These clinical algorithms are designed to support quality intrapartum care with the aim of optimizing birth outcomes for the woman and her baby, by promoting respectful care, providing evidence-based guidance for decision-making and potentially reducing the use of unnecessary interventions during labour and childbirth. — WHO Intrapartum Care Algorithms Working Group

In this blog post, I’ll be excerpting some of the World Health Organization’s recently published guidelines for evidence-based care in low-risk births in which labor began spontaneously (Pasquale 2024). I’d like you to see the WHO’s recommendations because, sad to say, they aren’t common obstetric practice (Declercq 2013; Sakala 2018)—and not because they’re new. The WHO isn’t the first authoritative organization or group to issue guidelines like these. I’ve written about others here, here, here, and here, some of them, like this one, published in multiple iterations over the years. Having them, though, provides you with a metric for judging whether your medical team and hospital are providing optimal care.

Note: These recommendations are intended for low- and middle-income countries, but as the authors state, they apply universally and, to emphasize what I wrote above, they are intended for low risk births in which labor began on its own.

General Considerations

All women . . . should receive individualized woman-centred care. Skilled birth attendants should aim to support pregnant women during labour and childbirth according to each individual woman’s choice without unnecessary interventions.

• Companionship: “All woman should receive emotional support, including labour companionship.”
• Mobility and choice of position: “Women should be encouraged to be mobile during labour and adopt a birth position of their choice.”
• Fetal heart rate assessment: “During low-risk labour, the WHO recommends the intermittent assessment of the fetal heart rate. Evidence shows that continuous [fetal heart rate] monitoring during admission and during labour probably increases the risk of caesarean section without improving birth outcomes, as well as the likelihood of a woman and her baby receiving unnecessary interventions.”

Active First-Stage Labor

Definition: a time “characterized by regular painful uterine contractions, a substantial degree of cervical effacement, and cervical dilation from 5 cm until full dilation.”
Comment: Many practitioners continue to adhere to 3 to 4 cm dilation as the demarcation line for onset of active labor, which has long since been disproven. This mistaken belief leads them to expect faster progress than is typical in early labor, which then results in unmerited diagnoses of progress delay and unnecessary medical intervention to treat it. In addition, practitioners may focus on cervical dilation alone. The WHO guidelines remind them to consider other aspects indicating active labor such as cervical effacement being complete or nearly complete and having strong, regular contractions.

Duration: usually not more than 12 hours in first labors and 10 hours in subsequent labors.

• Cervical dilation rate in active first stage: “A minimum cervical dilation rate of 1 cm/hr throughout active first stage should not be used for the identification of slow progress of labor, but progress of less than 2 cm every 4 h should raise concerns about possible delayed progress in the first stage of labor.”
  Comment: As with the dilation threshold for active labor, many practitioners continue to adhere to the outdated belief that cervical dilation in active labor should progress at a rate of 1 centimeter per hour, which again leads to unnecessary intervention.
• Nonmedical strategies that promote progress: “Interventions that have been proven to prevent any delay . . . include: continuous support; companionship; and the use of a comfortable position of the woman’s choice.”
  Comment: Curiously, the document doesn’t mention doulas specifically, although there is strong evidence for the benefits of 1:1 continuous care from a person skilled in labor support who isn’t a medical staff member (Bohren 2017).
• Oral intake: “Oral fluid and food intake during labor is recommended.”
  Comment: The WHO guidelines don’t specifically mention not needing a routine IV, but since the purpose of a routine IV is to replace oral fluids, that may be taken as a given.

Second-Stage Labor

Definition: the time between full cervical dilation and the birth of the baby, “during which the woman has an involuntary urge to bear down, as a result of expulsive uterine contractions.”
Comment: If there’s no epidural, the clock shouldn’t start on second-stage duration until the laboring woman/birthing person feels the urge to bear down.

Duration: up to 2 hours in first labors, 3 hours with an epidural, and 1 hour in subsequent labors and 2 hours with an epidural.
Comment: As with the demarcation lines between normal and abnormal for onset of active labor and progress in active labor, many practitioners don’t follow these guidelines for second-stage duration. Also, these guidelines should be taken as “alert” lines, not “take action” lines; they are minimal, not maximal, allowable second-stage durations.

• Pushing and birth position and pushing technique: “Women should be encouraged to adopt their preferred position for childbirth, including upright positions, and to follow their own urge to push.”
  Comment: Most women/birthing people will push and give birth on their backs and will be coached to bear down long and hard in defiance of what they would do instinctively. Even with an epidural, it is possible to push side lying or even squatting or on hands and knees with assistance and to push as they would if they didn’t have an epidural, i.e., waiting for the contraction to build, bearing down for five to seven seconds, taking four to six quick breaths, and repeating throughout the contraction (Simkin 2012).
• Fundal pressure: “Manual fundal pressure is not recommended.”
• Episiotomy: “Routine or liberal use of episiotomy is not recommended for women undergoing spontaneous vaginal birth. . . . If episiotomy is performed, . . . informed consent is essential.”

Third-Stage Labor

Definition: the time from the birth of the baby to the expulsion of the placenta.

Duration: “A prolonged third stage of labour is diagnosed if it is not completed within 30 min of the birth with active management, or within 60 min of the birth, with physiologic management.”
Comment: Many practitioners don’t wait as long as 30 minutes before attempting manual removal of the placenta. Also, the WHO guidelines do not take a position for or against active management of third-stage labor. I, in contrast, challenge the validity of the evidence in its favor.

• Skin-to-skin contact and early breastfeeding initiation: “Women should be encouraged to have skin-to-skin contact and to put babies to the breast early, within the first hour after birth.” Comment: Skin-to-skin contact promotes forming an attachment to the baby and reduces excessive postpartum bleeding, and early initiation of breastfeeding is one of the Baby-Friendly Childbirth Initiative’s “Ten Steps to Successful Breastfeeding.”
• Timing of umbilical cord clamping and cutting: “The cord should be cut at least 1 min after the birth of the baby or when pulsations stop, which can take several minutes.”
  Comment: Waiting one minute to clamp and cut the cord is better than immediate cord clamping, but waiting for the cord to stop pulsing, which signifies that the baby has retrieved all of its blood volume from the placenta, is better still.

References

Bohren MA, Hofmeyr GJ, Sakala C, et al. Continuous support for women during childbirth. Cochrane Database Syst Rev 2017;7:CD003766.

Declercq E, Sakala C, Corry MP, et al. Listening to Mothers III. Pregnancy and Birth. New York: Childbirth Connection; 2013.

Pasquale J, Gialdini C, Chamillard M, et al. Clinical algorithms for the monitoring and management of spontaneous, uncomplicated labour and childbirth. BJOG 2024;131 Suppl 2:17-27.

Sakala C, Declercq E, Turon JM, et al. Listening to Mothers in California. Washington, D.C.: National Partnership for Women & Families; 2018.

Simkin P. Moving beyond the debate: a holistic approach to understanding and treating effects of neuraxial analgesia. Birth 2012;39(4):327-32.