Guidelines on 8 key evidence

based practices during

labour
 Preface
Maternal mortality and morbidity and perinatal mortality are major public health problems in
India. It has long been recognized that majority of perinatal deaths have intrapartum origin and
result as a consequence of interventions carried out around the time of delivery.

Over the last few decades a lot of research has been carried out to assess the effectiveness of
interventions in labour and delivery. It has been found that many interventions

Recent decades have seen a rapid expansion in the development and use of a range of practices
designed to start, augment, accelerate, regulate or monitor the physiological process of labour,
with the aim of improving outcomes for mothers and babies, and sometimes of rationalising
work patterns in institutional birth. In the last few decades, questions are increasingly raised to
the value or desirability of such high levels of intervention. In 1996, a technical working group
of the World Health Organization (WHO) made a number of recommendations based on a
similar range of practices (Care in normal birth: a practical guide, WHO 1996). Cochrane
Collaboration uses scientific methods to determine which practices, drugs or procedures are
best for treating diseases. It also examines practices during labor and delivery and examines
which practices are best for women and newborns. Reproductive health library has compiled
evidence on most of these practices. As a result of this research on evidence based care, modern
labor and delivery care has undergone some dramatic changes over the last couple of decades.

In 2005, Government of India developed guidelines for doctors and ANMs/ LHVs on care
during antenatal period, labour and delivery and postpartum period. These guidelines are in
accordance with evidence based practices. Despite this, and despite the rapidly increased
emphasis on the use of evidence-based medicine, many of these practices remain common,
without due consideration of their value to women or their newborns. Many providers continue
to use a range of unhelpful, untimely, inappropriate and/or unnecessary interventions, all too
frequently poorly evaluated.

This guideline aims to examine the evidence for or against some of the commonest practices
and to establish recommendations, based on the best available evidence. This guideline gives
recommendations on those interventions which are or should be used to support the processes
of normal birth. There are many variations across institutions in the quality of care, the
sophistication of services available and the status of the provider for normal birth.

This guideline examines the evidence for 8 key practices in labour-delivery care:
1. Augmentation of labour
2. Routine episiotomy
3. 24 hour discharge
4. Active management of third stage of labor (AMTSL)
5. Monitoring of labour and partograph
6. Position for delivery
7. Breastfeeding < 1 hour
8. Drying & wrapping of newborn
 1. Augmentation of labour

Q 1. What is augmentation of labour?

A 1. Stimulation of uterus during labour to increase the frequency, duration and strength of
contractions1 when spontaneous contractions are considered inadequate

Q 2. What are the indications for augmentation of labour?

A 2. Augmentation of labour using oxytocin or misoprostol is a major obstetric intervention

and should be performed only for a valid indication such as crossing the action line on a WHO
approved partogram and failure to progress in cervical dilatation or fetal descent.

Q 3. At what level of facility can augmentation of labour be carried out?

A 3. As a rule, oxytocin or misoprostol should only be used to augment labour in facilities
where Caesarean section can be performed should the need arise2.

Q 4. What should be done if there is a need to augment labour at a lower level facility where
caesarean section is not available?

A 4. The need for augmentation in a lower level facility is considered an indication for referral
to the higher level where surgical facilities are available.

Q 5. How often is labour augmented?

A 5. Studies from Rajasthan show that augmentation of labour is very common and is used in
about 90% of institutional deliveries. There is evidence that IM oxytocin is used in deliveries in
PHCs, subcentres and homes3.

• In recent years, many providers have started using misoprostol to augment labor.
• Currently, augmentation of labor is being performed at all levels of health system –
medical colleges, district hospitals, CHCs, PHCs, subcentres and even homes. Although
medical colleges and district hospitals have more equipment, funding, staffing and
specialist, they are often overcrowded and staff may not have time to monitor fetal heart
sounds frequently. Conversely, at lower levels of health system,

1 World Health Organization. Managing complications in pregnancy and childbirth: A

guide for midwives and doctors. . 2003.
2Lovold A, Stanton C. Use of oxytocin and misoprostol for induction or augmentation of labor in low
resource settings: A working paper review for the POPPHI project, PATH, Washington DC. Department
of Population, Family and Reproductive Health. The Johns Hopkins Bloomberg School of Public Health.
Baltimore, Marland. March 6, 2008.
3 Iyengar SD, Iyengar K, Martines JC, Dashora K, Deora KK. Childbirth practices in rural Rajasthan,
India: implications for neonatal health and survival. J Perinatol 2008;28 (Suppl 2):S23-30
Q 6. Why do doctors augment labour?

A 6. Many doctors augment labour routinely, even when the progress of labour is satisfactory.
In fact, one study has found that very often oxytocin drip is started as soon as the patient arrives
i.e. without giving any chance for normal progression of labour. Discussions with some such
doctors revealed that they believe that:
• It is better to augment labor, families also want it
• You can wait in ideal situations, but with so much caseloads, it is not practical….
• There is no harm with augmentation
• Shorter duration of labour is better

Q 7. What does research show about side effects of augmentation?

A 7. The research from low resource countries shows that with induction or augmentation,
there is higher risk of fetal distress4 5and perinatal mortality6. Dujardin and colleagues reported
the risk of stillbirth and neonatal resuscitation associated with the use of oxytocin during
normal labor from 3 countries. Their results showed an increased relative risk of 1.9 fir stillbirth.
• A group of studies reviewing cases of rupture uterus found induction or augmentation
associated with 2-44% cases of rupture uterus7.8 91011
• Side effects of misoprostol include painful labor and uterine hyperstimulation (2% rate).
The fetal heart rate should be monitored and IV oxytocin should not be started until at
least 6 hours after the last dose of misprostol12. 13

4 Gdlantz JC Elective inductions vs. spontaneous labor: Association and outcomes. Journal Of
Reproductive Medicines for the obstetrician and Gynecologist.2005[ cited 16 October 2007]; 50(4): 235-40
5 Cammu H, Martens G, Amy J- Outcome after elective labor induction in nulliparous women: A matched

cohort study. American journal of Obstetric and gynecology,.2006

6 Dujardin B, Bousten M, De Schampheleire I, Kulker R, manshande JP, Bailey J, et al ; oxytocin in

developing countries: Int J Gynecology and Reproductive Biology.2005 [ cited 16 October 2007] ; 122 (1) :
40-4.
7 Ebeigbe PN, Enabudoso E, Ande ABA. Ruptured uterus in a nigerian community: Astudy of

sociodemographic and obstetric risk factors. Acta Obstetricia et Ginecológical candinavica. 2005 [cited 10
December 2007];84(12):1172-4.
8 Ekele BA, Nnadi DC, Gana MA, Shehu CE, Ahmed Y. Misoprostol use for cervical ripening and

induction of labor in a nigeian teaching hosptial. Niger J Clin Pract. 2007;10(3):234-766

9 Konje JC, Odukoya OA, Lapido OA. Ruptured uterus in ibadan - A twelve year review. International

Journal of Gynecology and Obstetrics. 1990 [cited 21 December 2007];32(3):207-13.

10 Allahbadia G, Ambiye V, Vaidya P. Unconventional use of oxytocin. Journal of the

Indian Medical Association. 1993 [cited 16 October 2007];91(2):40-1.

11 Chuni N. Analysis of uterine rupture in a tertiary center in eastern nepal: Lessons for obstetric care.

Journal of Obstetrics and Gynaecology Research. 2006 [cited 10 December 2007];32(6):574-9.

12 Sanchez-Ramos L, Kaunitz AM. Misoprostol for cervical ripening and labor

induction: A systematic review of the literature. Clinical Obstetrics and Gynecology.2000 [cited 10
December 2007];43(3):475-88.
13 Lin C, Raynor BD. Risk of uterine rupture in labor induction of patients with prior cesarean section:

An inner city hospital experience. Am J Obstet Gynecol. 2004 May;190(5):1476-8.

The labeling information of USFDA14 on use of misoprostol says “Cytotec can induce or
augment uterine contractions………….A major adverse effect of the obstetrical use of cytotec is
hyperstimulation of the uterus which may progress to uterine tetany with marked impairment
of uteroplacental blood flow, uterine rupture (requiring surgical repair, hysterectomy, and/or
salpingo-oophorectomy), or amniotic fluid embolism. Pelvic pain, retained placenta, severe
genital bleeding, shock, fetal bradycardia, and fetal and maternal death have been reported.
There may be an increased risk of uterine tachysystole, uterine rupture, meconium passage,
meconium staining of amniotic fluid, and cesarean delivery due to uterine hyperstimulation
with the use of higher doses of Cytotec; including the manufactured 100 mcg tablet. The risk o0f
uterine rupture increases with advancing gestational ages and with prior uterine surgery,
including Cesarean delivery. Grand multiparity also appears to be a risk factor for uterine
rupture………

Q 8. What are the safe methods to shorten the duration of labor?

A 8. Safe methods depend on the level of facility and availability to staff to monitor labor
frequently. In a facility where sufficient staff to monitor labor is available and caesarean section
can be performed, following methods are considered safe:
• Low dose oxytocin given in an IV drip
• Misoprostol
Use of intramuscular oxytocin before the birth of infant is considered dangerous because the
dosage is too high and cannot be adapted to the level of uterine activity15 . Hyper-stimulation of
uterus may result and can lead to uterus rupture, fetal asphyxia or fetal demise16.
17

• Non pharmacological methods are effective in some cases. They include:

– Ambulation during first stage of labor18 which reduces the need for oxytocin
without increasing duration of labor
– Presence of a supportive companion, which is associated with striking reduction
in duration of labor19
– Sweeping of membranes20

14 American college of obstetricians and gynecologists (2003). New US Food and Drug administration
labeling on Cytotec (misoprostol) use and pregnancy (committee opinion No 283). Washington DC.
15 World Health Organization. Managing complications in pregnancy and childbirth: A

guide for midwives and doctors. . 2003.

16 Zheng QL, Zhang XM. Analysis of 39 cases of maternal deaths caused by incorrect

use of oxytocin. Zhonghua fu chan ke za zhi. 1994 [cited 10 December 2007];29(5):276,277, 316.
17 Konje JC, Odukoya OA, Lapido OA. Ruptured uterus in ibadan - A twelve year review. International

Journal of Gynecology and Obstetrics. 1990 [cited 21 December 2007];32(3):207-13.

18 Hemminki E, Lenck M, Saarikoski S, Henriksson L. Ambulation versus oxytocin in

protracted labour: A pilot study. European Journal of Obstetrics Gynecology and Reproductive Biology.
1985 [cited 11 December 2007];20(4):199-208.
19 Klaus MH, Kennell JH, Robertson SS, Sosa R. Effects of social support during

parturition on maternal and infant morbidity. British Medical Journal. 1986 [cited 11 December
2007];293(6547):585-7.
20 Boulvain M, Stan C, Irion O. Membrane sweeping for induction of labour. Cochrane

database of systematic reviews (Online). 2005 [cited 26 November 2007](1).

Q 9. What is the recommendation about augmentation of labour?
A 9. Safe methods depend on the level of facility and availability to staff to monitor labor
frequently. In a facility where sufficient staff to monitor labor is available and caesarean section
can be performed, following methods are considered safe:
• Low dose oxytocin given in an IV drip
• Misoprostol
Hence, in facilities such as PHC or subcentre, labor should not be augmented.
In CHCs or district hospitals or medical colleges labor can be augmented only if the facility can
conduct caesareans in the same facility and there is sufficient staff to monitor labor.
2. Routine episiotomy

Q 1. How often is episiotomy given for primigravidas in institutional deliveries?

A 1. One quantitative survey from Rajasthan21 shows that episiotomy for primigravidas was
used in nearly 75% of district level government hospitals, 52% in district level private hospitals,
32% of CHCs & PHCs and 9% of subcentres and other village level facilities (See figure *).

Episiotomies by institutions

90.0%
80.0%
70.0%
60.0%
50.0% First delivery
40.0% Subsequent deliveries
30.0%
20.0%
10.0%
0.0%
PHC/CHC Govt district City Pvt SC,
(n=374) hospital hospital unqualified,
(n=217) (n=44) pvt clinic
(n=36)

2. Beliefs and research evidence about routine episiotomy

a. Belief: “A clean cut is better than a ragged tear”. “It has long term benefits for preserving
perineal integrity.
Reality: In a large study undertaken in Canada, women were followed up 3 months postpartum
to investigate pelvic floor functioning and compare those who had an episiotomy and those
who had a tear and those with intact perineum22. Results sowed that women regardless of
parity, wit the intact perineum ad the best pelvic floor functioning at 3 months postpartum.

b. Episiotomies will reduce the incidence of 3° tears”

Reality: If a woman does not have an episiotomy, she is likely to have no tear or a small tear.
Women who have no episiotomies hardly ever suffer deep tears23, 24, 25, 26. The above study in

21.Iyengar S.D, Iyengar K., Suhalka V. and Agarwal K: Comaprison of Domiciliary and Institutional
Delivery-care Practices in Rural Rajasthan, India; J HEALTH POPUL NUTR 2009 April 27(2);303-312
22 Klein Gauther (somp p 36)
23 Thorb JM and Bowes WA. Episiotomy: can its routine use be defended? Am J Obset Gynecol 1989;160

(5 Pt 1): 1027-1030
24 Thacker SB and Banta HD. Benefits and risks of episiotomy: an interpretive review of the English

language and literature, 1860-1980.Obset and Gynecol surv 1983; 38(6) : 322-338.
25 Hofmeyr GJ and Sonnedecker EW. Elective episiotomy in perspective. S Afr Med J 1987; 71(6) : 357-359.
Canada also found that primigravida women who ad a normal vaginal delivery wit episiotomy
were more at risk of having third or fourth degree tears27. Deep tears are usually extensions of
episiotomies. It has been suggested tat women who give birth in units were there is strict policy
for routine episiotomy are more at risk of third and fourth degree tears, in comparison to
women who give birth in units were episiotomy use is restricted28, 29.

b. Belief: “A clean incision easier to repair”. “Episiotomy heals better than a tear in
perineum”
Reality: Episiotomies are not easier to repair than tears.

c. Belief: “By preventing overstretching of pelvic floor muscles, episiotomies prevent pelvic
floor relaxation. Pelvic floor relaxation causes sexual dissatisfaction after childbirth, urinary
incontinence and uterine prolapse”.

Reality: Episiotomies do not prevent relaxation of pelvic floor muscultature. Therefore, they
do not prevent urinary incontinence or improve sexual satisfaction.30

• Nobody has ever explained how cutting a muscle and stitching it back preserves its strength
• Episiotomy is generally done until head is almost read to be borne. By then, pelvic floor
muscles are already fully distended.

d. Belief: It averts brain damage by lessening the pounding of the head on the perineum31
(Human labour and birth, 1986, Oxorne, Foote)

Reality: Episiotomies do not prevent birth injuries or fetal brain damage.

A woman’s perineum is soft, elastic tissue, not concrete. There is no evidence that an episiotomy
protects fetal neurological wellbeing32,33, 34.

e. Belief: “Episiotomy should be routinely used especially for primigravidas. “

26 Bromberg MH. Presumptive maternal benefits of routine episiotomy. J Nurse Midwefry 1986; 31 (3):121-
127
27 Klein MC, Gauthier RJ, Robbins JM, Kaczorowski J, Jorgensen SH, Franco ED, Johnson B, Waghorn K,

Gelfand MM, Guralnick MS, et al. (1994) Relationship of episiotomy to perineal trauma and morbidity,
sexual dysfunction, and pelvic floor relaxation. Br J obstet Gynecol 1994; 171 (3): 591-598
28 Anthony S, Buitendijk SE, Zondervan KT, van Rijssel EJ, Verkek PH (1994) Episiotomies and the

occurance of several perineal lacerations. Br J Obstet Gynaecol 1994; 101 (12): 1064-1067
29 Sleep JM, Grant A, Garcia J, Elbourne D, Spencer J, Chalmers I (1984) West Berkshire peineal

management trail. BMJ 1984; 289: 587-590

30 Sleep J and Grant A. West Berkshire perineal management trails: Three year follow up. Br Med J

1987;32 (3):181-183. (mediolateral)

31 Williams obstetrics, 10th edition, 1950
32 Lobb MO, Duthie SJ, and Cooke RW. The influence of episiotomy on the neonatal survival and

incidence of periventricular haemorrhage in very-low-birth-weight infants. Eur J Obstet Gynecol repord Biol
1986;22 (1-2): 17-21.
33 The TG. Is routine episiotomy beneficial in the low birth weight delivery? Int J Gynaecol Obstet

1990;31(2)135-140
34 Woolley RJ (1995) Benefits and risks of episiotomy: a review of the English-language literature since

1980 Part II. Obstet Gynecol Surv 1995; 50 (11) : 821-835

Reality: There are many complications associated with episiotomy35. These are:
8 More posterior perineal trauma & more risk of 3rd and 4th degree tears
8 More suturing needed
8 More severe vaginal trauma,
8 Blood loss,
8 Perineal pain,
8 Perineal infection,
8 Dyspareunia,
8 Psychological trauma
8 Similar fecal and urinary incontinence
There is no evidence to support the practice of routine episiotomy for primigravidas.

f. Belief: Episiotomy is a harmless procedure:

Reality: Like any surgical procedure, episiotomy carries a number of risks: excessive blood loss,
haematoma formation and infection.

• Episiotomies increase blood loss.

• Wound infections and abscess rates vary between 0.5-3%36. Extremely rarely, gangrenous
infections can occur known as ‘necrotising fascitis, clostridial myonecrosis); these
infections are fatal unless surgically treated (Ewing, Smale and Eliot 1979).
• There is no evidence that: routine episiotomy reduces the risk of severe perineal trauma,
improves perineal healing, prevents fetal trauma or reduces the risks of stress urinary
incontinence37.
• Episiotomies may cause prolonged pain , especially pain during intercourse.

g. Belief: The 2nd stage is prolonged if you don’t give episiotomy.

Reality: Research as sown tat delivery in the squatting or other upright positions can reduce the
amount of damage to the perineum. In upright positions, there is better positioning of the fetal
head on the perineum and shorter second stage of labor. The lithotomy position increases the
need for episiotomy probably because the perineum is tightly stretched. 38

3. What are the factors associated with less perineal trauma?

35 Carroli and Belizan 2000. Wooley 1995, Argentine Episiotomy trial collaborative group 1993, Eason et
al 2000; Sleep, Grant et al, 1984, WHO 1999.
36 Thacker SB and Banta HD. Benefits and risks of episiotomy: an interpretive review of the English

language and literature, 1860-1980. Obset Gynecol Surv 1983; 38 (6): 322-338.
37 Sleep, Robert and Chalmers, Challenging Obstetric Orhodoxy in the UK : 1989, 109
38 Nodine PM and Roberts J. Factors associated with perineal outcome during childbirth. J Nurse

Midwifery 1987 May-June; 32 (3): 123-130.

Answer: Review of the literature to learn which factors influenced perineal outcomes has found
that most important factors associated with less perineal trauma are 39,40:

1. Restricted use of episiotomy: (Systematic Review of 6 RCTs). Restrictive use

results in: less posterior trauma, less suturing, fewer healing complications
but more anterior trauma.
2. Delivery in squatting or upright positions
3. Operative vaginal delivery: Use of vacuum extraction v/s forceps
4. Method of pushing
5. Epidural anaesthesia

4. What is the current recommendation about episiotomy?

“Routine” episiotomy should be

abandoned41. Limiting the use of episiotomy
is strongly recommended to help protect the
integrity of the perineum42.

There is insufficient evidence to evaluate if

there are any indications for the use of
episiotomy. Till more research is generated, it
should be considered only for certain
conditions e.g.
• Assisted delivery (forceps or vacuum)
• Preterm delivery
• Breech delivery
• Predicted macrosomia
• Presumed imminent tears (threatened 3rd
degree tear or history of 3rd degree tear
with previous delivery degree tear or
history of 3rd degree tear

39 Flynn P, Frankiek J, Janssen P, Hannah WJ, Klein MC (1997) How can second stage management
prevent perineal trauma? Critical review. Can Fam Physician 1997; 43(1): 73-84
40 Preventing and Treating Perineal Damage in Childbirth: Best Evidence Approaches. Valerie J. King,

MD, MPH. OHSU Department of Family Medicine ...October 2005: (presentation downloaded; July
13,2009) www.ohsu.edu/son/news/MidwiferyGrndRnds-Perineum-10-05.ppt
41 Liljestrand J. Episiotomy for vaginal birth: RHL commentary (last revised: 20 October 2003). The

WHO Reproductive Health Library; Geneva: World Health Organization.

42World Health Organization. Standards of Midwifery Practice for Safe Motherhood. Volume 3: Notes on
advances in Practice. New Delhi: WHO, SEARO, 1999.
 3. Upright position for delivery
Q 1. How often is delivery carried out in lithotomy/ dorsal position in institutional
deliveries?

Answer: Majority of providers conduct delivery in dorsal or lithotomy position. One study in
which 87 providers from various levels of institutions in 29 districts of Rajasthan were
interviewed, 93% said that they prefer to conduct delivery in lithotomy or dorsal position43.

Q 2. What are the traditional beliefs and research evidence about dorsal/ lithotomy
position?

Belief: Supine position (dorsal/ lithotomy position) is better for mother and baby. Provider can
conduct pelvic examinations and episiotomy in this position.
Reality:
1. Use of upright position compared with supine or lithotomy position is associated
with:44,45
8 Shorter second stage of labor
8 Fewer assisted deliveries
8 Fewer episiotomies
8 Fewer reports of severe pain
8 Less abnormal fetal heart rate patterns

2. In a review of 17 randomised control trials evaluating the effect of woman’s position in

labor and delivery, it was concluded that woman who adopt an upright position are less
likely to report less discomfort and intolerable pain, to report that bearing down was
less difficult, to experience a shorter second stage of labor (in the absence of oxytocin
augmentation) and to have more chances of spontaneous birth with fewer perineal and
vaginal tears and better apgar scores at 1 and 5 minutes46, 47.
3. Supine position has many disadvantages for both mother and baby. Due to aortocaval
compression, it can cause fetal distress, and progressive acidosis of baby. In the mother,

43 Prem S. Rapid assessment of labor and delivery practices in government institutions of Rajasthan
(unpublished). Action Research and Training for Health. 2009.
44 Lavender T and Mlay R. Position in the second stage of labour for women without epidural

anaesthesia: RHL commentary (last revised: 15 December 2006). The WHO Reproductive Health Library;
Geneva: World Health Organization.
45 Gupta JK and VC Nikodem. 2000. Woman’s position during second stage of labour (Cochrane Review),

in The Cochrane Library. Issue 4. Update Software: Oxford.

46 Nikodem VC (1995) Upright versus recumbent positions during second stage of labour. In: Enkin M,

Keirse MJNC, Renfrew MJ, Neilson JP (eds.) Pregnancy and childbirth module of the Cochrane Database of
Systematic Reviews; Issue 2.published through BMJ Publishing, London
47 McCandish R(1997) Care during the second stage of labour. In: Alexander J, Levey V, Roth C (1997)

Midwifery Practice: Core Topics 2. London: Macmillan

 the supine position is associated with slower progress of labor, more painful
contractions and greater perineal trauma.484950
4. There is less pain, less vaginal trauma & improved fetal outcome with other positions
5. Women who adopt an upright position for delivery have better birth outcomes

Belief: Provider cannot give and stitch episiotomy unless the woman is in dorsal position.
Reality: Episiotomy should not be routinely used for all women. Delivery in upright positions is
associated with less perineal damage.

Belief: Providers can’t guard the perineum in upright positions

Reality: A multicentric randomized trial on guarding the perineum (protecting the perineum
wit the hand), as opposed to hands off the perineum has not demonstrated a need to guard the
perineum51.

Belief: Women can push baby better in dorsal position.

Reality: Women can push the baby better in upright positions.

Q 3. What is the recommendation about position in 2nd stage of labour?

A 3. Lithotomy position should not be used routinely for delivery and should be abandoned.5253

Q 4. What are the alternate positions?

A 4. There are many upright positions like shown in picture below. Squatting in particular has
been found to be a very useful position. There is radiological evidence that in the squatting
position, there is some separation of the lower end of the symphysis pubis and results in 28%
increase in the area of the pelvic outlet54.

48 Kurtz CS, Schneider H, Huch R, Huch A(1982) The influence of maternal position on the foetal
transcutaneous oxygen pressure(tO). J Perinat Med 1982; 10 (suppl 2): 74-75
49 Caldeyro- Bracia R (1979) The influence of maternal bearing down efforts during second stage of

labour on foetal well being. Birth Fam J 1979; 6(1): 17-21

50 Roemer VM, Harms K, Buess H, Horvath TJ (1976) Response of Foetal acid-base balance to duration of

second stage of labour. Int J obstet Gynaecol 1976; 14: 712-715.

51 HOOP collaborative study trial

52 Gupta JK, Hofmeyr GJ, Smyth R. Position in the second stage of labour for women without
epidural anaesthesia (Cochrane Review). The Cochrane Database of Systematic Reviews;2004, Issue
1.

54 Sweet 1997, Nelki 1995, Vedam 1993

Alternative positions for delivery

lgjk ysdj cSBs gq,

Q 5. How is it practical to deliver in upright positions?

A 4. Persuading staff to abandon the use of lithotomy and dorsal position may be difficult,
because:
• it is the common practice in most institutions and those providers who try alternate
positions may be ridiculed by their colleagues and supervisors.
• Most doctors and nurses have become accustomed to conduct delivery in certain positions
and find it difficult to consider other positions.
• Many women have started believing that hospital delivery means delivering in supine
positions, hence they do not request other positions. They might feel afraid about asking
to deliver in other positions. Therefore it is important that doctors and nurses explain to
the women the benefits of using different positions in labor and for childbirth and
support them in using these positions.
• Most labour rooms have been equipped wit delivery tables designed for lithotomy
position. Some labour rooms will have to invest in new delivery tables. However,
everyone need not wait for a new labour table to arrive.
o Many tables allow women to sit with back support, or squat at least for some
time during the 2nd stage.
o Reducing the height of labor table will allow women to feel more confident about
assuming alternate positions.
o Special beds are not essential and local ordinary beds can be used effectively.
o To begin with, providers can allow women to adopt upright positions in early
second stage of labor and only at the time of delivery, have women in
semisupine positions with back support.

If doctors and nurses are willing to change their old habits, it is certainly possible to conduct
delivery in non supine positions.

Just like a bedridden person finds it difficult to pass stools in a supine position, and find it
easier if they can sit or squat, a woman also finds it easier to push the baby when she is in a
upright position. Providers should try to allow women to sit/ squat or assume oter positions in
which they feel comfortable.
 4. Active Management of 3rd stage of labour

Q 1. To what extent does postpartum haemorrhage contribute to maternal mortality?

A 1. Postpartum hemorrhage is the excess blood loss after the birth of the baby. In India, PPH is
responsible for 38% of maternal deaths55. However, many women who survive of postpartum
haemorrhage, develop longterm morbidity, especially severe postpartum anemia56 (hemoglobin
less than 7 g%). It is estimated by WHO that the incidence of severe postpartum haemorrhage is
10.5 per 100 live births (46).

Q 2. Why does PPH occur?

In order to understand why the PP occurs, it
is important to understand the
characteristics of third stage.
• After childbirth the muscles of the
uterus contract and placenta begins to
separate from the uterine wall.
• The amount of blood lost depends on
how quickly this occurs.
• If the uterus does not contract
normally the blood vessels at the
placenta site do not adequately
contract and severe bleeding results.
• Uterine atony accounts for 70-90% of
cases of PPH.

Risk factors of uterine atony: There are many risk factors for uterine atony such as multiple
pregnancy, multiparity, prolonged labor, augmented labor, episiotomy, general anesthesia,
placenta previa, abruption etc. However it is important to remember that up to 90% of women
who experience PPH have no identifiable risk factors.

Q 3. How can PPH be prevented?

A 3. Most important ways to prevent PPH are:
• Active management of third stage of labor
• Restricting Episiotomy
• Infection prevention practices

Q 4. What is active management of 3rd stage of labour?

A 4. Active management of 3rd stage of labour (AMTSL) involves 3 steps after delivery of baby:
1. Uterotonic drug given immediately after birth of baby
2. Placenta delivered by controlled cord traction with counter-traction on the fundus
during contraction

55
Registrar General of India. Sample registration system. Maternal mortality in India: 1997-2003: trends, causes and
risk factors. New Delhi: Registrar General of India, 2006. 29 p.
56 Dolea C, Abou Zahr C, Stein C. Global burden of maternal hemorrhage in the year 2000. Evidence and

information for policy, World health Organization, Geneva, 2003.

 3. Fundal massage after delivery of the placenta

Q 5. What is the common practice about management of 3rd stage of labor?

A 5. Research from Rajasthan shows that only after 43% of institutional deliveries, women were
given injections57. Even when used, the drug more commonly used is methylergometrine. All
components of AMTSL are not followed.

Research from other parts shows that although 94% obstetricians use oxytocics after delivery,
only 14.8% use it before delivery of placenta58.

Q 6. What does research show about management of 3rd stage of labor?

A 6. Many trials have been conducted which have compared active and physiological
management of labor. Two well known trails (Bristol trial and Hinchingbrooke Trial) have
found that the risk of PPH is 1/3rd when active management is used (table *).

Active Management Physiologic OR and 95% CI

Management
Bristol Trial59 50/846 (5.9%) 152/849 (17.9%) 3.13 (2.3-4.2)

Hinchingbrooke Trial60 51/748 (6.8%) 126/764 (16.5%) 2.42 (1.78-3.3)

These and other studies61 have concluded that active management of the third stage of labor has
following advantages:
• reduces the risk of PPH:
• reduces the need of blood transfusion
• reduces the incidence of prolonged third stage
• reduces the incidence of maternal anaemia
There are no apparent adverse effects on the baby.

The use of oxytocin halves the risk of PPH of >500 ml of blood loss and decreases the risk of
severe PPH (blood loss >1000 ml) compared with placebo/no uterotonics. These results are

57Iyengar SD, Iyengar K, Suhalka V, Agarwal K. Comparison of domiciliary and institutional

delivery care practices in rural Rajasthan, India. Journal of Health Population and Nutrition,
2009; 27(2): 303-312
58Dolea C, Abou Zahr C, Stein C. Global burden of maternal hemorrhage in the year 2000. Evidence and
information for policy, World health Organization, Geneva, 2003.
59 Prendiville et al. 1988. The Bristol third stage trial: active versus physiological management of
the third stage of labor. BMJ 297:1295–1300.
60 Rogers J et al. 1998. Active versus expectant management of third stage of labour: The

Hinchingbrooke randomised controlled trial. Lancet 351(9104): 693–699.

61Sanghvi Harshad Stephenson: Patricia Preventing Mortality From Postpartum Hemorrhage: MAQ
2004 Mini University; May10, 2004 www.maqweb.org/.../Preventing%20Post%20partum%20hem-
H.%20Sanghvi-P.%20Stephenson.ppt
consistent even if oxytocin is used as part of the active management approach or on its own
without other components of active management.62

A WHO multicentre trial in 9 hospitals across 9 countries63 (MISO trial) found that the incidence
of PPH (defined as blood loss > 1000 ml) within 1 hour postpartum was as follows:
• 2.85% in those who were actively managed using oxytocin
• 5.7% in those with expectant management by skilled birth attendant

A Cochrane review demonstrated that the blood loss within 24 hours with active management
is 33% of results in blood loss.

Maternal Outcomes of AMTSL trials

McMormick, Sanghvi, Kinzie, McIntosh, IJGO200364

30

20
Percent

10

0
Transfusion Prolonged Third Therapeutic Low Retained
Stage Uterontonic Hemoglobin Placenta

Active Management Physiological Management

o Oxytocin
was drug of choice for active management
o No increase in entrapment of placenta with active management

Q 7. What is the recommendation about management of 3rd stage of labor?

A 7. In all deliveries conducted by a skilled birth attendant, active management of 3rd stage of
labor (AMTSL) should be practiced. Most important step of this is the use of a uterotonic drug.

62Sackett DL, Haynes RB. Summarising the effects of therapy: a new table and some more
terms. Evidence based medicine 1997;2:103–104.
63 Gulmezoglu MA, Villar J et al. WO multicentre randomised trial of misoprostol in te management of te
tird syaeg of labor. Lancet, 2001, 358: 689-695.
64 Sanghvi Harshad Stephenson: Patricia Preventing Mortality From Postpartum Hemorrhage: MAQ

2004 Mini University; May10, 2004 www.maqweb.org/.../Preventing%20Post%20partum%20hem-

H.%20Sanghvi-P.%20Stephenson.ppt
Q 8. What is the traditional belief about choice of uterotonics drug?
A 8. Many providers in Rajasthan believe Ergometrine is a better drug than Oxytocin to use
after delivery. If used before placental delivery, it leads to entrapment of the placenta.
• There is not much difference in blood loss even if oxytocic is given after delivery of
placenta

Q 9. What are the oxytocic drugs used in AMTSL?

A 9. There are 4 kinds of drugs used in third stage of labor

• Oxytocin- posterior pituitary extract
• Ergometrine- preparation of ergot
• Syntometrine- combination of oxytocin and ergometrine
• Misoprostol- prostaglandin E1 analogue

Q 10. What does the research show about choice of drug?

A 10. Comparison of various drugs has been given in table below. Research shows that oxytocin
is more effective than Ergometrine and misoprostol65. It assists with separation and expulsion of
placenta & with control of bleeding 66. There is no increase in incidence of entrapment of the
placenta. The rate of severe PPH and the use of additional uterotonics were statistically
significantly higher with 600 µg of oral misoprostol compared with conventional injectable
uterotonics67.

Advantages Disadvantages
Oxytocin • Causes uterus to contract • IM or IV preparations only
• Acts within 2.5 minutes • Not heat stable
when given IM
• Generally does not cause
side effects
• Safe in hypertension
Ergometrine • Low price • Takes 6–7 minutes to become
• Effect lasts 2–4 hours effective when given IM; oral form
insufficiently effective
• Causes tonic uterine contraction

65Hoj L, Cardoso P, Nielsen BB, Hvidman L, Nielsen J, Aaby P. Effect of sublingual misoprostol on
severe postpartum haemorrhage in a primary health centre in Guinea-Bissau: randomised double
blind clinical trial. BMJ 2005;331(7519):723.
66World Health Organization (WHO). 1999. Care in Normal Birth: A Practical Guide. Report of a Technical Working
Group. WHO: Geneva.

67Gülmezoglu AM, Villar J, Ngoc NN, Piaggio G, Carroli G, Adetoro L, Abdel-Aleem H, Cheng L,
Hofmeyr GJ, Lumbiganon P, Unger C, Prendiville W, Pinol A, Elbourne D, El-Refaey H, Schulz KF. for
the WHO Collaborative Group To Evaluate Misoprostol in the Management of the Third Stage of Labour.
WHO multicentre double-blind randomized controlled trial to evaluate the use of misoprostol in the
management of the third stage of labour. The Lancet 2001;358:689-695.
 • Increased risk of hypertension,
vomiting, headache
• Contraindicated in women with
hypertension or heart disease
• Not heat stable

Syntometrine Combined effect of rapid action of • Increased risk of hypertension,

oxytocin and sustained action of
ergometrine
Misoprostol • Effective orally, buccally,
vaginally and rectally
• Rapid absorption after oral
intake.
• Tmax = 12 + 3 minutes
T1/2 life = 20-40 minutes
nausea and vomiting
• Not heat stable
• Predictable side effects: shivering,
pyrexia, nausea, vomiting and diarrhea
• Rate of PPH is higher with misoprostol
compared to oxytocin.

Management of third Blood Loss

stage of labor (> 1000 ml)
Physiologic 13-18%
Active (oxytocin) 2.9%
Misoprostol 4.0%
Prendiville et al 1988. Villar et al 2002

Q 11. Does oxytocin need to be refrigerated ?

A 11. Stability of oxytocin is better than ergometrine/ methylergometrine, especially regarding

light. If possible, it should be store refrigerated, in dark. However, short periods without
refrigeration are fine (1 month at 30°C, 2 weeks at 40°C).

Q 12. What is the relevance of results?

A 11. Severe bleeding in the postpartum is the single most significant cause of maternal death
worldwide. More than half of all maternal deaths occur within 24 hours of delivery, most
commonly from excessive bleeding. It is estimated that 140,000 women die of postpartum
haemorrhage each year (4).
• The primary cause of PPH is uterine atony and this can be addressed with active
management of the third stage of labor.
• We cannot predict who will experience PPH on the basis of risk factors.
• A uterotonic drug should always be used after delivery of baby.
5. Monitoring of labour and partograph
Q 1. What is meant by monitoring of labour?
A 1. The wellbeing of both the mother and the fetus must be carefully monitored during labour.
Monitoring of labour should not be restricted to assessment of uterine contractions and cervical
dilatation.
Most common parameters that need to be assessed are:
1. Condition of the mother (every 2 hours, more often if abnormal):
o Pulse,
o BP,
o temperature
2. Condition of the fetus (every ½ hour, more often if abnormal):
o Fetal heart rate,
o color of liquor
3. Progress of labour:
o Uterine contractions (every ½ hour, more often if abnormal),
o cervical dilatation (every 4 hours in active phase, more often if required),
o descent of presenting part (

Q 2. What is a partograph?
A 2. Several methods of recording the
progress are in use:

A time based diary of events permo6ts a

detailed documentation of important
maternal and fetal assessments, but a
inspection of such a record is difficult to
follow.

A partograph is a graphic representation of

the progress of labour. The progress of
labour can be seen at a glance on one sheet
of paper. It is simple to use

Q 3. What is the traditional belief about

monitoring of labour and partograph?
A 4.
8 No benefit to use partograph
8 Labor can be managed as well
without partograph
8 Time consuming
8 Difficult to learn
Q 4. What does research show about partograph?
A 4. When used effectively, the partograph:
– provides a graphic representation of labor progress and the condition of the
mother and fetus
– Reminds providers to monitor the labour timely
– guides early detection of prolonged labor
– Avoids unnecessary and early interventions e.g. augmentation of labour,
caesarean sections

Table : WHO partograph Trial in Indonesia, Malaysia and Thailand68

No Partograph p
Outcomes
partograph used
Total deliveries 18254 17230
Labor > 18 hours 6.4% 3.4% 0.002
Labor augmented 20.7% 9.1% 0.023
Postpartum sepsis 0.70% 0.21% 0.028
Spontaneous cephalic 83.9% 86.3% < 0.001
Forceps 3.4% 2.5% 0.005

In a large multicentre trial in SE asia, the use of partogram with an agreed labour
management protocol reduced the incidence of:
• prolonged labour
• the proportion of labours requiring augmentation,
• intrapartum stillbirth rate
• emergency caesarean section rate

• The partograph is a tool, not an end in itself.

Q 5. What is the recommendation about position at 2nd stage of labour?

A 5. WHO recommends using the partograph to monitor all women during labor and use it for
decision making

68World Health Organization Safe Maternal Health and Safe Motherhood Programme. 1994. World Health
Organization Partograph in management of labour. Lancet 343 (8910):1399–1404.
6. Discharge at 24 hours
Q 1. What is common practice about timing of discharge after institutional delivery?
A 1. Research shows that the timing of discharge varies with the level of institution. In one
study in Rajasthan, it was found that the average time if discharge with various levels of
facilities is as follows:
• Subcentre/ village level clinic:
• PHC:
• CHC :
• District govenrment hospital
• District level private hospital

Q 2. What is the belief about timing of discharge among providers and patients?

A 2. Many providers prefer early discharge because they don’t have to monitor and look after
woman and her newborn.
• Families and women prefer early discharge because they can go back home early, their
household work does not get interrupted, their older children can be looked after and
they don’t have to undergo the inconvenience of sleeping and eating in a hospital.
• Jeep drivers also prefer early discharge for a woman whom they brought for delivery
because they can make more money by transporting the same woman back, so they
prefer to take women to those facilities where discharge is early.

Q 3. What does research show about maternal and neonatal mortality?

A 3. Research shows that first 24 hours is a very crucial time for both mothers and newborns.
Nearly half of maternal deaths occur in first 24 hours. 50% of neonatal deaths occur in first 24
hours after birth.

Postpartum period is the most critical period for the mother. Data on timing of maternal deaths
shows that69:
„ More than a half of all maternal deaths occur within 24 hours of delivery. Postpartum
hemorrhage is the most important cause of these deaths
„ 22% maternal deaths occur days 1-7
„ 15 % maternal deaths days 8-14
„ 3% maternal deaths days 31-42

69Patricia Daly Judith Moore. MCH in developing countries. Essential postpartum and newborn care.
January 2009. Presentation downloaded on 14 July 2009 from:
courses.washington.edu/hserv544/ppc_nbc09.ppt
 Figure 1: Timing of maternal death70.

160

140
Most deaths
cluster around
Deaths per 1000 person year

120
labour or within
100 24 hours after
80
delivery
60

40

20

0
1

2
7

90

65
y

3-

18
c

ay

ay

ar
8-

-3
an

43

Ye
ay

-
D

91

1
gn

ay

18
D

ay
D
e

ay
D
pr

ay
D

D
g
in
ur
D

Q 4. What are the main purposes to keep the woman during first 24 hours after delivery?
A 4. The main purposes to keep mother and baby for first 24 hours are (1) to detect and manage
complications (2) to prevent problems.

Maternal Neonatal
Detect and – Haemorrhage – Hypothermia )
manage – Retained placenta or – Asphyxia (color change,
these membranes breathing change)
problems – Eclampsia – Breastfeeding problems
– Severe anemia

Preventive – Nutritional support – Early and exclusive

measures – Danger signs for mother and breastfeeding and breast
baby care
– Vitamin A supplement – maintainance of
temperature

70Hussain Julia, University of Aberdeen, Maternal Mortality and morbidity: a global perspective.
Presentation downloaded on 14 July 2009 from: www.abdn.ac.uk/public_health/.../international-health-
module.ppt
Q 5. What are the main parameters that providers should monitor in first 24 hours?

A 5. A detailed examination for both mother and baby should be carried out. However, the
main parameters to be monitored are:

Parameters for the new mother: Parameters for the newborn baby:
– Pulse – respiratory rate, cry
– Vaginal bleeding – warmth
– Uterine firmness – bleeding from cord
– Blood pressure – breastfeeding

Up to 50%
of neonatal
deaths are in
the first 24 hours

Q 6. Relevance of results
A 6. Given the high risk of maternal and neonatal mortality in first 24 hours after delivery, it is
crucial that women and newborns are monitored by a skilled provider at least for 24 hours so
that their complications can be detected and managed.

Q 7. What is the recommendation about timing of discharge after institutional delivery?

A 7. Government of India recommends that women be discharged at 48 hours after delivery.
Initiation of breast feeding within 1 hour

Q 1. When is breastfeeding started in

Rajasthan? Initiation of breastfeeding by place of delivery,
Rajasthan (NFHS-3, 2005-06)
A 1. It is well known to most doctors
that breastfeeding should be started 80
early after birth. However, in reality this
70
is not the practice. Data from NFHS-3
60
survey71 shows that even after

Percentage
institutional delivery, only one fifth of 50
Institutional delivery
babies were breastfed within 1 hour 40
Home delivery
after birth. Only two thirds of babies 30
delivered in institutions of Rajasthan 20
start breastfeeding even by 1 day.
10
Nearly 40% of babies in Rajasthan do
0
not start breastfeeding even till 24 hours
Within 1 hour of birth Within 1 day of birth
after birth.

Q 2. Why is it so important to initiate breastfeeding within 1 hour?

A 2. A large recent study72 has shown that there was a marked dose response of increasing risk
of neonatal mortality with
increasing delay in initiation of
breastfeeding from 1 hour to day
7. Overall, late initiation (after day
1) was associated with a 2.4-fold
increase in the risk of neonatal
mortality. If breastfeeding was
initiated between 1 hour to end of
day 1, the risk of neonatal
mortality went up by 1.2 times.

The size of this effect was similar

when infants at high risk of death
or when deaths during the first

71 NFHS-3
Karen M. E., Zandoh C., Quigley MA, Amenga-Etego M, Owusu-Agyei S, Kirkwood BR,
72

Delayed Breastfeeding Initiation Increases Risk of Neonatal Mortality. PEDIATRICS Vol. 117
No. 3 March 2006, pp. e380-e386 (doi:10.1542/peds.2005-1496) Published online March 1, 2006.
week (days 2-7) were excluded. Infants who were given prelacteal feeds (any food or fluids
before breastfeeding was established) on day 1 also had a high neonatal mortality risk.

Q 3. What are the potential mechanisms of this beneficial effect of early breastfeeding?
A 3. Early breastfeeding reduces neonatal mortality by following mechanisms:
• Suckling shortly after birth has a greater chance of successfully establishing and
sustaining breastfeeding throughout infancy. The effect of early initiation persisted after
controlling for established neonatal breastfeeding patterns.
• Early feeding with non human milk proteins may severely disrupt normal gut function
• By breast feeding, a mother begins the immunization process at birth and protects her
child against a variety and bacterial pathogens before the acquisition of active immunity
through vaccination.
• Commencing breast feeding as soon as possible after birth, ideally with in 1 hour is also
effective in preventing heat loss, as lower blood glucose levels can result in
hypothermia73.
• Initiating breast-feeding early, by putting the baby to the breast as soon as possible after
the delivery has been shown to have a positive effect on the length of time (in weeks) that
a woman will continue to breast-feed. The earlier breast-feeding is commenced, the
longer the duration in weeks of breast-feeding. 74
• Healthy baby does not need large volume of fluids any earlier than it is physiologically
available from the mother75
• Early suckling provides the baby with colostrums that offers protection from infection,
• gives important nutrients, and has beneficial effect on maternal uterine contraction.
• Colostrum helps to expel meconium and to prevent jaundice. It also contains a very
high concentration of nutrients and helps prevent low blood sugar in the first hour of life.
• Immediate skin-to-skin contact helps the baby stay at breast temperature.

Therefore, it is recommended that all the babies should be put to the breast to feed as soon as
possible after the delivery.

Q 4. What proportion of neonatal deaths can be prevented by early initiation of

breastfeeding?
A 4. It is estimated that 1st ONE hour initiation cuts 22% of all neonatal deaths( 0-28 days). If it
is assumed that breastfeeding has no impact on deaths during the first day of life.

Currently, only 15.8% of newborns start breastfeeding within 1 hour. If all babies can start
breastfeeding within 1 hour, then 2.5 LAC newborn deaths can be prevented. It means that with
just ONE action, just ONE hour support and just ONE message, we can save 2.5 LAC newborns
babies every year in India and 18000-20000 babies in Rajasthan.

73 Van den Bosh CA, Bullough CH (1990) ; Effects of early sucking in tern neonates’ core body
temperature. Ann Trop Paediatr 1990; 10(4):347-353
74 Righart L, Alade MO (1990) ; Duration of breast-feeding after early initiation and frequent feeding.

Lancet 1978;2: 1141-1143

75 Family and Reproductive Health Division of Child Health and Development, evidence for the ten steps to

successful breastfeeding(Revised); World Health Organization; WHO/CHD/98.9

5. What are the added advantages of early breast feeding?

A5 Early breastfeeding protects against infectious diseases, especially gastrointestinal

infections, which largely contribute to child morbidity and mortality in developing countries76

ƒ Most newborns have a strong suck reflex and are awake the first hour after birth.
ƒ The newborn sucking helps the mother make breast milk
ƒ Early breast feeding prevents maternal breast related complications such as mastitis, breast
abscess etc.
• Early breastfeeding helps the uterus return to its normal size.
• It reduces post delivery bleeding and anemia77

Q6. What is recommended about breast-feeding during the First hour after birth ?

A 6 The World Health Organization (WHO), United Nations Children’s Fund (UNICEF) and
government of India recommend that breast feeding be initiated with in 1 hour78, 79.

76Collaborative WHO. Study team on the Role of Breastfeeding on the Prevention of Infant Mortality.
Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed
countries: a pooled analysis. Lancet 2000;355:451-5

77 Successful Exclusive Breastfeeding For the First Six Months International Baby Food Action Network
(IBFAN) Asia Pacific Breastfeeding Promotion Network of India Draft - 31 March 2005
78 WHO. Evidence for the ten steps to successful breastfeeding. WHO/CHD/98.9.World Health

organization: Geneva
79 UNICEF. Fact for Life.3rd edn United Nation’s Children’s Fund: New York,2002.
Immediate thermal protection of the newborn
Q 1. What is thermal protection of the newborn?

A 1. Thermal protection includes a series of measures taken at birth and during the first few
days of life to ensure that the baby maintains a normal body temperature (36.5-37.5°C), does not
become too cold (<36.5°C = hypothermia) and does not become too hot (>37.5°C =
hyperthermia).

Q 2. How does the newborn lose body heat?

Four ways a newborn may lose heat to the environment.

Most cooling of the newborn occurs during the first minutes after birth. Hence it is very
important that all babies are quickly dried and then wrapped in another piece of cloth.

Q 3. Why do newborns lose heat quickly?

A3. Newborns have immature temperature-regulating systems. Therefore, they often have
difficulty maintaining normal body temperature. They loose body heat quickly if they are wet,
uncovered, exposed to drafts, or if they are placed on or near a cool surface80. Pre-term and low
birth weight infants have lesser subcutaneous fats for insulation and thus loose heat more
easily. Newborns can maintain their body temperature in a cool environment only by greatly
increased energy expenditure. Even vigorous newborns exposed to cold delivery rooms may
experience marked drops in body temperature and develop metabolic acidosis during first two
hours of life 81.

Q 4 How can heat loss be prevented at the time of birth?

80 World Health Organization. (1997). Thermal Protection of the newborn: a practical guide. Geneva:
WHO. [WHO/RHT/MSM/97.2]
81 Murray Enkin, Marc J.N.C Keirse, James Neilson, Caroline Crowther Leila Duley, Ellen Hondnett an

Justus Hofmeyr; A guide to effective Care in pregnancy and childbirth: OXFROD Medical Publication.
A 4. Heat loss can be prevented by maintaining a warm chain. Warm chain is a set of ten
interlinked procedures carried out at birth and during the following hours and days which will
minimize the likelihood of hypothermia in all newborns. The key components of warm chain
are:

a. Keeping the delivery room warm: It is recommended that the most effective way to
prevent heat loss at delivery is to keep the temperature of the birth room warm at 25 °C
or above. The delivery room should be a clean warm drought free room. Adults should
never determine the temperature of the delivery room according to their comfort.
b. Immediate drying of the newborn baby: It is also important to ensure pre-warmed
towels or soft absorbent material is available to first dry the newborn immediately on
birth, giving particular attention to drying the head. (WHO,1997) 82
c. Wrapping the baby with dry cloth: After drying, the baby should be covered and a
warm cap should be put on the baby’s head to prevent heat loss from the head.
d. Baby and mother together: They should be held by their mothers, preferably in skin-to-
skin contact, and covered with a dry warm blanket. The baby should be given to the
mother to hold close to her own body. Studies have also found that putting the newborn
to the mother’s breast and wrapping the mother and the baby so that the skin of the
mother is in direct contact with the skin of the newborn, is a very effective method for
preventing heat loss at birth83. Where it is not possible to put the baby to the breast, then
the mother can hold the baby close to her body, or the baby could be placed on the
woman’s abdomen and covered.
e. Bathing and weighing should be postponed. Babies should be bathed when
temperature is stable (after 24 hours).

82 World Health Organization(1997) Thermal Protection of the Newborn: A Practical Guide. Maternal and
Newborn Health/Safe Motherhood Unit. Division of Reproductive Health (Technical Support). World
Health Organization. Geneva : World Health Organization.
83 Bergman NJ, Jurisoo LA (1994) ; The kangaroo method for treating low-birth-weight babies in

developing countries. Trop Doct 1994; 24: 57-60.

Q 5. What is recommended about drying and wrapping?
A 5. Studies from Rajasthan have shown that in some facilities, the sheets to dry and cover the
baby are not available before delivery84. After the baby is born, the relatives outside labor room
are asked to provide a sheet, which is used to cover the baby.

Babies should be dried immediately after the birth. In the first 1-2 minutes, the newborn may
lose enough heat for his body temperature to fall 20 C, which is very dangerous. Using a
clean, warm cloth, the baby’s back and then the whole body should be quickly dried.

After drying, another dry towel or cloth should be used to cover the baby, to prevent the
cool/cold air from coming in contact with the newborn’s skin. Baby’s head should be covered
with a cap. Then the baby should be warmly dressed with several layers of loose clothing and
bedding according to the environment.

Q 6. What steps should be taken to keep a baby warm during resuscitation?

A 6. It is important to keep the babies warm, because Newborns with asphyxia cannot produce
heat efficiently and thus get cold easily. During resuscitation, following steps should be taken to
keep the babies warm:
o Wrap in a warm cloth
o Lay on a warm surface in a warm room
o Put under an addition source of heat.
o Uncover as little as possible during procedure.

84Iyengar SD, Iyengar K et al. Childbirth practices in rural Rajasthan: implications for neonatal health and
survival. Journal of perinatology. 2008.
Q 8. What is early skin to skin contact?
A 8. Early skin-to-skin contact (SSC) means that as soon as the newborn is stable and breathing,
he/she may be placed on the mother’s chest, prone, in skin-to-skin contact, with a warm, dry
cloth covering the infant’s back and the mother’s chest. Routine delivery room procedures (such
as cleaning and weighing) should be delayed for at least the first hour85.

Q 7. When should the babies be given to the mother?

A 7. It is recommended that the babies are given to the mother as soon as possible and they are
placed in skin to skin contact with their mothers immediately after birth for the first few hours
after a vaginal or caesarean birth.

Q 8. What is early skin to skin contact?

A 8. Early skin-to-skin contact (SSC) begins ideally at birth and involves placing the naked
baby, covered across the back with a warm blanket, prone on the mother's bare chest.
According to mammalian neuroscience, the intimate contact inherent in this place (habitat)
evokes neurobehaviors ensuring fulfillment of basic biological needs. This time may represent a
psychophysiologically 'sensitive period' for programming future behavior.

Although skin-to-skin contact starting immediately after a vaginal delivery is optimal, there
may be up to 5 minutes of separation before continuous skin-to-skin contact starts. As a guide
to measuring 5 minutes, the baby should be on the mother’s chest in skin-to-skin contact before
the second Apgar.

Continues undisturbed: Skin-to-skin contact should continue “for at least an hour”. If the
mother’s condition necessitates a toilet break before the baby has breastfed, then the
interruption should be as brief as possible, before resuming skin-to-skin contact.

Q 9. What are the benefits of early skin to skin contact?

A 9. A Cochrane review86 (included 30 studies involving 1925 mothers and their babies) done to
see the impact of early skin-to-skin contact between the mother and her newborn baby showed
that babies interacted more with their mothers, stayed warmer, and cried less. Babies were more

85 American Academy of Pediatrics (AAP). Policy Statement: Breastfeeding and the use of human milk. Pediatrics
2005;115(2):496-506.
86 Moore ER, Anderson GC, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn
infants. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD003519. DOI:
10.1002/14651858.CD003519.pub2
likely to be breastfed, and to breastfeed for longer, if they had early skin-to-skin contact.
Furthermore, on a positive note, no important negative effects were identified.
Skin-to-skin contact first few hours after childbirth87 is crucial because it:
– Keeps the baby warm
– Promotes bonding
– Enables early breastfeeding:
– Breathing

Q 10. Is it feasible to promote skin to skin contact in our settings?

A 10. On one hand, factors such as room temperature, lack of privacy/space, overcrowding,
etc., may interfere with its potential benefits and, on the other hand, the situation is often
worsened by inaccurate medical advice from health workers who lack proper skills and training
in early breastfeeding support starting with early skin-to-skin contact.

Practices such as how infants are handled after birth are part of institutional functioning, and
may not be easy to change. For example, the current practice at Maternidad Martin in Rosario
(Argentina), with 4000 deliveries per year, is to place the newborn prone on the mother’s bare
abdomen for one minute while it is smoothly dried with a blanket88. This new practice has been
recently introduced following the implementation of delayed cord clamping intervention. In
this scenario, SSC starts immediately after birth but it lasts only 1-3 minutes.

Q 11. What is recommended about washing and bathing the newborn?

A 11. It is recommended to postpone washing and bathing the newborn at least till 24 hours. If
the baby is particularly soiled with blood or meconium washing 2-6 hours after birth is
permissible so long as the baby’s body temperature is normal.

Q 12 What are the consequences if the baby is not immediately dried and kept warm?
A 12. If the above measures to keep the baby warm are not observed, then the baby can develop
hypothermia. Hypothermia is defined as body temperature drops below 36 .5 °C. Newborn
infant is most sensitive to hypothermia during the stabilization period in the first 6-12 hours
after birth, although hypothermia may occur at any time if the environmental temperature is
low and thermal protection is inadequate89. It is one of the major causes of neonatal mortality
and morbidity as the physiological adaptation of outside the uterus sometimes makes it difficult
for the newborn to maintain their own temperature, even in hot climates. In a study undertaken

87 Puig G, Sguassero Y. Early skin-to-skin contact for mothers and their healthy newborn infants: RHL
commentary (last revised: 9 November 2007). The WHO Reproductive Health Library; Geneva: World
Health Organization.
88 Puig G, Sguassero Y. Early skin-to-skin contact for mothers and their healthy newborn infants: RHL

commentary (last revised: 9 November 2007). The WHO Reproductive Health Library; Geneva: World
Health Organization.
89 World Health organization (1996); Maternal And Newborn Health safe Motherhood; Essential

Newborn care; Report of a Technical Working Group Trieste, 25-29 April 1994: WHO/FRH/MSM/96.13,
9
in Kuala Lumpur it was noted that the body temperature of neonates fell significantly within
the first 15 minutes following delivery90. Similar results have been noted in other countries91.

Finally, Thermal protection should be a high priority when planning the care of newborn infants.
Thermal protection does not require expensive, sophisticated equipment but rather, a well organized effort
to teach to all health care providers and parents of newborn babies, the simple principles of thermal
protection.

References

1) The Lancet Series: Neonatal Survival March, 2005

2) WHO – Integrated Management of Pregnancy and Childbirth: Managing Newborn
Problems – a guide for doctors, nurses, and midwives. World Health Organization 2003
3) Opportunities for Africa’s Newborns: practical data, policy and programmatic support for
newborn care in Africa. Joy Lawn and Kate Kerber, eds. PMNCH, Cape Town, 2006
4) Save the Children: care of the newborn reference manual

90 Raman S, Shahla A: Temperature drop in normal term newborn at the University Hospital, Kuala

Lumpur: Aust N Z J Obstet Gynaecol 1992 May ; 32(2): 117-119

91 Jirapet V : The effects of measures minimizing body heat loss on the prevention of neonatal

hypothermia in the delivery room. Siriraj Hosp Gaz 1995; 47(3): 215-221