Safe Motherhood, pt. 1

The following is taken from the World Health Organization’s report on Safe Motherhood, Care in Normal Birth: a practical guide. There are a couple of introductory pages and about fifteen pages of references, and the remainder of the 57 pages of this pdf file are devoted to a discussion of the typical practices in birth around the world, finally dividing them into one of four categories: 1) practices which are demonstrably useful; 2) practices which are clearly harmful; 3) practices for which insufficient evidence exists; and 4) practices which are frequently used inappropriately. They arrived at these conclusions from studying birth practices around the world (from the high-tech U.S. to the impoverished third-world countries), citing a plethora of published research along the way. This document is pretty “meaty” or “heavy” reading, but quite understandable. Some of the practices (like using sterile instruments) are obviously always done in the U.S., but other countries need to improve on them. I would encourage you to read the full document, especially to see how they arrive at some of the following conclusions (the numbers at the end of each point correspond to the discussion sections in the document, and they are in chronological order–pregnancy, first stage of labor, second stage of labor, etc.). This discussion is for normal labor with normal women; there are things that could make a woman high-risk during pregnancy, or things that happen during labor that would change the “risk category”. But this is for most of the women in the world. This is part one. (I will put italicized explanatory notes on some of these; and I will emphasize certain words from the original in bold.)

6.1Practices which are Demonstrably Useful and Should be Encouraged

1. A personal plan determining where and by whom birth will be attended, made with the woman during pregnancy and made known to her husband/partner and, if applicable, to the family (1.3).

2. Risk assessment of pregnancy during prenatal care, reevaluated at each contact with the health system and at the time of the first contact with the caregiver during labour, and throughout labour (1.3).

3. Monitoring the woman’s physical and emotional well-being throughout labour and delivery, and at the conclusion of the birth process (2.1).

4. Offering oral fluids during labour and delivery (2.3). [Note, this is not limited to ice chips!]

5. Respecting women’s informed choice of place of birth (2.4).

6. Providing care in labour and delivery at the most peripheral level where birth is feasible and safe and where the woman feels safe and confident (2.4, 2.5). [“The most peripheral level” means with the lowest possible interventions; and note that the feelings of the woman are considered, and her confidence is important.]

7. Respecting the right of women to privacy in the birthing place (2.5). [I recently read some statistic that at a teaching hospital, a woman may have as many as 16 different strangers in her room during her labor, yet still be alone most of the time.]

8. Empathic support by caregivers during labour and birth (2.5).

9. Respecting women’s choice of companions during labour and birth (2.5).

10. Giving women as much information and explanation as they desire (2.5).

11. Non-invasive, non-pharmacological methods of pain relief during labour, such as massage and relaxation techniques (2.6).

12. Fetal monitoring with intermittent auscultation (2.7). [This means listening occasionally, either by fetoscope, Doppler, or electronic fetal monitoring. Most hospitals and/or doctors in the U.S. have a policy that once a woman is admitted to the hospital, she must be on EFM continuously until the baby is born. If the woman has risk factors, or if the labor has risk factors (i.e., use of Pitocin or epidural, which may cause sudden fetal distress), then continuous EFM is appropriate. For most women, though, occasional listening to the fetal heart-rate provides equal safety to the baby, with a much lower risk to the mom and baby of C-section, episiotomy, and forceps/vacuum-assisted delivery.]

13. Single use of disposable materials and appropriate decontamination of reusable materials throughout labour and delivery (2.8).

14. Use of gloves in vaginal examination, during delivery of the baby and in handling the placenta (2.8).

15. Freedom in position and movement throughout labour (3.2). [As opposed to imposed bed-rest.]

16. Encouragement of non-supine position in labour (3.2, 4.6). [Ditto above. It explicitly stated that if the fetal head is “engaged”, there is no risk of umbilical cord prolapse.]

17. Careful monitoring of the progress of labour, for instance by the use of the WHO partograph (3.4). [“Slow progress should be a reason for evaluation rather than for intervention” (pg. 22); although it talks of interventions that may be beneficial in some cases, much of the emphasis is on evaluating when these interventions are beneficial, rather than just assuming that they always are either beneficial or necessary.]

18. Prophylactic oxytocin in the third stage of labour in women with a risk of postpartum haemorrhage, or endangered by even a small amount of blood loss (5.2, 5.4). [Some women, such as those with anemia, may be at increased risk of illness if they lose normal or large amounts of blood; these women may benefit from an injection of oxytocin after the baby is born; although the report did cite a possible increased risk of retained placenta. And the report covers the entire world, from third-world women giving birth a few hours’ drive from any medical help, to those giving birth in the hospital. It seems obvious to me that most normal, healthy, American women would not fall into this increased-risk category; but that if there is a danger of hemorrhage, that can be remedied very quickly as it becomes apparent, rather than always routinely intervening.]

19. Sterility in the cutting of the cord (5.6).

20. Prevention of hypothermia of the baby (5.6). [The report specifically mentioned placing the baby on the mother’s abdomen or in her arms and drying him off and covering him with a blanket, and assessing the baby’s condition there, not taking him half-way across the room to a heat lamp where his mother can’t see him.]

21. Early skin-to-skin contact between mother and child and support of the initiation of breast-feeding within 1 hour postpartum in accordance with the WHO guidelines on breast-feeding (5.6). [The report specifically talked about the baby being colonized with maternal skin bacteria, instead of the bacteria of strangers (i.e., doctors, midwives, nurses). One blog I read recently was from a woman who remarked with sadness that over a dozen people held her baby before she had a chance to look at her.]

22. Routine examination of the placenta and the membranes (5.7). [Mostly to make sure there are no retained pieces in the uterus, but also to check for abnormalities.]


2 Responses

  1. I love this. *sigh*

  2. […] “Safe Motherhood” guidelines; I more fully discuss these in a 4-part post, beginning here.) In brief, here are the ten […]

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