
and flexible approach for the maintenance of labor analgesia.

o Single shot spinal-injection spinal opioids with or without local anesthetics may be used
to provide a less expensive but effective, although time-limited, analgesia for labor when
spontaneous vaginal delivery is anticipated.

o Patients in early labor (i.e. 2 cm dilation) should be given the option of neuraxial
analgesia when this service is available. Neuraxial analgesia should not be
withheld on the basis of achieving an arbitrary cervical dilation, and should
be offered on an individualized basis.

* Patients may be reassured that the use of neuraxial analgesia does not
increase the incidence of cesarean delivery. (Level 1)


o Patients and care providers should be informed that epidural analgesia may increase the
need for labor augmentation (use of oxytocin), need for instrumental delivery, and slight
prolongation of second stage labor. (Level 1, Grade A)

o For imminent delivery the following may be used:
a. Pudendal block may offer analgesia for episiorraphy and repair if needed (Level
III, Grade C)
b. Single shot spinal (saddle block) (Level III, Grade C)
c. Intravenous thiopental, propofol, or ketamine may be administered parenterally
by a skilled anesthesiologist (Level III, Grade C)

o The use of low concentrations of volatile anesthesia for labor analgesia, is no longer
accepted as a standard of care for labor and vaginal delivery. General anesthesia obtunds
the patients airways reflexes and increases the risk for airway aspiration and its
subsequent sequelae. (Level III, Grade C)


References
1. ACOG Committee on Obstetric Practice. (2002) ACOG Committee Opinion number 269
February 2002: analgesia and cesarean delivery rates. Obstet Gynecol 99, 369-70.
2. American Society of Anesthesiologists Task Force on Obstetric Anesthesia. (2007). Practice
guidelines for obstetric anesthesia: an updated report by the American Society of
Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiol, 106(4), 843-63.
3. Anim-Somuah M, Smyth R and Howell C. (2005). Epidural versus nonepidural or no analgesia in
labour. The Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD000331.pub2. DOI:
10.1002/14651858.CD000331.pub2.
4. Bofill JA, Vincent RD, Ross EL, Martin RW, Normal PF, Werhan CF, Morrison JC. (1997).
Nulliparous active labor, epidural analgesia, and cesarean delivery for dystocia. Am J Obstet
Gynecol 177,1465-70.
5. Bricker L, Lavender T. Parenteral opioids for labor pain relief: a systematic review. American
Journal of Obstetrics and Gynecology. 2002;186(5 Part 2):S94-S109.
6. Chestnut DH, McGrath JM, Vincent RD Jr, et al. (1994). Does early administration of epidural
analgesia affect obstetric outcome in nulliparous women who are in spontaneous labor?
Anesthesiol 80, 1201-8.
7. D Elbourne, RA Wiseman. Types of intra-muscular opioids for maternal pain relief in labour. The
Cochrane Database of Systematic Reviews 1998, Issue 4. Art. No.: CD001237. DOI:
10.1002/14651858.CD001237.
8. Dashe JS, Rogers BB, McIntire DD, Leveno KJ. (1999). Epidural analgesia and intrapartum
fever: placental findings. Obstet Gynecol 93, 341-4.
9. Dickinson JE, Paech MJ, McDonald SJ, Evans SF. (2002). The impact of intrapartum analgesia
on labour and delivery outcomes in nulliparous women. Aust New Zeal J Obstet Gynaecol, 42,
59-66.
10. Dickinson JE, Paech MJ, McDonald SJ, Evans SF. (2003). Maternal satisfaction with childbirth
and intrapartum analgesia in nulliparous labour. Aust New Zeal J Obstet Gynaecol, 43, 463-8.
11. Goyert GL, Bottoms SF, Treadwell MC, Nehra PC. (1989). The physician factor in cesarean birth
rates. N Engl J Med, 320, 706-9.
12. Gribble RK, Meier PR. (1991). Effect of epidural analgesia on the primary caesarean rate. Obstet
Gynecol, 78, 231-3.

13. Halpern SH, Leighton BL, Ohlsson A, Barrett JF, Rice A. (1998). Effect of epidural vs parenteral
opioid analgesia on the progress of labor: a meta-analysis. JAMA 280, 2105-10.
14. Hawkins JL, Beaty BR, Gibbs CP. (1999). Update on U.S. OB anesthesia practice. Anesthesiol
91, Suppl: A1060. abstract.
15. Henderson JJ, Dickinson JE, Evans SF, McDonald SJ, Paech MJ. (2003) Impact of intrapartum
epidural analgesia on breast-feeding duration. Aust New Zeal J Obstet Gynaecol, 43, 372-7.
16. Howell CJ, Kidd C, Roberts W, et al. (2001). A randomised controlled trial of epidural compared
with non epidural analgesia in labour. Br J Obstet Gynecol 108, 27-33.
17. Howell CJ, Dean T, Lucking L, Dziedzic K, Jones PW, Johanson RB. (2002). Randomised study
of long term outcome after epidural versus non-epidural analgesia during labour. BMJ 325(7360),
357.
18. Howell CJ, Dean T, Lucking L, Dziedzic K, Jones PW, Johanson RB. (2003). Randomised study
of long term outcome after epidural versus non-epidural analgesia during labour [abstract]. Obstet
Gynecol, 101(1), 195-6.
19. Impey L, MacQuillan K, Robson M. (2000). Epidural analgesia need not increase operative
delivery rates. Am J Obstet Gynecol 182, 358-63.
20. Jain S, Arya S, Gopalan S, Jain V. (2003). Analgesic efficacy of intramuscular opioids versus
epidural analgesia in labor. Internat J of Gynecol & Obstet, 83:19-27.
21. Leighton B L, Halpern S H. The effects of epidural analgesia on labor, maternal and neonatal
outcomes: a systematic review. American Journal of Obstetrics and Gynecology. 2002;186 (5
Part 2):S69-S77.
22. Lieberman E, et al (1996). The association of epidural analgesia with caesarean section in low
risk women. Obstet Gynecol, 88, 993-1000.
23. Lieberman E, Lang JM, Frigoletto F Jr, Richardson DK, Ringer SA, Cohen A. (1997). Epidural
analgesia, intrapartum fever, and neonatal sepsis evaluation. Pediat 99, 415-9.
24. Loughnan B, Carli F, Romney M, Dore C, Gordon H. (2002). Epidural analgesia and backache: a
randomized comparison with intramuscular meperidine for analgesia during labour. B J of
Anaesth, 89(3), 466-72.
25. Loughnan BA, Carli F, Romney M, Dore C, Gordon H. (1997). The influence of epidural
analgesia on the development of new backache in primiparous women: report of a randomized
controlled trial. Int J of Obstet Anesth, 6, 203-4.
26. Loughnan BA, Carli F, Romney M, Dore CJ, Gordon H. (2000). Randomized controlled
comparison of epidural bupivacaine versus pethidine for analgesia in labour. B J of Anaesth,
84(6), 715-9.
27. Lucas MJ, Sharma SK, McIntire DD, et al.(2001). A randomized trial of labor analgesia in
women with pregnancy-induced hypertension. Am J Obstet Gynecol 185:970-5.
28. Luxman D, Wohlman I, Grouz A, et al. (1998). The effect of early epidural block administration
on the progression and outcome of labor. Int J Obstet Anesth 7, 61-4.
29. M Anim-Somuah, R Smyth, C Howell. Epidural versus non-epidural or no analgesia in labour.
The Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD000331.pub2. DOI:
10.1002/14651858.CD000331.pub2.
30. Mardirosoff C, Dumont L, Boulvain M, Tramer M R. (2002). Fetal bradycardia due to intrathecal
opioids for labour analgesia: a systematic review. Br J Obstet Gynecol, 109(3), 274-281.
31. Martin JA, Hamilton BE, Ventura SJ, Menacker F, Park MM. (2002). Births: final data for 2000.
National vital statistics reports. Vol. 50. No. 5. Hyattsville, Md.: National Center for Health
Statistics, 1-101. (DHHS publication no. (PHS) 2002-1120 PRS 02-0135.)




H. AMNIOTOMY

Definition:

o Amniotomy is the artificial rupture of membranes.
Artificial rupture of the amniotic membranes during labor is one of the most commonly
performed procedures in modern obstetrics.


Recommendations:

Timing

There is still no conclusive evidence to support that early amniotomy has a clear advantage
over expectant management (Level 1, Grade C).

Supporting Statements:
o Early amniotomy appears to lead to an average reduction of labor.
o Routine amniotomy doesnt significantly reduce the duration of first-stage labor in either
primiparous or multiparous women (Grade A).
o It slightly shortens second-stage labor in primiparous women only (Grade A).

Use

o The primary aim of amniotomy is to speed up contractions and shorten the length of
labor.
o Amniotomy may also be used to assess the status of the fetus.
o Amniotomy is employed with the assumption that shortening the length of labor is
beneficial, with little apparent regard for any potential associated adverse effects.
o Many caregivers promote amniotomy on the clinical assumption that it increases labor
contractions and therefore improves labor progress
4
especially in those women with
prolonged labor.
5

o To observe the colour and amount of amniotic fluid as clinically indicated.

Complications

o With regard to labor dystocia, ACOG states that amniotomy may enhance progress in
the active phase and negate the need for oxytocin augmentation, but it may increase the
risk of chorioamnionitis.
o Possible complications include umbilical cord prolapse, cord compression and fetal heart
rate decelerations, increased ascending infection rate, bleeding from fetal or placental
vessels and discomfort of the actual procedure.
6



References
1. Smyth RMD, Alldred SK, Markham C. Amniotomy for shortening spontaneous labour.
Cochrane Database of Systematic Reviews 2007; Issue 4.
2. American College of Obstetricians and Gynecologists Committee on Practice Bulletins
Obstetrics. ACOG Practice Bulletin. Dystocia and augmentation of labor. Obstetrics and
Gynecology 2003; 102: 1445 1454.
3. American College of Obstetricians and Gynecologists Committee on Practice Bulletins
Obstetrics. ACOG Practice Bulletin. Induction of labor. Obstetrics and Gynecology 1999; 94: 1
10.
4. Frigoletto 1995.
5. Bohra 2003.
6. Busowski 1995.



I. CONTINUOUS SUPPORT DURING LABOR

Recommendations:
o There is sufficient evidence that women who receive continuous one-on-one support
during labor are more likely to deliver without analgesia or anesthesia, will have a
slightly shorter duration of labor and are more likely to deliver spontaneously. They are
also less likely to be dissatisfied with their childbirth experience. (Level I)
o The person providing labor support may be a trained caregiver, not an employee of the
institution, and is physically present to provide this care. She/He should be present early
in labor and remain all throughout until delivery and help initiate breastfeeding
immediately postpartum.
o Most beneficial in institutions that do not allow laboring women to bring companions of
their choice, or where epidural anesthesia is not available or where continuous electronic
fetal monitoring is not routine

Elements of Support:
! emotional support (continuous presence, reassurance and praise)
! physical measures of comfort (massages, comforting touches, acupressure, etc)
advocacy like helping the woman to express her wishes and needs to others

Continuous support by a lay woman during labor and delivery:
! facilitates birth
! enhances the mothers memory of the experience
! strengthens mother-infant bonding; increases breastfeeding success
! significantly reduces many forms of medical intervention, including cesarean
delivery, the use of analgesia, anesthesia, and vacuum extraction.

Duration of Support:
! Continuous (without interruption except for toileting)
! Intermittent

Types of Provider:
! Untrained lay women
! Trained lay women (doulas)
! Female relatives
! Nurses
! Monitrices (lay midwives acting solely as labor support persons)

Outcomes assessed:
! Use of any analgesia
! Need for oxytocin augmentation
! Need for forceps or vacuum
! Need for Cesarean Section
! Duration of labor

Those who received continuous labor support:
! 26% less likely to give birth by cesarean section
! 41% less likely to give birth with vacuum extraction or foceps
! 28% less likely to use any pain medications and
! 33% less likely to be dissatisfied with or negatively rate their birth experience

Benefits of continuous labor support appear to be greater when women receive it:
! beginning earlier rather than later in labor
! in settings that do not allow them to bring
! companions of choice (versus settings that do
! allow husbands, friends, etc.)
! in settings where epidural analgesia is not routine


Reference

Hodnett ED. Caregiver support for women during childbirth (Cochrane Review). In: Cochrane
Library, 2007.































































III. SECOND STAGE OF LABOR


A. ROUTINE PERINEAL SHAVING BEFORE DELIVERY

o There is insufficient evidence to recommend routine perineal shaving for women on
admission in labor. (Level I, Grade E)

Late side effects attributable to shaving occur later such as:
1. Irritation
2. Redness
3. Multiple superficial scratches from the razor
4. Burning and itching of the vulva.

o No trial assessed the views of the woman about shaving such as:
1. Pain
2. Embarassment
3. Discomfort during hair regrowth

SUPPORTING STATEMENTS
Shaving the pubic hair of women in labour is done routinely before birth as a hygienic
practice in some settings.
This practice should be evaluated to see whether it really has value or not.
In some settings, women in labor are routinely shaved upon admission to hospital
The aim is to minimize infection risk if there is tearing or cutting of the area between the
vagina and anus (which is common) during the birth process.
It also has been suggested that a shaved area may make stitching tears or cuts easier.


Reference

Basevi. Cochrane Database of Systemic Reviews 2009.



B. MATERNAL POSITION DURING THE SECOND STAGE OF LABOR
Recommendations:

o The upright position in the second stage of labor is associated in women without
epidural anesthesia with a 4-minute shorter interval to delivery, less pain, lower
incidences of nonreassuring fetal heart rate monitoring and of operative vaginal delivery,
as well as higher rates blood loss of > 500 ml compared with other positions in 20 trials
including 6135 women.

o The upright positions studied include sitting (obstetric chair/stool); semi-recumbent
(trunk tilted backwards 30 to the vertical); kneeling; squatting (unaided or using
squatting bars); and squatting aided with birth cushion.
o The benefits of the upright position may be related to gravity, less aortovagal
compression, improved fetal alignment, and larger anterior- posterior and transverse
pelvic outlets. The higher blood loss may be secondary to easier collection of blood in the
upright position.
o In women with mostly epidural anesthesia, 1 small trial assessed lateral vs supported
sitting position, without enough power for meaningful conclusion
o Another trial compared 2 upright positions, and associated kneeling with no difference in
duration of second stage but less pain compared with sitting (recommendation: A;
quality: good US preventive services task force).

References

1. Gupta JK, Hofmeyr GJ, Smyth R. Position in the second stage of labour for women without
epidural anaesthesia. Cochrane Database Syst Rev 2003;2:CD002006.
2. Downey S, Gerrett D, Renfrew MJ. A prospective randomized trial on the effect of position
the passive second stage of labour on birth outcome in nulliparous women using epidural
analgesia. Midwifery 2004;20:157-68.
3. Ragnar I, Altman D, Tyden T, Olsson S-E. Comparison of the maternal experience and
duration of labour in two upright delivery positionsa randomized controlled trial. BJOG
2006;113:165-70.



C. ALTERNATIVE METHODS OF BEARING DOWN

o There is no evidence that the rate of adverse perineal outcomes is affected by different
types of bearing down during the second stage of labor (Level 1, Grade C). A systematic
review of controlled trials has found no evidence of a difference holding (Valsalva) or
spontaneous exhalatory methods of pushing are used during the second stage of labor.


References

1. Nikodem. Sustained (Valsalva) vs exhalatory bearing down in the second stage of labor. In: The
Cochrane Library, Issue 2, 1998. Oxford: Update Software.
2. Parnell C, Langhoff-Roos J, Iversen R. Damgaard P. Method in the expulsive phase of labor. A
randomized trial. Acta Obstet Gynecol Scand 1993; 72(1):31-5.
3. Yildirim G., Beji NK. Effects of pushing techniques in birth on mother and fetus: a randomized
study. Birth 2008; 35(1): 25-30.




D. PERINEAL SUPPORT: HANDS POISED VERSUS HANDS ON

Definition:

o Hands On = touch the perineum
o Hands poised / Hands off = do not touch the perineum


Recommendations:

o Hands Off and Hands On techniques did not affect the frequency or severity of
perineal trauma in women undergoing childbirth for the first time.
1
(Level I, Grade C)
o Perineal trauma is associated with other factors
1
:
1. Position during delivery
2. Use of oxytocin
3. Maternal expulsive efforts
4. Presence of a support person

SUPPORTING STATEMENTS

The hands poised method increased short term perineal pain and increased the risk of
manual removal of the placenta, however it found no evidence of an effect on the risk of
perineal trauma or third/fourth degree tears.


References

1. De Souza A, da Costa C, Reisco MLG. A Comparison of hands on versus hands off techniques
for decreasing perineal lacerations during birth. Journal of Midwifery and Womens Health 2006;
51(2): 106-111.
2. Beckman M, Garrett A. Antenatal perineal massage for reducing perineal trauma. Cochrane
Database of Systematic Reviews 2009; Issue 2.
3. Dame J. Does antepartum perineal massage reduce intrapartum lacerations? Journal of Family
Practice 2008.



E. INSTRUMENTAL VAGINAL DELIVERY
o An analysis of maternal and fetal outcomes in assisted vaginal deliveries does not
indicate that vacuum extraction is superior to forceps or vice versa. Each instrument
appears to have its own advantages and disadvantages. The greater frequency of maternal
perineal trauma with forceps deliveries evens out with the increased occurrence of fetal
injuries with vacuum extractions. It is therefore recommended that only practitioners who
are adequately trained or are well-supervised should perform the instrumental delivery of
their choice. The mode of intervention (forceps or vacuum) should be individualized after

consideration of the operators skills and experience, and the clinical situation. (Level 1,
Grade A)


Vaginal Delivery

Recommendations:

o Indications for operative vaginal delivery are never not absolute.
o When the fetal head is engaged and the cervix fully dilated, the following indications
apply.
1. Prolonged second stage
o Nulliparous women: lack of continuing progress
> 3 hours with regional anesthesia
> 2 hours without regional anesthesia.
o Multiparous women: lack of continuing progress
> 2 hours

with regional anesthesia
> 1 hour without regional anesthesia.
2. Suspicion of immediate or potential fetal compromise
3. Shortening of the second stage for maternal benefit.


Forceps Delivery

o Elective forceps delivery should be done only when the criteria for outlet forceps have
been met.
o Criteria for types of forceps delivery have been defined by ACOG as follows. (The
definition of types of forceps deliveries have been refined to avoid the inclusion of either
trivial or extremely difficult deliveries under the category of midforceps).

Criteria
Outlet forceps
Scalp is visible at introitus without separating the labia
Fetal skull has reached pelvic floor
Sagittal suture is in anteroposterior diameter or ROA/LOA or ROP/LOP
Fetal head is at or on perineum
Rotation does not exceed 45 degrees

Low forceps
Leading point of fetal skull is at station =/> 2 cm and not on the pelvic floor
Rotation is 45 or less (LOA/ROA to OA, or LOP/ROP to OP)
Rotation is greater than 45

Midforceps
Station is above +2 cm but head is engaged (to include caput formation?)


High forceps
o Not included in classification

* Mid/High forceps are not currently recommended.


Recommendations:

o If a satisfactory application of the forceps cannot be achieved, then the procedure is
abandoned and delivery accomplished by use of either vacuum extraction or cesarean
section.

o If application has been achieved but gentle downward pulls do not result in descent, the
procedure is abandoned.

o In some situations, vacuum extraction may be successful, otherwise cesarean delivery is
performed.
11


Vacuum Delivery

Recommendations:

o There is inadequate evidence upon which to base a recommendation for use of a
particular type of vacuum for all circumstances when a vacuum assisted delivery is
attempted.
o A successful vacuum extraction is most likely if there is:
- accurate cup application at the flexion point
- appropriate traction technique
- a favorable flexed fetal cranial position
- low station at the time of application
o Only attempt a vacuum assisted delivery when a specific obstetric indication is present.
As in forceps, no indication is absolute.
o The use of soft, bell-shaped vacuum extractor is recommended for uncomplicated, OA
deliveries
o Limit vacuum assisted procedures to 2 to 3 "pop-offs," and a total time of 15 to 30
minutes.
o Failure of an attempted vacuum assisted delivery increases the likelihood of neonatal
morbidity; the subsequent use of sequential forceps in this setting should be undertaken
with extreme caution.
o Prompt cesarean delivery is advised after an unsuccessful vacuum assisted procedure.

In the U.S., the percentage of births delivered by forceps or vacuum extraction

reported in 1997 increased slightly from 9.0% to 9.4%.
4
In the Philippines,
forceps delivery range from 1.7% to 6.8%.
5
The Philippine Board of Obstetrics
and Gynecology (PBOG) requires trainees to complete at least 15 forceps and/or
vacuum deliveries by the end of the 2
nd
year of the four-year training period.
6


References

1. Johanson RB. Vacuum extraction vs. forceps delivery. Oxford, England: The Cochrane Library:
pregnancy and childbirth database, 2000. Disk Issue I.
2. Johanson RB, Rice C, Doyle M, et al. A randomized prospective study comparing the new
extractor policy with forceps delivery. British Journal of Obstetrics and Gynaecology
1993;100:524-30.
3. Office of Surveillance and Biometrics. FDA public health advisory: need for caution when using
vacuum assisted delivery devices. Rockville, MD: Food and Drug Administration, 1998.
4. American College of Obstetricians and Gynecologists. Operative Vaginal Delivery
( ACOG Practice Bulletin # 17). June 2000.
5. Philippine Obstetrical and Gynecological Society Annual Reports
6. Handbook of the Philippine Board of Obstetrics and Gynecology, 3
rd
edition 2006
7. Williams MC, Knuppel RA, OBrien WF, Weiss A, Kanarek KS. A randomized comparison of
assisted vaginal delivery by obstetric forceps and polyethylene vacuum cup. Obstetrics and
Gynecology 1991;78(5 pt 1): 789-794.
8. Bofill JA, Rust OA, Schorr SJ, Brown RC, Martin RW, Martin JN, Morrison JC. A
randomized prospective trial of the obstetric forceps versus the M-cup vacuum extractor.
American Journal of Obstetrics and Gynecology 1996;175:1325-1330.
9. Islam A, Khan AH, Murtaza JN. Vacuum extraction and forceps deliveries: comparison of
maternal and neonatal complications. Professional Med J 2008;15(1):87-90.
10. Shi Wu Wen, Shiliang Liu, Kramer MS, Marcoux S, Ohlsson A, Sauve R, Liston R. Comparison
of maternal and fetal outcomes between vacuum extraction and forceps deliveries. American
Journal of Epidemiology 2001;153(2):103-107.
11. Forceps delivery and vacuum extraction in Cunningham, Leveno, Bloom, Hauth, Gilstrap III,
Wenstrom, eds. Williams Obstetrics 22
nd
edition. McGraw-Hill Medical Publishing Division.
New York. 2005.
12. Murphy DJ, Libby G, Chien P, Forsyth S, Greene S, Morris A. Cohort study of forceps delivery
and the risk of epilepsy in adulthood. American Journal of Obstetrics and Gynecology
2004;191(2):392-397.
13. Bodner-Adler B, Bodner K, Kimberger O, Wagenbichler P, Mayerhofer K. Management of the
perineum during forceps delivery. Association of episiotomy with the frequency and severity of
perineal trauma in women undergoing forceps delivery. Journal of Reproductive Medicine.
2003;48(4):239-242.
14. Doumouchtsis SK & Arulkumaran S. Head injuries after instrumental vaginal deliveries. Current
Opinion in Obstetrics and Gynecology 2006;18(2):129-134.
15. Doumouchtsis SK & Arulkumaran S. Head trauma after instrumental births. Clin Perinatol. 2008
Mar;35(1):69-83, viii.











IV. THIRD STAGE OF LABOR


A. USE OF EPISIOTOMY AND REPAIR

Recommendations:
o Restricted use of episiotomy preferable to routine use (Level I, Grade A)
o Median episiotomy is associated with higher rates of injury to the anal sphincter and
rectum (Level I, Grade A)
o Mediolateral episiotomy may be preferable to median episiotomy in selected cases (Level
I, Grade B)
o Routine episiotomy does not prevent pelvic floor damage leading to incontinence (Level
I, Grade B)


Repair

o In either median or mediolateral episiotomy, 2-layered closure can improve postpartum
pain and healing complications vs a 3-layered closure.
o Polyglycolic acid derivative suture, with minimal reaction, is recommended to reduce
wound inflammation. (Level I, GradeA)


Episiotomy

Purpose: facilitate second stage of labor to improve maternal and neonatal outcome
Maternal benefit
Reduced risk of perineal trauma, subsequent pelvic floor dysfunction and prolapse,
urinary incontinence, fecal incontinence and sexual dysfunction
Fetal benefit
Shortened second stage of labor


Indications:
Expedite delivery in the second stage of labor
When spontaneous laceration is likely
Maternal or fetal distress
Breech position
Assisted forceps delivery
Large baby
Maternal exhaustion

Routine vs. Restrictive Episiotomy

Routine
o Routinely conducted, usual care
o Use to pre-empt a tear

Restrictive
o Avoid episiotomy unless indicated for fetal well-being or to avoid laceration

Reference
ACOG Practice Guidelines April 2006



B. SUTURE MATERIALS FOR EPISIORRAPHY

o There is good evidence to support the use of fast-absorption polyglactin 910 as material
of choice for perineal closure. (Level I, Grade A)

Fast-absorbing Polyglactin 910
- Obviates need for suture removal up to 3 months postpartum for 1 in 10 women
sutured
1

- Less dyspareunia at 6 weeks
2

- Similar wound breakdown profile as chromic rarely requires late removal
3

- Earlier resumption of sexual intercourse
4



Recommendations:

RCOG Guideline No. 23

o Rapid-absorption polyglactin is the most appropriate suture material for perineal repair.
o Catgut suture material has been withdrawn from the UK since 2002.


Technique

o Continuous suturing techniques form perineal closure compared to interrupted methods,
are associated with less pain. Moreover, if the continuous technique is used for all layers
(vagina, perineal muscles and skin) compared to perineal skin only, the reduction in pain
is even greater.
5

o Less short term pain with continuous technique.
6




References

1. Kettle, C. et al., Lancet 2002 June 29; 359(9325):2217-23.
2. McElhinney, et al., Episiotomy repair: vicryl versus vicryl rapide. Ulster Medical Journal 2000.
3. Greenberg JA, et al. Obstetrics and Gynecology 2004; 103(6):1308-13.
4. Leroux N, Bujold E. AJOG 2006 Jun.
5. Morano S. Journal of Minimally Invasive Gynecology 2006; 13(5):457-62.



C. MANAGEMENT OF THIRD STAGE OF LABOR

Recommendations:
o Active management includes a group of interventions such as
1. administration of prophylactic uterotonin within one minute after the delivery of the
baby and prior to the delivery of the placenta
2. early cord clamping and cutting
3. controlled cord traction to deliver the placenta


Physiologic bases of the steps in the active Management of 3
rd
stage of labor to prevent
Postpartum Hemorrhage (PPH):

The 3 interventions hasten placental delivery by increasing uterine contractions, thus
decreasing blood loss and preventing PPH by averting uterine atony.
Giving uterotonics " increased uterine contractions/retraction" total detachment and
expulsion of the placenta " optimal occlusion of the myometrial vessels" preventing
PPH.

Early clamping and controlled cord traction = shorter duration of the 3
rd
stage, lower
maternal blood loss, lower incidence of retained placenta.
Early clamping decreases mother-to-baby transfusion. Giving uterotonics without
early clamping accelerates this transfusion and may disturb the physiological
equilibrium of the blood volume within the feto-maternal unit and creating a variety
of undesirable effects in the neonate.
The use of combination preparation (oxytocin and ergometrine) as part of the routine
active management of the third stage of labor appears to be associated with a
statistically significant reduction in the risk of PPH when compared to oxytocin alone
where blood loss is less than 1000 ml. (Level I, Grade B)
Administration of oxytocin alone is as effective as the use of oxytocin plus
ergometrine in the prevention of PPH, but is associated with a significantly lower rate
of unpleasant maternal side effects (nausea, vomiting and hypertension). (Level II,
Grade B)




Recommended Doses :
1. Oxytocin 10 u/500 ml NSS (20u/1000 ml NSS) - continous IV drip OR
5 u IV bolus
2. Ergometrine 200-250 mcg IM OR 100-125 mcg IV bolus



D. DRUGS IN THE THIRD STAGE OF LABOR

Recommendations:

o Oxytocin is effective as 1st line prophylactic uterotonic during the 3
rd
stage of labor in
the prevention of PPH and is safe to use on all patients. (Level I)
o Use of ergot alkaloid and ergometrine-oxytocin are valid alternatives in the absence of
oxytocin. Their use have to be weighed against maternal adverse effects. (Level I)
o Use of ergot alkaloid and ergometrine-oxytocin combination have to be avoided in
hypertensive patients. (Level I)
o In low resource area, and in the absence of other uterotonics, Misoprostol, if legally
available, is a valid alternative and may be administered orally, sublingually or rectally.
(Level I)


Uterotonic Drugs

Oxytocin
Ergot alkaloid
Ergometrine oxytocin
Prostaglandin

3 components:
Uterotonics using oxytocin by IM within 1 min after delivery of baby
Early clamping and cutting of the cord
Controlled cord traction


References

1. Preventing postpartum hemorrhage. Managing the third stage of labor. Maternal and Neonatal
Health. September 2001 Outlook Issue. Vol.19 No.3, pp.1-8
2. Liabsuettrakul T, Choobun T, Peeyananjarassri K, Islam QM. Prophylactic use of ergot alkalid in
the third stage of labor. Cochrane Database Systematic Reviews 2008, Issue 3. Art.
No.:CD005456. DOI:10.1002/14651858.pub2
3. Surbek DV; Fehr PM; Hosli I; Holzgreve W. Oral Misoprostol for third stage of labor:
randomized placebo-controlled trial. Obstetrics and gynecology 1999;94(2):255-8



V. FOURTH STAGE OF LABOR


EARLY BREASTFEEDING

o The American Academy of Physicians, American College of Obstetricians and
Gynecologists, American Academy of Family Physicians, Academy of Breastfeeding
Medicine, World Health Organization, United Nations Childrens Fund, and many other
health organizations recommend exclusive breastfeeding for the first 6 months of life.
Education
Minimize maternal medications intrapartum
Avoid traumatic procedures on infant
Direct skin to skin contact right after delivery
Rooming-in
Frequency of feedings
o Breastfeeding should be continued for at least the first year of life and beyond for as long
as mutually desired by mother and child.
o Certain conditions enumerated below may preclude or make difficult direct breastfeeding
or latch-on right after birth. When these are present, expressed human milk collected by
manual expression or pumping is advised. These maneuvers may help maintain milk
production.
1. Maternal anatomic abnormalities of the breast
2. Neonatal anatomic abnormalities
3. Neonatal depression
o Breastfeeding is contraindicated in mothers with the following conditions:
Use of street drugs/alcohol
Infant with galactosemia
Maternal infection (HIV, active PTB, varicella, herpes simplex)
Use of neoplastic, thyroid, immunosuppressants
Undergoing treatment for breast cancer


References

1. American Academy of Pediatrics, Work Group on Breastfeeding. Breastfeeding and the use of
human milk. Pediatrics 1997; 100: 10351039.
2. American Academy of Pediatrics, Policy Statement on Breastfeeding and the use of human milk.
Pediatrics 2005;115;496-506.
3. American College of Obstetricians and Gynecologists. Breastfeeding: maternal and infant
aspects. ACOG Educational Bulletin Number 258. Washington, DC: American College of
Obstetricians and Gynecologists; 2000.
4. American Academy of Family Physicians. AAFP Policy Statement on Breastfeeding. Leawood,
KS: American Academy of Family Physicians; 2001.












































APPENDIX

1. LEVEL OF EVIDENCE

LEVEL I: Evidence obtained from at least one properly randomized, controlled trial
LEVEL II-1: Evidence obtained from well designed controlled trials without randomization
LEVEL II-2: Evidence obtained from well designed cohort or case control analytic
studies, preferably from more than one center or research group.
LEVEL II-3: Evidence obtained from multiple time series with or without the intervention .
Dramatic results in uncontrolled experiments (such as the results of the introduction of
penicillin treatment in the 1940s) could also be regarded as this type of evidence.
LEVEL III: Opinions of respected authorities, based on clinical experience; descriptive
studies and case reports or reports of expert committees.

2. STRENGTH OF RECOMMENDATION
A. There is good evidence to support the recommendation of the practice in the management
of normal labor and delivery.
B. There is fair evidence to support the recommendation of the practice in the management
of normal labor and delivery
C. There is insufficient evidence to recommend for or against the inclusion of the practice in
the management of normal labor and delivery.
D. There is fair evidence to support the recommendation that the practice be excluded in the
management of normal labor and delivery
E. There is good evidence to support the recommendation that the practice be excluded in
the management of normal labor and delivery.

3. SENSITIVITY: Reflects the true positive rate; the percentage of patients with the disease
who have a positive test result.

4. SPECIFICITY: Reflects the true negative rate; the percentage of patients without the
disease who have a negative test result.