PCOG CPG - Normal Labor and Delivery

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

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CLINICAL PRACTICE GUIDELINES on NORMAL LABOR and DELIVERY !

Second Edition, November 2009

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

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

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CLINICAL PRACTICE GUIDELINES on NORMAL LABOR and DELIVERY

Second Edition, November 2009

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

FOREWORD

! 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

INTRODUCTION

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

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 Imelda O. Andres, MD Cecilia Joyce M. Bascarra, MD Mayumi S. Bismark, MD Ricardo R. Braganza, MD Sylvia A. Carnero, MD Virgilio B. Castro, MD Lyra Ruth Clemente-Chua, MD Maria Lourdes B. Coloma, MD Godofreda V. Dalmacion, MD Ditas Cristina D. Decena, MD Santiago A. del Rosario, MD Rey H. Delos Reyes, MD Virginia R. de Jesus, MD Arcangel N. Diamante, MD

Rommel Z. Dueñas, MD Joseline A. Ferrolino, MD Ma. Corazon N. Gamilla, MD Erlinda G. Germar, MD Ma. Antonia E. Habana, MD Myrna R. Habaña, MD Bernardita B. Javier, MD Milagros T. Jocson, MD Lilia P. Luna, MD Augusto M. Manalo, MD Diosdado V. Mariano, MD Jocelyn Z. Mariano, MD Christia S. Padolina, MD Mildred N. Pareja, MD Wilhelmina Pineda, MD

Regional Directors Ellen A. Manzano, MD (Region 1) Melchor C. dela Cruz, MD (Region 2) Concepcion P. Aronza, MD (Region 3) Ernesto S. Naval, MD (Region 4) Rowena M. Auxillos, MD (Region 4A) Cecilia Valdes-Neptuno, MD (Region 5)

Patria P. Punsalan, MD Ma. Carmen H. Quevedo, MD Rebecca M. Ramos, MD Cristina C. Raymundo, MD Rosendo R. Roque, MD Marilyn D. Ruaro, MD Ma. Socorro M. Solis, MD Sherri Ann L. Suplido, MD Walfrido W. Sumpaico, MD Carmencita B. Tongco, MD Ma. Victoria Torres, MD Milagros P. Torres, MD Ma. Trinidad R. Vera, MD Ma. Guadalupe N. Villanueva, MD

Evelyn R. Lacson, MD (Region 6) Belinda N. Pañares, MD (Region 7) Realino G. Molina, MD (Region 8) Suzette S. Montuno, MD (Region 9) Jana Joy R. Tusalem, MD (Region 10) Amelia A. Vega, MD (Region 11)

DISCLAIMER, RELEASE AND WAIVER OF RESPONSIBILITY

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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 ……………………………………………………………….. 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

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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 3rd 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 20th 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 1960’s, 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 1st stage of labor and every 5 minutes in the 2nd 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 Confirmation of Term Gestation (ACOG Practice Bulletin #230, November 1996) • • •

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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.

presentation Bishop’s score

Table 1. Bishop’s Preinduction Cervical Score System FACTOR Cervical Dilatation (in cm) Cervical Effacement (%) Station Cervical Consistency Cervical Position

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SCORE 0 closed

1 1-2

2 3-4

3 !5

0-30

40-50

60-70

>80

-3 Firm Posterior

-2 Medium Midposition

-1 Soft Anterior

+1,+2

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.

Induction is indicated when the continuance of pregnancy may no longer be advisable in the following clinical circumstances: 1. 2. 3. 4. 5. 6. 7. 8.

9.

Gestational hypertension Preeclampsia, eclampsia Prelabor rupture of membranes Maternal medical conditions (e.g., diabetes mellitus, renal disease, chronic hypertension) Gestation ! 41 + 1/7 weeks Evidence of fetal compromise (eg, severe fetal growth restriction, isoimmunization) Intraamnionic infection Fetal demise Logistic factors for term pregnancy (e.g., history of rapid labor, distance from hospital, psychosocial indications)! Contraindications for Labor Induction

1. 2. 3. 4. 5. 6. 7. 8.

Malpresentations (e.g., transverse, breech) Absolute cephalopelvic disproportion Placenta previa Previous major uterine surgery or classical cesarean section Invasive carcinoma of the cervix Cord presentation Active genital herpes Gynecological, obstetrical, or medical conditions that preclude vaginal birth 9. Obstetrician’s convenience!

o Assess cervical ripening with the use of Bishop’s 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

o o o

o o o o o o

produce cervical change and fetal descent while avoiding uterine hyperstimulation and fetal compromise. It is recommended that oxytocin be ordered and recorded in milliunits (mU)/minute. Oxytocin should be delivered through a secondary intravenous (IV), piggy-backed to the main IV line as close to the venipuncture site as possible. 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). 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). 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). Regular observations of uterine contractions and fetal heart rate should be recorded every 15 to 30 minutes and with each incremental increase of oxytocin. Continuous intrapartum electronic fetal monitoring is recommended when oxytocin is being used for induction of labor. 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. If restarting the oxytocin, it may be necessary to lower the dosage and lengthen the interval between subsequent increases. 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

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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

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.

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 membranes19, 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 40th and 41st week of antenatal visit of nulliparous women, and at the 41st 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, O’Brien 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, Gülmezoglu 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 women’s 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 acidpulmonary-aspiration syndrome (Mendelson’s syndrome). Lancet 1966;1:288-291. 3. Tettambel MA. Preoperatvie use of antacids to prevent Mendelson’s 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 & Women’s 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 Friedman’s labor curve (Figure 1), or the WHO partogram (Figure 2). (Level 2, Grade B) Figure 1: Friedman’s Curve

The FriedmanÕ s Curve (Dilatational and Descent)

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, Friedman’s Curve) 1. Cervical effacement and dilation (straight lines below) 2. Fetal descent through the birth canal

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 Friedman’s 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.

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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, 2nd 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.

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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 parturient’s 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 spinal–epidural (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 patient’s 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 doesn’t 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 progress4 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 mother’s 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 positions—a 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 factors1: 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 Women’s 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 operator’s 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 2nd 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, 3rd edition 2006 7. Williams MC, Knuppel RA, O’Brien 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 22nd 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 sutured1 - Less dyspareunia at 6 weeks2 - Similar wound breakdown profile as chromic rarely requires late removal3 - Earlier resumption of sexual intercourse4 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. 2. 3. 4. 5.

Kettle, C. et al., Lancet 2002 June 29; 359(9325):2217-23. McElhinney, et al., Episiotomy repair: vicryl versus vicryl rapide. Ulster Medical Journal 2000. Greenberg JA, et al. Obstetrics and Gynecology 2004; 103(6):1308-13. Leroux N, Bujold E. AJOG 2006 Jun. 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 3rd 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 3rd 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 (20”u”/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 3rd 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 Children’s 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: 1035–1039. 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 disease who have a negative test result.

the