Care in Normal Birth (WHO, 1996, 60 p.) 2. GENERAL ASPECTS OF CARE IN LABOUR 2.1 Assessing the Well-being of the Woman during Labour 2.2 Routine Procedures 2.3 Nutrition 2.4 Place of Birth 2.5 Support in Childbirth 2.6 Labour Pain (introduction...) 2.6.1 Non-pharmacological methods of pain relief 2.6.2 Pharmacological pain relief in labour 2.7 Monitoring the Fetus during Labour (introduction...) 2.7.1 Assessment of amniotic fluid 2.7.2 Monitoring the fetal heart rate 2.7.3 Fetal scalp blood examination 2.7.4 Comparison of auscultation and electronic fetal monitoring 2.8 Cleanliness

Care in Normal Birth (WHO, 1996, 60 p.)

2. GENERAL ASPECTS OF CARE IN LABOUR

2.1 Assessing the Well-being of the Woman during Labour

Where the onset of labour is spontaneous women themselves usually initiate care, either by sending for their birth attendant or by making arrangements to be admitted to a health facility. The attendant’s responsibility for assessing the most appropriate care at the outset of labour has already been addressed, and the importance of support throughout labour is discussed below. Wherever birth takes place the establishment of good rapport between the woman and her caregiver is vital, whether or not they have met previously. The quality of welcome extended to a woman who seeks institutional care may well determine the level of trust which she and her family feel able to put in her carers.

Throughout labour and delivery the woman’s physical and emotional well-being should be regularly assessed. This implies measuring of temperature, pulse and blood pressure, checking fluid intake and urine output, assessing pain and need of support. This monitoring should be maintained until the conclusion of the birthing process.

The assessment of the woman’s well-being also comprises attention to her privacy during labour, respecting her choice of companions and avoiding the presence of unnecessary persons in the labour room.

2.2 Routine Procedures

The preparation for birth on admission to a hospital or health centre often includes several “routine” procedures such as the measuring of temperature, pulse and blood pressure, and an enema, followed by shaving of all or some of the pubic hair.

The first three procedures, taking and recording temperature, pulse and blood pressure, can have implications for the final outcome of birth, and could therefore influence the management of labour. These routine procedures should not be dismissed, although they should be introduced and explained to the woman and her partner. Measuring the temperature every 4 hours, according to the WHO partograph, is important, because a rise in temperature may be a first sign of infection, and thus may lead to early treatment, especially in case of prolonged labour and ruptured membranes; this may prevent sepsis. Sometimes it may be a sign of dehydration. Taking the blood pressure at the same intervals, is an important check on maternal well-being. A sudden rise in blood pressure can indicate the need to expedite delivery or transfer the woman to a higher level of care.

Enemas are still widely used because they supposedly stimulate uterine contractions and because an empty bowel allows the head to descend. They are also believed to reduce contamination and thereby infection of mother and child. However, they are uncomfortable and carry a certain risk of damage to the bowel. Even though some women ask for an enema, many women find them an embarrassment. Two randomized controlled trials (Romney and Gordon 1981, Drayton and Rees 1984) found that, with use of an enema, the rate of faecal soiling is unaffected during the first stage of labour, but reduced during delivery. Without an enema soiling is mainly slight, and easier to remove than soiling after an enema. No effects on the duration of labour or on neonatal infection or perineal wound infection were detected.

Pubic shaving (Johnston and Sidall 1922, Kantor et al 1965) is presumed to reduce infection and facilitate suturing but there is no evidence to support this. Women experience discomfort as the hair grows back and the risk of infection is not reduced. The routine use could even increase the risk of infection by the HIV and hepatitis virus, either to the care provider or the woman.

In conclusion, measuring temperature, pulse and blood pressure are observations rather than interventions and are part of ongoing assessment in labour. They have a clear place in care, since they can indicate the need to change the course of action in any particular birth. However, they are only feasible in some settings. The last two procedures, enemas and pubic shaving, have long been considered unnecessary and should not be done except at the woman’s request. There is no documentation on the above mentioned routine procedures in the case of home birth, let alone research. Neither is there evidence that at home the need for them is different from the need in hospital.

2.3 Nutrition

Views on nutrition during childbirth differ widely across the world. In many developed countries, the fear of aspiration of gastric contents during general anaesthesia (Mendelson’s syndrome) continues to justify the rule of no food and drink during labour. For most women in labour the withholding of food poses no problem, as they do not want to eat during labour anyway, although many desperately need to drink. In many developing countries traditional culturally-bound beliefs restrain the food and fluid intake of women in labour.

The fear that eating and drinking during labour will put women at risk of aspirating stomach contents during anaesthesia is real and serious. Keeping a restriction on the food and fluid intake during labour however, does not guarantee reduced stomach content (Crawford 1956, Taylor and Pryse-Davies 1966, Roberts and Shirley 1976, Tettambel 1983, Mckay and Mahan 1988). Several trials on methods to reduce stomach content or the acidity of the content, both by pharmacological means and by restriction of oral intake, have not been able to establish a 100% positive effect of any specific method. The range of pH values found was wide and therefore, a researcher concludes, routine administration of antacids during labour cannot be relied on to prevent Mendelson’s syndrome, neither does it affect the volume of gastric contents.

The risk of aspiration is associated with the risk of general anaesthesia. As there is no guarantee against Mendelson’s syndrome, the correct approach for normal childbirth should include an assessment of the risk of general anaesthesia. Once categorized, the low risk birth can be managed without administration of antacids.

Labour requires enormous amounts of energy. As the length of labour and delivery cannot be predicted, the sources of energy need to be replenished in order to ensure fetal and maternal well-being. Severe restriction of oral intake can lead to dehydration and ketosis. This is commonly treated by an intravenous infusion of glucose and fluid. The maternal effects of this treatment have been evaluated in a number of randomized trials (Lucas et al 1980, Rutter et al 1980, Tarnow-Mordi et al 1981, Lawrence et al 1982). The rise in mean serum glucose levels appears to be accompanied by a rise in maternal insulin levels (and a reduction in mean levels of 3-hydroxybutyrate). It also results in an increase in plasma glucose levels in the baby and it may result in a decrease in umbilical arterial blood pH. Hyperinsulinism can occur in the fetus when women receive more than 25 grammes of glucose intravenously during labour. This can result in neonatal hypoglycaemia and raised levels of blood lactate. The excessive use of salt-free intravenous solutions can lead to hyponatraemia in both mother and child.

The above mentioned complications, especially dehydration and ketosis, can be prevented by offering oral fluids during labour, and by offering light meals. Routine intravenous infusions interfere with the natural process and restrict women’s freedom to move. Even the prophylactic routine insertion of an intravenous cannula invites unnecessary interventions.

In the home birth situation no specific treatment is given; no use of antacids, no restriction of food and fluid intake. Sometimes women are cautioned that eating and drinking during labour can make them nauseous, but as they are in their own home, there is no control over what they eat and drink. When women do decide to eat they tend to eat light foods that are easily digestible. Intuitively they leave heavy meals and beverages alone. It is safe to say that for the normal, low-risk birth in any setting there is no need for restriction of food. However, serious discussion is necessary to determine whether the effects of intervention in maternal nutrition during labour are not worse than the risks of Mendelson’s syndrome. And many questions remain, such as: Is there any research on labour with a full stomach? Is there any difference between eating and drinking a little or not at all? Are there any data on the effects of food and fluid restriction during labour in the developing countries, where there are no means of substituting the loss of energy in prolonged labour?

In conclusion, nutrition is a subject of great importance and great variability at the same time. The correct approach seems to be not to interfere with the women’s wish for food and drink during labour and delivery, because in normal childbirth there should be a valid reason to interfere with the natural process. However, there are so many die-hard fears and routines all over the world that each needs to be dealt with in a different way.

2.4 Place of Birth

Does the place of birth have an impact on the course of labour and delivery? This question has been abundantly researched in the past two decades (Campbell and Macfarlane, 1994). When in many developed countries labour went from a natural process to a controlled procedure, the place of birth changed from home to hospital. At the same time much of the human touch was taken out. Pain was alleviated pharmacologically and women were left alone for long periods of time as they were in a light sleep anyway; they were monitored closely from afar. This was the opposite end of the spectrum of those parts of the world where fewer than 20% of women have access to any type of formal birth facility. For them, home birth is not an option, it is virtually inevitable, for reasons ranging from the economic to the cultural, and including the geographical (Mbizvo et al 1993, Onwudiego 1993, Smith 1993). The call for a return to the natural process in many parts of the developed world opened up delivery rooms to fathers and to other family members, but the location stayed the same: the hospital. Some hospitals have made an effort by installing a home-like birth room and this was found to increase maternal satisfaction and reduce the rate of perineal trauma, as well as reducing the desire for a different setting for the next birth, but randomised trials found no effect on the use of epidural analgesia, forceps delivery and caesarean section (Klein et al 1984, Chapman et al 1986). These trials were primarily concerned with a more attractive labour ward setting without a fundamental change in care; apparently this is not enough to improve the quality of care and the obstetric outcome.

Other studies found that a woman with a low risk delivery giving birth to her first child in a teaching hospital could be attended by as many as 16 people during 6 hours of labour and still be left alone for most of the time (Hodnett and Osborn 1989b). Routine, though unfamiliar, procedures, the presence of strangers and being left alone during labour and/or delivery caused stress, and stress can interfere with the course of birth by prolonging it and setting off what has been described as a “cascade of intervention”.

Home birth is a practice which is unevenly spread across the world. With the widespread institutionalisation of childbirth since the 1930s the option of a home birth in most developed countries disappeared, even where it was not banned. The system of obstetric care in the Netherlands, where still more than 30% of pregnant women deliver at home, is exceptional among developed countries (Van Alten et al 1989, Treffers et al 1990). On the other hand, in many developing countries, great distances between women and the health facilities restrict options and make home birth the only choice.

Although risk assessment may be appropriately performed by trained birth attendants their advice about the place of birth, made on the basis of such assessment, is not always followed. Many factors keep women away from higher level health facilities. These include the cost of a hospital delivery, unfamiliar practices, inappropriate staff attitudes, restrictions with regard to the attendance of family members at the birth and the frequent need to obtain permission from other (usually male) family members before seeking institutional care (Brieger et al 1994, Paolisso and Leslie 1995). Often, high and very high risk women do not feel ill or show signs of disease, so they give birth at home, attended by a family member, by a neighbour or by a TBA (Kwast 1995a).

However, a properly attended home birth does require a few essential preparations. The birth attendant must make sure that there is clean water at hand and that the room in which the birth takes place is warm. There is a need for careful handwashing. Warm cloths or towels must be ready to wrap around the baby to keep it warm. There must also be at least some form of clean delivery kit as recommended by WHO in order to create as clean a field as possible for birth and to give adequate treatment to the umbilical cord. Furthermore, transport facilities to a referral centre must be available if needed. In practical terms this means that community participation and revolving funds are necessary to enable transport to be arranged for emergencies in areas where transportation is a problem.

In some developed countries birth centres in and outside hospitals have been established where low-risk women can give birth in a home-like atmosphere, under primary care, usually attended by midwives. In most such centres electronic fetal monitoring and augmentation of labour are not used and there is a minimum use of analgesics. An extensive report about birth centre care in the USA described care in alternative birth centres in and outside hospitals (Rooks et al 1989). Experiments with midwife-managed care in hospitals in Britain, Australia and Sweden showed that women’s satisfaction with such care was much higher than with standard care. The number of interventions was generally lower, especially obstetric analgesia, induction and augmentation of labour. The obstetric outcome did not significantly differ from consultant-led care, though in some trials perinatal mortality tended to be slightly higher in the midwife-led models of care (Flint et al 1989, MacVicar et al 1993, Waldenström and Nilsson 1993, Hundley et al 1994, Rowley et al 1995, Waldenström et al 1996).

In a number of developed countries dissatisfaction with hospital care led small groups of women and caregivers to the practice of home birth in an alternative setting, often more or less in confrontation with the official system of care. Statistical data about these home births are scarce. In an Australian study data were collected which suggested that the selection of low-risk pregnancies was only moderately successful. In planned home deliveries the number of transfers to hospital and the rate of obstetric interventions was low. Perinatal mortality and neonatal morbidity figures were also relatively low, but data about preventable factors were not provided (Bastian and Lancaster 1992).

The Netherlands is a developed country with an official home birth system. The incidence of home deliveries differs considerably between regions, and even between large cities. A study of perinatal mortality showed no correlation between regional hospitalisation at delivery and regional perinatal mortality (Treffers and Laan 1986). A study conducted in the province of Gelderland, compared the “obstetric result” of home births and hospital births. The results suggested that for primiparous women with a low-risk pregnancy a home birth was as safe as a hospital birth. For low-risk multiparous women the result of a home birth was significantly better than the result of a hospital birth (Wiegers et al 1996). There was no evidence that this system of care for pregnant women can be improved by increasing medicalization of birth (Buitendijk 1993).

In Nepal the decentralization approach of maternity care has been adapted to the special needs of urban areas in a developing country, where a hospital’s capacity to deliver the specialist obstetric services needed by women with childbirth complications was being swamped by the sheer numbers of low-risk women experiencing normal birth - a common scenario in many countries. The development of a “low-technology” birthing unit in the vicinity of the main hospital not only took the pressure off the specialist unit but made it much easier to deliver appropriate care to women in normal labour. A similar, larger-scale project took place in Lusaka, Zambia, where a University teaching hospital, serving as a specialist referral centre for the entire country, was overcrowded by large numbers of low-risk pregnant women. The extension of the capacity of the peripheral delivery centres and the opening of new centres for low-risk births reduced the number of deliveries in the hospital from around 22,000 to around 12,000, and at the same time the total number of births in the dozen satellite clinics rose from just over 2000 in 1982 to 15,298 in 1988. The care of high-risk women in the hospital was improved by the reduction in numbers of low-risk women, while in the peripheral units time was available to ensure that the low-risk women received the care and attention they needed (Nasah and Tyndall 1994).

So where then should a woman give birth? It is safe to say that a woman should give birth in a place she feels is safe, and at the most peripheral level at which appropriate care is feasible and safe (FIGO 1992). For a low-risk pregnant woman this can be at home, at a small maternity clinic or birth centre in town or perhaps at the maternity unit of a larger hospital. However, it must be a place where all the attention and care are focused on her needs and safety, as close to home and her own culture as possible. If birth does take place at home or in a small peripheral birth centre, contingency plans for access to a properly-staffed referral centre should form part of the antenatal preparations.

2.5 Support in Childbirth

Reports and randomized controlled trials on support in labour by one single person, a “doula”, midwife or a nurse, showed that continuous empathetic and physical support during labour resulted in many benefits, including shorter labour, significantly less medication and epidural analgesia, fewer Apgar scores of <7 and fewer operative deliveries (Klaus et al 1986, Hodnett and Osborn 1989, Hemminki et al 1990, Hofmeyr et al 1991).

This report identifies a doula as a female caregiver, who has had a basic training in labour and delivery and who is familiar with a wide variety of care procedures. She provides emotional support consisting of praise, reassurance, measures to improve the comfort of the mother, physical contact such as rubbing the mother’s back and holding her hands, explanation of what is going on during labour and delivery and a constant friendly presence. Such tasks can also be fulfilled by a nurse or midwife, but they often need to perform technical/medical procedures that can distract their attention from the mother. However, the constant comforting support of a female caregiver significantly reduced the anxiety and the feeling of having had a difficult birth in mothers 24 hours postpartum. It also had a positive effect on the number of mothers who were still breast-feeding 6 weeks postpartum.

A woman in labour should be accompanied by the people she trusts and feels comfortable with; her partner, best friend, doula or midwife. In some developing countries this could also include the TBA. Generally these will be people she has become acquainted with during the course of her pregnancy. Professional birth attendants need to be familiar with both the supportive and the medical tasks they have and be able to perform both with competence and sensitivity. One of the supportive tasks of the caregiver is to give women as much information and explanation as they desire and need. Women’s privacy in the birthing setting should be respected. A labouring woman needs her own room, where the number of attendants should be limited to the essential minimum.

However, in actual practice conditions often differ considerably from the ideal situation described above. In developed countries women in labour often feel isolated in labour rooms of large hospitals, surrounded by technical equipment and without friendly support of caregivers. In developing countries some large hospitals are so overcrowded with low-risk deliveries that personal support and privacy are impossible. Home deliveries in developing countries are often attended by untrained or insufficiently trained caregivers. Under these circumstances support of the labouring woman is deficient or even absent, for a significant number of women deliver with no attendant at all.

The implications of the above statements for the location of birth and the provision of support can be far reaching, because they suggest that caregivers in childbirth should work on a much smaller scale. Skilled care in childbirth should be provided at or near to the place where women live, rather than bringing all women to a large obstetric unit. Large units that perform 50 to 60 deliveries a day would need to restructure their services to be able to cater to women’s specific needs. Caregivers would need to reorganise work schedules in order to meet women’s need for continuity of care and support. This also has cost implications and thus becomes a political issue. Both developing and developed countries need to address and resolve these issues in their own specific ways.

In conclusion, normal birth, provided it is low-risk, only needs close observation by a trained and skilled birth attendant in order to detect early signs of complications. It needs no intervention but encouragement, support and a little tender loving care. General guidelines can be given as to what needs to be in place to protect and sustain normal birth. However, each country willing to invest in these services needs to adapt these guidelines to its own specific situation and the needs of the women as well as to ensure that the basics are in place in order to adequately serve women at low, medium and high risk and those who develop complications.

2.6 Labour Pain

Almost all women experience pain during labour, but the responses of individual women to labour pain are widely different. According to clinical experience, abnormal labour, prolonged or complicated by dystocia, induced or accelerated by oxytocics, or terminated by instrumental delivery, seems to be more painful than “normal labour”. Nevertheless, even completely normal labour is painful too.

2.6.1 Non-pharmacological methods of pain relief

An important task of the birth attendant is to help women cope with labour pain. This may be achieved by pharmacological pain relief, but more fundamental and more important is the non-pharmacological approach, starting during prenatal care by providing reassuring information to the pregnant woman and her partner, and if need be to her family. Empathetic support, before and during labour, from caregivers and companions, can reduce the need for pharmacological pain relief and thus improve the childbirth experience (see 2.5).

Apart from support during labour (the most important factor) there are several other methods to alleviate labour pain. The first is the opportunity to assume any position the woman wishes, in or out of bed, during the course of labour. This means that she should not be restricted to bed, and certainly not to the supine position, but that she should have the freedom to adopt upright postures such as sitting, standing, or walking, without interference by caregivers, especially during the first stage of labour (see 3.2).

There are several non-invasive, non-pharmacological methods of pain relief that can be used during labour. Many women find relief of pain by the use of a shower or a bath. Touch and massage by a companion are often felt to be helpful. The same holds true for methods that help women cope with pain by attention-focusing techniques like patterned breathing, verbal coaching and relaxation, drawing a woman’s attention away from her pain. These methods are sometimes applied in combination with other strategies, including a range of psychosomatic approaches to support a woman in labour such as hypnosis, music and biofeedback. The practices are experienced as useful by many women, they are harmless and can be recommended.

Specific non-pharmacological methods for relief of pain in women in normal labour include methods that activate peripheral sensory receptors (Simkin 1989). Among the newest of these is transcutaneous electrical nerve stimulation (TENS). The self-administered nature of this technique has contributed to its success among many women, but its availability is limited to high-resource areas of the world, and its effectiveness has not been demonstrated in randomized trials (Erkolla et al 1980, Nesheim 1981, Bundsen et al 1982, Harrison et al 1986, Hughes et al 1986, Thomas et al 1988). Other techniques are the use of superficial heat and cold, acupuncture, immersion in water, herbs and aromatherapy with fragrant oils. For most of these techniques randomized trials to establish their effectiveness are not available yet. These practices should undergo the same process of critical review as is required for pharmacological intervention. The same holds true for a semi-pharmacological method as intradermal injections of sterile water at four spots in the lower back area (Enkin et al 1995).

In conclusion, all cultures have their own ways of attending and coaching pregnant women, some of them explain their customs in a magic way, others try to give a more logical explanation for the system they apply. A common feature of many of these methods is the intense attention paid to the woman during pregnancy and childbirth; perhaps this is the reason why so many pregnant women find them comforting and helpful. The reports that women find them comforting are mainly observational, but nevertheless a number of these methods are harmless, and their use by women who experience relief of pain by them may be justified. Training in counselling and inter-personal communication skills is vital for all who care for childbearing women (Kwast 1995a).

2.6.2 Pharmacological pain relief in labour

Pharmacological methods of pain relief have gained ample application, especially in the developed countries. The effects of several techniques have been investigated by clinical trials; the benefits of pain relief became obvious, but the possible adverse effects on mother or infant have received less attention.

Systemic agents

A number of drugs have been and are being used for pain relief: opioid alkaloids, of which by far the most popular is pethidine, followed by phenothiazine derivatives (promethazine), benzodiazepines (diazepam) and others. In some countries inhalation analgesia for normal labour has decreased in recent years (it has been replaced by epidural analgesia); the most commonly used agent is nitrous oxide combined with 50 percent oxygen. All these agents can provide reasonable pain relief, but at the cost of unwanted side-effects (Dickersin 1989). Maternal side-effects of pethidine are orthostatic hypotension, nausea, vomiting, and dizziness. All of the systemic drugs used for pain relief cross the placenta and all except nitrous oxide are known to cause respiratory depression in the baby and neonatal behavioural abnormalities, including reluctance to breast-feed. Diazepam can cause neonatal respiratory depression, hypotonia, lethargy and hypothermia (Dalen et al 1969, Catchlove and Kafer 1971, Flowers et al 1969, McCarthy et al 1973, McAllister 1980).

Epidural analgesia

Of the different techniques of regional analgesia (epidural, caudal, paracervical, spinal) epidural analgesia is the method most widely used in normal labour. Its effects have been investigated in a number of trials, all of which compare epidural analgesia with other techniques of pain control (Robinson et al 1980, Philipsen and Jensen 1989, 1990, Swanstrom and Bratteby 1981, Thorp et al 1993). It provides better and more lasting pain relief than systemic agents. The adoption of epidural analgesia in obstetric care is resource-intensive and calls for several important facilities: labour and delivery should take place in a well-equipped hospital, the technical apparatus should be sufficient, an anaesthetist should be available at all times and constant skilled supervision of the mother is called for.

With epidural analgesia there is a tendency for the first stage of labour to be somewhat longer, and for oxytocin to be used more frequently. In several reports and trials the number of vaginal operative deliveries was increased, especially if the analgesic effect was maintained into the second stage of labour, thereby suppressing the bearing-down reflex. In a recent American trial the number of caesarean sections was increased when epidural analgesia was used, especially when the epidural was started before 5 cm dilatation (Thorp et al 1993). There is a paucity of data from randomized trials on possible effects of epidural analgesia on either mother or baby in the long term. No randomised trial compared epidural analgesia to “no pain control” or a non-pharmacological method, all comparisons are between different methods of epidural analgesia, or different methods of pharmacological pain relief. The main effect measured in the trials was the degree of pain relief, but in none of the trials of epidural analgesia was maternal satisfaction with childbirth measured. An observational study (Morgan et al 1982) suggests that there is no direct relation between pain relief and satisfaction. In a trial of birth centre care in Sweden the use of epidural analgesia and other methods of pharmacological pain relief was significantly lower in the birth centre group compared with standard care; nevertheless the attitude towards labour pain when asked two months after the birth was not different between the groups. Apparently many of the women regarded pain in labour in a positive light, as a feeling of achievement, which illustrates the different character of pain in childbirth compared to pain related to illness (Waldenström and Nilsson 1994). In a study of new mothers, support by caregivers had a positive effect on women’s total birth experience, while pain relief did not explain any of the variations in women’s responses (Waldenström et al 1996).

There is little doubt that epidural analgesia is useful in complicated labour and delivery. However, if epidural analgesia is administered to a low-risk pregnant woman, it is questionable whether the resulting procedure can still be called “normal labour”. Naturally, the answer depends on the definition of normality, but epidural analgesia is one of the most striking examples of the medicalization of normal birth, transforming a physiological event into a medical procedure. The acceptance of this transformation is largely determined by cultural factors. For instance, in Britain and the USA a large number of low-risk pregnant women deliver under epidural analgesia, while in the vast majority of developing countries very many deliveries take place at home, without any pharmacological pain control. This is not merely a contrast between developing and developed countries: in the Netherlands more than 30% of all pregnant women give birth at home without any pharmacological pain control, and even if they deliver in hospital only a minority of low-risk women receive pain relieving medication (Senden et al 1988).

In conclusion, in the care surrounding normal birth, non-pharmacological methods of pain relief, such as paying personal attention to the labouring woman, are of utmost importance. Methods requiring a large number of technical facilities like epidural analgesia, are only applicable in well-equipped, well-staffed hospitals. In many countries these technical facilities are not generally available, especially for normal childbirth. However, the demand for these methods is in large measure culturally determined, the quality of care in normal delivery is not dependent on the availability of these technical facilities. They are no part of essential care during childbirth. Pharmacological methods should never replace personal attention to the labouring woman and tender loving care.

2.7 Monitoring the Fetus during Labour

Monitoring fetal well-being is part of essential care during labour. The occurrence of fetal distress, usually through hypoxia, can never be fully excluded, even though a labour may meet the criteria for “normal” that is: it starts at term, after an uneventful pregnancy without factors indicating an increased risk of complications. The risk of fetal distress is somewhat higher during the second stage of labour and in the case of prolonged labour.

2.7.1 Assessment of amniotic fluid

The passage of meconium may reflect fetal distress and is associated with intrapartum stillbirth and neonatal morbidity or death (Matthews and Martin 1974, Gregory et al 1974, Fujikura and Klionsky 1975, Meis et al 1978, MacDonald et al 1985). Where services permit, the passage of meconium during labour is considered an indication for referral of the labouring woman by the primary caregiver. Thick meconium recognized after rupture of the membranes carries the worst prognosis; undiluted meconium also reflects reduced amniotic fluid volume, which is a risk factor in itself. The absence of amniotic fluid at the time of rupturing the membranes should also be considered a risk factor. Slight staining of the amniotic fluid probably reflects a far less serious risk, but this has not been fully investigated.

2.7.2 Monitoring the fetal heart rate

The relation between fetal well-being and fetal heart rate has been investigated in numerous studies. It is clear that fetal distress may express itself in abnormalities of the heart rate: bradycardia (<120/min), tachycardia (>160/min), reduced variability or decelerations. There are two methods of monitoring the heart rate: intermittent auscultation and continuous electronic surveillance.

Intermittent auscultation can be done by using a monaural (Pinard’s) stethoscope, as it has been since the beginning of this century, or by a simple hand-held ultrasound Doppler apparatus. When the stethoscope is used the woman usually lies on her back or on her side, though it is possible to hear the heart sounds even with the woman sitting or standing. The Doppler apparatus is applicable in various positions. The auscultation is usually performed once every 15-30 minutes during the first stage of labour, and following every contraction during the second stage. If necessary, the fetal heart rate is compared to the maternal heart rate. Intermittent auscultation with monaural stethoscope is the only available option for the vast majority of caregivers at the periphery, whether at the health centre or in the home. An advantage of intermittent auscultation is its sheer simplicity - a clear example of appropriate technology, with an implement (the monaural stethoscope) which is both cheap to produce (it can even be improvised quite easily) and uncomplicated to use, and which leaves the woman free to move about at will. This means that, with appropriate training, the caregiver can monitor the fetal heart anywhere and is not confined to hospitals with sophisticated technical equipment, such as electronic monitors. Surveillance of the labouring woman and the fetus can be done by a midwife at home, or in a small maternity unit.

Electronic fetal heart rate monitoring is used during pregnancy in the surveillance of high-risk pregnancies, and also during labour. Its use is normally limited to institutional births. The monitoring is most commonly achieved by an external Doppler ultrasound transducer, or by an internal (vaginal) electrode attached to the fetal scalp, after rupture of the membranes. Although the information on fetal heart rate is more accurate in the latter method than with auscultation, the interpretation is difficult; the tracings are often interpreted differently by different care-givers, and even by the same people at different times (Cohen et al 1982, Van Geijn 1987, Nielsen et al 1987). The sensitivity of the method with respect to the detection of fetal distress is high, but the specificity is low (Grant 1989). This means that the method results in a high rate of false positive signals, and a concomitant high number of (unnecessary) interventions, especially if used in a group of low-risk pregnant women (Curzen et al 1984, Borthen et al 1989). In high-risk pregnancies and in high-risk cases during labour the method has proven to be useful and may, in addition, offer reassurance to the woman, although its use inevitably limits the woman’s capacity to move about as she wishes.

Among the drawbacks associated with the application of electronic monitoring is a tendency in some caregivers, and even partners and family, to focus on the apparatus instead of on the woman. In some technically well-equipped hospitals the monitoring is even centralized, enabling the attendant to look at the monitor in a central office without being obliged to enter the labour room.

2.7.3 Fetal scalp blood examination

A microtechnique of sampling blood from the fetal scalp in order to confirm fetal hypoxia has been in use since the early 1960s. The acid-base status of the blood is examined, especially the pH. There are some doubts about the representativeness of a blood sample from a chronically oedematous part of the skin and about the reproducibility, but nevertheless the method has proven its value in clinical use, in combination with fetal heart rate monitoring. The method is resource-intensive, expensive, invasive, time-consuming, cumbersome, and uncomfortable for the woman. As with the fetal scalp electrode, its use can occasionally result in trauma, infection and possibly pain for the fetus. Finally, it requires continuous availability of laboratory facilities and skilled personnel. Its use is therefore generally limited to larger hospital departments serving many high-risk cases. Its role in the surveillance of low-risk labour is limited: only for diagnostic purposes after the detection of fetal heart rate abnormalities (Grant 1989).

2.7.4 Comparison of auscultation and electronic fetal monitoring

These two methods of fetal surveillance have been compared in a number of trials (Haverkamp et al 1976, 1979, Kelso et al 1978, MacDonald et al 1985, Wood et al 1981, Neldam et al 1986). Caesarean section rate and operative vaginal delivery rate were both higher in all the electronically monitored groups. If scalp pH estimations were not available, the increase in caesarean section rates was even higher. There is little evidence that the increased number of interventions in the electronically monitored groups led to substantive benefits for the infants. Perinatal deaths and low Apgar scores were not reduced in the groups with electronic monitoring. Only one measure of neonatal outcome was improved by electronic monitoring, in the largest trial: neonatal seizures (MacDonald et al 1985). A further analysis of this trial suggested that the excess risk of neonatal seizures in the auscultation group was mainly limited to labours that were induced or augmented with oxytocin. The follow-up data of the infants with seizures showed an equal incidence of major neurological disabilities in the groups monitored electronically and by auscultation.

These data have important consequences for fetal surveillance during normal labour. The substantial increase of interventions if labour is monitored electronically is in agreement with the low specificity of the method in low-risk cases, and does not seem to lead to substantive benefits for the infant. The only exception is the occurrence of neonatal seizures. However, these occurred primarily in infants born after the use of oxytocin infusions, and one may rightly ask if labour induced or augmented by oxytocin is to be considered as “normal labour”. In countries with sophisticated facilities and a high proportion of institutional births labour which is induced or augmented by oxytocin or prostaglandin is considered high-risk, and such labours only take place under the responsibility of the obstetrician; fetal surveillance will then be by electronic monitoring. In a large follow-up study of midwifery care with intermittent auscultation in normal births but electronic monitoring after referral for oxytocin augmentation, the number of neonatal seizures was very low (Van Alten et al 1989, Treffers et al 1990).

Intermittent electronic monitoring is a variation of continuous electronic monitoring. This method is used during a period of half an hour at the start of labour, and subsequently at regular intervals for a period of about twenty minutes. In a randomized trial Herbst and Ingemarsson (1994) compared the method with continuous monitoring: the results in both groups were equally good. Although in this trial the intervention rate was low in both groups, it is to be expected that the method, if widely adopted in normal labour, would have the same disadvantages as continuous monitoring, though they would perhaps be less obvious. These include restriction of movement during the application and low specificity with concomitant interventions. Moreover, its routine use could lead to mistrust of intermittent auscultation, if there is any suggestion that auscultation might be less reliable than electronic monitoring. Of course, routine use of intermittent electronic fetal monitoring must be distinguished from recourse to electronic monitoring (where it is available) where auscultation indicates the possibility of fetal distress; such practice leads to closer attention to deviations from normality in auscultation.

In conclusion, the method of choice for the monitoring of the fetus during normal labour is intermittent auscultation. In many countries it is the only method available for the large majority of women. But also in industrialized countries, where electronic equipment is more easily accessible, auscultation is the method of choice in normal labour. Individualized care of the labouring woman is essential, and this may be achieved more smoothly by the personal contact required by regular auscultation. Only in women with increased risk, such as labours which are induced or augmented, complicated by meconium-stained amniotic fluid or by any other risk factor, does electronic monitoring seem to be advantageous. In the majority of labours without increased risk, electronic monitoring increases the number of interventions with no clear benefit for the fetus and with a degree of additional discomfort for the women.

2.8 Cleanliness

Wherever labour and delivery are managed, cleanliness is a first and foremost requirement. There is no need for the form of sterility commonly used in an operating theatre, but nails must be short as well as clean and hands must be carefully washed with soap and water. Attention should be paid to the personal hygiene of birthing women and birth attendants as well as to the cleanliness of the environment and all materials used during birth. In some countries masks and sterile gowns are used traditionally to protect labouring woman from infection. For that purpose they are useless (Crowther et al 1989). However, in regions with a high prevalence of HIV and hepatitis B and C virus protective clothing is useful to protect the caregiver from contact with contaminated blood and other materials (WHO 1995).

WHO has established the contents of a clean delivery kit and its correct, effective use (WHO 1994a). The programmes already in place to advocate the positive effect of the use of the “three cleans” (hands, perineal area, umbilical area) need to be maintained or expanded. The contents of the clean delivery kit may vary from country to country, but they must fit the specific needs of the women giving birth and be easily obtainable at every street corner and in all remote regions of a country. These simple but effective kits can even be assembled at home and include a new, sterile razor blade for the umbilical cord. The clean delivery kit itself and its contents should indeed be clean and need not be sterilized. The disposable materials in the kit should not be reused.

Instruments destined to be reused should be decontaminated appropriately according to guidelines provided by WHO (1995). Equipment which comes into contact with intact skin can be washed thoroughly, instruments which come into contact with mucous membranes or non-intact skin should be sterilized, boiled or chemically disinfected, and instruments which penetrate the skin should be sterilized. These methods serve to prevent the contamination of women and caregivers.

Some measures should be taken during all deliveries, to prevent possible infection of the woman and/or the birth attendant. These measures include the avoidance of direct contact with blood and other body fluids, by the use of gloves during vaginal examination, during delivery of the infant, and in handling the placenta. It is important to reduce the potential for infection by keeping invasive techniques such as episiotomy to the strict minimum and taking additional care with the use and disposal of sharp instruments (for instance during suturing) (ICN 1996).