List of Abbreviations
BP – blood pressure
HIV – human immunodeficiency virus
HSV – herpes simplex virus
WHO – World Health Organization
CTG – cardiotocography
RCTs – randomized controlled trials
US – ultrasound scan
HR – heart rate
Terms and Definitions
Term birth – delivery at 370 - 416 weeks of gestation.
Normal labor – term delivery of a single fetus, starting spontaneously, with a low risk of obstetric complications by the onset of labor and proceeding without complications, in which the baby is born spontaneously in cephalic presentation, after which the mother and newborn are in a satisfactory condition.
Analgesia (from Lat. – analgesia, analgia, "without pain") – reduction of pain sensitivity (including selective, where other types of sensitivity are unaffected) using pharmacological and non-pharmacological methods.
Neuraxial labor analgesia – pain relief in labor using epidural, spinal, and combined spinal-epidural analgesia.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Normal labor – term delivery of a single fetus, starting spontaneously, in patients with a low risk of obstetric complications by the onset of labor and proceeding without complications, in which the baby is born spontaneously in cephalic presentation, after which the mother and newborn are in a satisfactory condition [1].
These recommendations may also be applied to high-risk obstetric patients if labor proceeds without complications [1]
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Not applicable.
1.3 Epidemiology of the Disease or Condition
According to the World Health Organization (WHO), nearly 140 million births occur worldwide every year, and the majority of them are low-risk for both mother and child. According to the statistical report of the Russian Ministry of Health (main indicators of maternal and child health, activities of the child and obstetric care service in the Russian Federation), the proportion of normal births in 2018 was 37.3%, i.e., 584,767 [157].
1.4 Features of Coding the Disease or Condition
O80.0 Single spontaneous delivery, occipital presentation.
O80.9 Single spontaneous delivery, unspecified
O47.1 False labor starting at 37 completed weeks of pregnancy
O47.9 False labor, unspecified
1.5 Classification of the disease or condition
Not applicable.
1.6 Clinical presentation of the disease or condition
Objective signs of labor include: uterine contractions with a specific regularity (during the active phase, at least 3 contractions per 10 min) and structural changes in the cervix (shortening-effacement-dilation).
Labor consists of 3 stages. The first stage of labor is the time from the onset of labor to full cervical dilation. The exact time of the onset of labor is most often established on the basis of interviewing the parturient woman – clarifying the time when uterine contractions (labor pains) began to occur regularly every 5 minutes for more than 1 hour [2].
The first stage of labor consists of a latent and an active phase. The latent phase is characterized by uterine contractions (often painful), effacement, and progressive cervical dilation up to 5 cm [3]. The active phase is characterized by regular painful uterine contractions and more rapid cervical dilation from 5 cm to full dilation [3]. The standard duration of the latent phase has not been established and can vary greatly among different women [3]. The maximum duration of the latent phase is 20 hours in nulliparous women and 14 hours in multiparous women [4]. The duration of the active phase usually does not exceed 12 hours in the first labor and 10 hours in subsequent labors [3]. The rate of cervical dilation in the active phase is usually ≥1 cm/hour, but may be slower [3]. The minimum rate of cervical dilation in the active phase is 0.5 cm/hour in both nulliparous and multiparous women [5, 6].
The second stage of labor is the time from full cervical dilation to the birth of the fetus. The duration of the second stage in the first labor is usually no more than 3 hours, and in subsequent labors no more than 2 hours [3]. The duration of the second stage may increase by another 1 hour with epidural analgesia, reaching 4 hours in nulliparous and 3 hours in multiparous patients [7].
The third stage of labor is the time from the birth of the fetus to the delivery of the placenta. In 90% of cases, the third stage of labor is completed within 15 minutes, and in another 7% within 30 minutes after the birth of the fetus [8, 9]. As the duration of the third stage of labor exceeds 10 minutes, the risk of postpartum hemorrhage increases [10]. Gestational age is the primary factor influencing the duration of the third stage of labor; preterm births are associated with a longer third stage than term births [11]. The WHO recommends adhering to a 30-minute interval if the placenta is not delivered before manual removal and extraction are initiated in the absence of bleeding [12].
2. Diagnostics, medical indications and contraindications for diagnostic methods
The diagnosis of normal labor is established in term delivery (at 370 - 416 weeks of gestation) of a single fetus, starting spontaneously, in patients with a low risk of obstetric complications by the onset of labor and proceeding without complications, in which the baby is born spontaneously in cephalic presentation, after which the mother and newborn are in a satisfactory condition.
2.1 Complaints and Anamnesis
Upon admission to the inpatient facility, it is recommended to interview the patient regarding the presence of contractions (their strength, frequency, and duration), the presence and nature of vaginal discharge, and fetal movements in the past 24 hours to assess the presence of labor activity and the likelihood of obstetric complications [3].
GR CLEL 5Grade of Recommendation C (Level of Evidence – 5).
Upon admission to the inpatient facility, it is recommended to determine the gestational age and expected date of delivery based on the date of the last menstrual period and fetal ultrasound (US) data (optimally, a 1st-trimester US) to determine labor management tactics [13–15].
GCR ALEL 2Grading of Recommendations Assessment, Development and Evaluation — Recommendation Grade A (Level of Evidence – 2).
Upon admission to the inpatient facility, it is recommended to collect obstetric and medical history to assess the likelihood of successful labor and obstetric complications [3].
GR CLEL 5Grade of Recommendation C (Level of Evidence – 5).
2.2 Physical Examination
Upon admission to the inpatient facility, it is recommended to measure blood pressure on peripheral arteries (BP) to diagnose hypertensive disorders of pregnancy [16–18].
GCR CLEL 5Grading of Recommendations Assessment, Development and Evaluation — Recommendation Grade C (Level of Evidence – 5).
Upon admission to the inpatient facility, it is recommended to measure body temperature to diagnose infectious and inflammatory complications of pregnancy [2], [3], [19], [20].
GCR CLEL 5Grading of Recommendations Assessment, Development and Evaluation — Recommendation Grade C (Level of Evidence – 5).
Upon admission to the inpatient facility, it is recommended to determine fetal lie, presentation, and the relation of the fetal head to the pelvic inlet to determine labor management tactics [21–23].
GCR BLEL 2Grading of Recommendations Assessment, Development and Evaluation — Recommendation Grade B (Level of Evidence – 2).
Upon admission to the inpatient facility, it is recommended to measure uterine dimensions (fundal height – FH, abdominal circumference – AC) and calculate the FH-AC index to assess the estimated fetal weight and determine labor management tactics [24, 25].
GCR BLEL 2Grading of Recommendations Assessment, Development and Evaluation — Recommendation Grade B (Level of Evidence – 2).
Comment: The FH-AC index (IFHAC) is calculated using the formula IFHAC = 100 * FH * AC2 (fundal height and abdominal circumference should be given in meters). In healthy pregnant women, an IFHAC value >37 and in women with gestational diabetes mellitus an IFHAC value >41.7 highly predicts macrosomia.
Upon admission to the inpatient facility, it is recommended to assess the duration, frequency, and regularity of uterine contractions to evaluate the presence and nature of labor activity, the stage and phase of labor, and to determine labor management tactics [3].
GR CLEL 5Grade of Recommendation C (Level of Evidence – 5).
Upon admission to the inpatient facility, to assess the condition of the fetus, it is recommended to determine the fetal heart rate (FHR) (perform fetal auscultation) using an obstetric stethoscope or fetal Doppler after a contraction for at least 1 minute simultaneously with determining the patient's heart rate [2, 3, 19, 20].
GCR CLEL 5Grading of Recommendations Assessment, Development and Evaluation — Recommendation Grade C (Level of Evidence – 5).
Upon admission to the inpatient facility, it is recommended to perform a bimanual vaginal examination to assess the state of the birth canal, including the bony pelvis and the location of the fetal head relative to the pelvic planes, and to determine labor management tactics [2, 3, 19, 20].
GCP CLeE 5Grade of recommendation C (Level of evidence – 5).
Comments: Perineal and pubic shaving and cleansing enemas are not routinely performed in normal labor and are done only at the patient's request [3].
2.3 Laboratory Diagnostics
The list of preoperative and pre-labor laboratory diagnostic tests must comply with the clinical guidelines «Normal Pregnancy» [158]. If tests required in the 3rd trimester of pregnancy are missing, they should be performed upon the patient's admission to the inpatient facility.
2.4 Instrumental Diagnostics
Upon admission to the inpatient facility, pelvic measurement (pelvimetry) using a pelvimeter is recommended to determine the management of labor [26].
GR CLEL 5Grade of Recommendation C (Level of Evidence – 5).
Comment: Height ≤155 cm, transverse diameter of the Michaelis romboid ≤9.5 cm, longitudinal diameter of the Michaelis romboid ≤10.5 cm, interspinous diameter ≤10 cm, height/fundal height ratio ≤4.7 may be risk factors for cephalopelvic disproportion in labor.
If external obstetric and vaginal examination data and fetal auscultation are uninformative, or if fundal height and abdominal circumference do not correspond to the gestational age, fetal ultrasound is recommended to determine fetal presentation and condition, fetal growth restriction and macrosomia, as well as placental localization [27], [28, 29].
GCP BLeE 1Grade of recommendation B (Level of evidence – 1).
2.5 Other Procedures
Not applicable.
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1. Management of the first stage of labor
With the onset of the active phase of labor, catheterization of the cubital or another peripheral vein is recommended to ensure the timely initiation of intensive therapy in the event of a critical situation during labor and the early postpartum period [30].
GR CLEL 5Grade of Recommendation C (Level of Evidence – 5).
To prevent obstetric complications, it is recommended not to perform labor induction in patients in the latent phase of the first stage of labor if the maternal and fetal condition remains satisfactory [3, 31, 32].
GR CLEL 5Grade of Recommendation C (Level of Evidence – 5).
It is recommended to offer mobility and freedom of movement during labor [3, 33].
GCP BLeE 1Grade of recommendation B (Level of evidence – 1).
Comment: Walking and an upright position in the first stage of labor shorten the duration of labor and reduce the rate of cesarean section and epidural analgesia [33].
The use of non-pharmacological methods of pain relief in labor is recommended to reduce pain, lower the risk of obstetric complications, and increase patient satisfaction [3, 34–37], [38, 39].
GCP ALeE 1Grade of recommendation A (Level of evidence – 1).
Comment: The presence of a birth companion is encouraged and can be offered to patients if individual delivery rooms are available in the maternity department [3, 40]. Non-pharmacological methods of pain relief in labor are presented in Appendix A3.
To reduce pain, lower the risk of obstetric complications, and increase patient satisfaction when non-pharmacological pain relief methods are ineffective, pharmacological methods of pain relief in labor are recommended [3, 41], taking into account the patient's condition and preferences, the capabilities of the medical organization, as well as indications and contraindications for various pain relief methods.
GCP ALeE 1Grade of recommendation A (Level of evidence – 1).
Comment: Various pharmacological methods can be used for labor pain relief, including neuraxial analgesia (Appendix A3). Among all methods of labor pain relief, epidural analgesia has a number of advantages. Modern local anesthetics (ropivacaine**, bupivacaine**, lidocaine**, levobupivacaine**) are used for neuraxial analgesia in obstetrics. In addition to epidural, spinal, and combined spinal-epidural analgesia, paravertebral lumbar sympathetic blockade can be used. Systemic pain relief methods include opioids (trimeperidine**, #fentanyl**). Trimeperidine** is administered at a dose of 20–40 mg, #fentanyl** at 50–100 mcg [170]. Inhalation methods of pain relief can also be used, although they are less effective (Appendix A3). Dinitrogen oxide** and #sevoflurane** are used for this purpose. Dinitrogen oxide** is used as a mixture with oxygen (50% to 50%), and the inspired concentration of #sevoflurane** is 0.8 vol.% [167, 168]. It must be taken into account that these drugs have the property of relaxing the uterine musculature, which increases the risk of hypotonic hemorrhage.
Before and during the neuraxial analgesia procedure, infusion support is recommended – #Sodium chloride compound solution [Potassium chloride+Calcium chloride+Sodium chloride]**, #Potassium chloride+Calcium chloride+Magnesium chloride+Sodium acetate+Sodium chloride or other ATC group drugs: V05BB01 in a restrictive regimen (500–1000 ml) to correct hypovolemia [162, 165, 166].
Grade of Recommendation CLevel of Evidence 5Grade of Recommendation C (Level of Evidence – 5).
Comment: Infusion support is one of the key steps in neuraxial analgesia [162]. Infusion preload reduces the likelihood of maternal hypotension (RR 0.07; 95% CI 0.01–0.53) and fetal heart rate abnormalities (RR 0.36; 95% CI 0.16–0.83) when high doses of anesthetic are used [165].
Fluid intake during labor is recommended to prevent dehydration and ketosis [3, 31].
Grade of Recommendation CLevel of Evidence 5Grade of Recommendation C (Level of Evidence – 5).
Comment: Food intake should be restricted [43, 44]. Light food in small portions may be allowed in the latent phase of labor in the absence of indications for operative delivery [45].
For rehydration and as a source of carbohydrates, intravenous administration of a 5% dextrose solution at 250 ml/hour is recommended if oral fluid intake is limited or insufficient [46–48], [49].
GCP ALeE 1Grade of recommendation A (Level of evidence – 1).
Comment: Water and glucose requirements in labor are similar to those observed during prolonged and energetically demanding physical exertion [48]. Administration of 5% dextrose at 250 ml/h when oral intake is insufficient helps reduce the duration of labor and the rate of cesarean section [48].
The maintenance of a partogram during labor is recommended for the dynamic assessment of the mother's and fetus's condition [30, 31, 49].
Grade of Recommendation CLevel of Evidence 5Grade of Recommendation C (Level of Evidence – 5).
Comment: A sample partogram is presented in Appendix A3. The partogram replaces the patient observation chart, except for notes on changes in labor management involving a vaginal examination. Filling out the partogram begins with the onset of the active phase of labor. Prior to the active phase (in the latent phase of the first stage of labor, heart rate, blood pressure, body temperature, urine output, uterine tone, strength and frequency of contractions, and the nature of genital secretions are recorded every 4 hours). In the active phase of the first stage of labor, maternal heart rate, body temperature, and blood pressure are assessed every 60 minutes, and urination is assessed at least every 4 hours [12], [156]. Fetal heart rate and labor activity are assessed every 30 minutes.
Recommended fetal auscultation during labor using a stethoscope or fetal doppler to assess the condition of the fetus [51].
GCP BLeE 1Grade of recommendation B (Level of evidence – 1).
Comment: Fetal auscultation in the first stage of labor is performed for 1 minute after a contraction: every hour in the latent phase, every 30 minutes in the active phase, and every 15 minutes in the second stage of labor and after each pushing effort; the fetal heart rate is cross-checked with the mother's heart rate [3, 19, 52]. If acceleration or deceleration of the fetal rhythm is heard, auscultation continues for at least 3 uterine contractions. At the same time, potential causes that may affect changes in the fetal heart rate are evaluated (e.g., maternal position, hypovolemia). If the fetal rhythm acceleration or deceleration does not resolve, fetal cardiotocography (CTG) is performed. If CTG reveals no signs of fetal distress within 20 minutes, periodic fetal auscultation is resumed.
Monitoring of uterine contractions during labor is recommended for the timely diagnosis of uterine inertia or hyperstimulation in order to determine labor management tactics [20].
GR CLEL 5Grade of Recommendation C (Level of Evidence – 5).
Comment: Contractions are counted over a 10-minute period. Normally, the number of contractions during the active phase of labor is 3–5 per 10 minutes. Tachysystole is defined as >5 contractions in 10 minutes in two consecutive counts or over a 30-minute period.
Bimanual vaginal examination is recommended every 4 hours in the active phase of the first stage of labor to assess labor progression [53].
GCP BLeE 2Grade of recommendation B (Level of evidence – 2).
Comment: Vaginal examinations should be performed at established intervals, as clinically indicated, and their frequency should be minimized whenever possible to reduce the risk of purulent-septic complications [3, 53]. Routine use of antispasmodics in labor is not indicated. However, in the event of uterine cervix spasm in the active phase of labor, antispasmodics (drotaverine** 40 mg and #hyoscine butylbromide 20 mg) may be used to relieve it [54, 55], [56, 57], [159, 160].
It is recommended to perform a physical examination with bimanual vaginal examination prior to prescribing pharmacological analgesia in order to determine the period and phase of labor for the selection of the anesthetic technique and anesthetic dose [161, 162, 163].
GPP CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comment: The obstetric situation should be taken into account when choosing the anesthetic technique and anesthetic dose, including prior to the administration of repeat doses, due to its effect on the duration of labor and the anticipated time of delivery.
It is recommended to perform a bimanual vaginal examination after amniotomy in order to promptly diagnose umbilical cord prolapse [2].
GPP CLOE 5Grade of Recommendation C (Level of Evidence – 5).
It is recommended to perform a bimanual vaginal examination upon detection of fetal heart rate abnormalities in order to promptly diagnose obstetric complications leading to these abnormalities (umbilical cord prolapse, uterine rupture, premature detachment of a normally positioned placenta) [2].
GPP CLOE 5Grade of Recommendation C (Level of Evidence – 5).
It is recommended to perform a bimanual vaginal examination if the laboring woman's condition worsens or if there is any other change in the clinical situation, in order to timely assess the obstetric situation [2].
GPP CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Routine antibiotic prophylaxis in labor is not recommended [58].
GCP BLeE 1Grade of recommendation B (Level of evidence – 1).
If group B Streptococcus (S. agalactiae) is detected in the urogenital tract of the laboring woman, antibacterial therapy is recommended [59], [60].
GPP ALOE 1Grade of Recommendation A (Level of Evidence – 1).
Comment: Systemic antibacterial drugs should be administered upon the onset of labor even with intact fetal membranes, as well as in case of premature rupture of membranes before the onset of labor. Systemic antibacterial drugs of choice are penicillins: ampicillin** intravenously 500 mg every 6 hours until the end of labor, or amoxicillin+[clavulanic acid]** intravenously 1200 mg every 8 hours until the end of labor, or cephalosporins: cefazolin** intravenously 1000 mg every 6 hours until the end of labor, or cefuroxime** intravenously 750 mg every 6 hours until the end of labor [169]. In case of allergy to beta-lactam antibiotics, clindamycin** may be prescribed, provided that the colonizing strain of S. agalactiae in the birth canal is susceptible to it, administered intravenously 300 mg every 8 hours until the end of labor; if susceptibility of S. agalactiae to clindamycin** cannot be assessed, vancomycin** should be administered intravenously 500 mg every 6 hours until the end of labor. Due to the global increase in resistance of S. agalactiae to macrolide drugs (erythromycin, azithromycin**), their empirical use is currently not recommended [61].
Vaginal delivery is not recommended for patients with HIV infection if the viral load before delivery is >1000 copies/mL, if the viral load before delivery is unknown, or if antiretroviral therapy was not used during pregnancy and/or antiretroviral prophylaxis was not administered in labor [62, 63].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5).
Comment: These patients undergo scheduled Cesarean section to prevent mother-to-child transmission of HIV infection.
Vaginal delivery is not recommended for patients in whom the primary episode of genital herpes occurred after 34 weeks of gestation or who have clinical manifestations of genital herpes immediately prior to delivery [64], [65].
GGR CLOC 5Grade of Recommendation C (Level of Evidence – 5).
Comment: These patients undergo Cesarean section to prevent mother-to-child transmission of HSV infection.
It is not recommended to irrigate the vagina with antiseptic and disinfectant agents (ATC D08A) during labor for the purpose of reducing the risk of maternal and neonatal infection [66].
GPP ALOE 1Grade of Recommendation A (Level of Evidence – 1).
Comment: In the cited Cochrane meta-analysis, vaginal irrigation with chlorhexidine** solution (D08AB03) in labor is not recommended. There is no evidence regarding the use of other antiseptics in normal labor to reduce the risk of maternal and neonatal infection; however, given the identical antimicrobial action of all antiseptics, this recommendation statement should be extrapolated to the entire list of antiseptic agents used in obstetrics and gynecology.
Routine early amniotomy is not recommended [67].
GGR BLOC 1Grade of Recommendation B (Level of Evidence – 1).
Comment: Rupture of fetal membranes increases the risk of ascending infection and cord prolapse. Routine amniotomy does not shorten the duration of the first or second stage of labor and does not reduce the risk of Cesarean section [67]. However, it should be remembered that in the second stage of labor, the absence of signs of fetal head descent for 1 hour in nulliparous women and 30 minutes in multiparous women requires evaluation of the clinical situation and amniotomy with intact membranes [19]. In patients with active hepatitis B, hepatitis C, and HIV infection, amniotomy should be avoided to reduce the risk of ascending infection [20].
3.2. Management of the second stage of labor
It is recommended to perform a bimanual vaginal examination every hour to assess the descent of the fetal head through the birth canal [3, 20].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comment: Once full dilatation of the uterine cervix is confirmed on vaginal examination, comprehensive pelvic ultrasound (transvaginal and transabdominal) may be performed, if available, to assess the position and descent of the fetal head [27].
It is recommended to perform fetal auscultation using a stethoscope or fetal Doppler every 15 minutes, or after each push, or via continuous monitoring (cardiotocography, CTG) to assess fetal condition [52, 68], [69], [156].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
It is recommended to encourage mobility and assumption of a comfortable position by patients with a low risk of obstetric complications, regardless of the use of epidural analgesia, in order to reduce the risk of episiotomy and instrumental vaginal delivery [70], [71].
Level of Evidence BLevel of Confidence 2Level of recommendation B (level of evidence – 2).
Comment: Access to continuous fetal monitoring in the position chosen by the patient must be available, and her position should be changed if necessary to ensure adequate fetal monitoring. Most modern types of epidural analgesia allow patients to choose a comfortable position during labor [3, 72].
It is recommended to encourage and support patients to follow their own urges to push in order to prevent complications in labor [3].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
It is recommended to use methods aimed at reducing perineal trauma and facilitating spontaneous delivery, such as perineal massage and a warm perineal compress, taking into account patient preferences and available resources [73].
Level of Evidence BLevel of Confidence 2Level of recommendation B (level of evidence – 2).
Comment: A warm compress made of clean fabric soaked in warm water (43°C) applied to the perineum and perineal massage with gel during the second stage of labor reduce the risk of 3rd+ degree perineal lacerations, but do not affect the risk of 1st and 2nd degree perineal lacerations [73, 74]. These techniques are performed during and between pushes. Digital massage is performed using sweeping side-to-side movements inside the patient's vagina with gentle downward pressure [75, 76]. Perineal protection maneuvers may be used to prevent perineal trauma and facilitate the birth of the baby, and should be based on established practice [3, 73].
Routine perineal incision (episiotomy) is not recommended to reduce the risk of perineal trauma [77], [78, 79].
GPP ALOE 1Grade of Recommendation A (Level of Evidence – 1).
Comment: When indicated, mediolateral episiotomy should be used (starting the incision from the midline of the perineum at an angle of 45°).
To prevent fetal hypoxia and neonatal asphyxia, it is recommended to attempt to slip the umbilical cord over the fetal head if it is looped around the neck after the birth of the head [20].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comment: If the umbilical cord cannot be slipped over the fetal head, an attempt should be made to deliver the baby's body through the cord loop and perform the somersault maneuver. To perform the somersault maneuver, place the palm of your hand on the fetal occiput and deflect the fetal head face-towards the mother's thigh, which will allow the shoulders, and then the body and legs of the fetus, to be born [80–84]. If the somersault maneuver fails, the umbilical cord should be clamped and cut between two clamps; however, this increases the risk of hypovolemia, anemia, and hypoxic-ischemic encephalopathy in the newborn [83].
Recommended in labor management for all women to ensure readiness to provide neonatal resuscitation [3].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comment: Regardless of the prognosis and risk factors for the birth of a child in asphyxia, the personnel participating in childbirth must be proficient in neonatal resuscitation. The on-duty neonatologist, upon taking over the shift, is required to check the serviceability of the equipment used and the availability of medications necessary for primary resuscitation, and before delivery — to review the maternal medical history and documentation to assess perinatal risks for the newborn, prepare the resuscitation station, assess perinatal risks, and ensure the presence of 2 or more specialists fully skilled in neonatal resuscitation if a child is predicted to be born requiring resuscitative measures.
Recommended in labor management for all women to ensure a set of measures to maintain the newborn's optimal body temperature for the prevention of hypothermia [85, 86].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comment: Before the baby's birth, the midwife must rule out drafts, close the windows and doors of the delivery room, turn on the radiant warmer above the neonatal table, warm the tray and blankets for receiving the newborn, and check the ambient temperature using a thermometer located in the delivery room. The optimal air temperature should be at least 240C. After birth, it is necessary to immediately wipe the newborn with a warm blanket gently, without rough movements, replacing the first damp blanket with a dry one.
Recommended in labor management for all women to examine the newborn with evaluation of their condition using the Apgar score [87].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comment: The first examination of the newborn must be carried out immediately after birth to assess the newborn's condition and rule out visible congenital malformations. The child's condition is evaluated using the Apgar score at 1 minute (60 seconds) and 5 minutes after birth. The Apgar score should not be used as the sole criterion to justify a diagnosis of asphyxia. The term asphyxia should not be used unless there is evidence of gas exchange impairment (blood acid-base balance).
Recommended for all newborns not requiring resuscitation after birth to be placed on the mother's abdomen and chest, ensuring skin-to-skin contact, to improve postnatal outcomes and stimulate breastfeeding [88].
GCR ALoE 2Grade of Recommendation A (Level of Evidence – 2).
Comment: Placing the newborn on the mother's abdomen and chest and ensuring direct skin-to-skin contact during the first hour of life increases the frequency and duration of breastfeeding and reduces the risk of hypothermia.
Recommended delayed cord clamping (no earlier than 1 minute and no later than 3 minutes from the moment of fetal birth) regardless of the patient's HIV status in order to improve postnatal outcomes [3, 89].
Strength of Recommendation A (Level of Evidence 5)
Comment: In term infants, the main advantage of delayed cord clamping is a higher iron reserve in children aged from birth to six months [90], as well as better psychomotor development [91]. In HIV-infected parturient women, patients living with an HIV-positive partner, and patients with unknown HIV status, there is no evidence that delayed cord clamping increases the likelihood of mother-to-child transmission of HIV [3, 89]. Too late cord clamping is accompanied by a significant increase in red blood cell count and hemoglobin level, which can lead to metabolic disorders accompanied by hyperbilirubinemia and an increase in indications for phototherapy [90].
Not recommended routine upper airway suctioning in infants born with clear amniotic fluid who have begun to breathe spontaneously [3, 92].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comment: Studies do not confirm a positive effect of routine upper airway suctioning, but show its possible adverse impact on the newborn. Suctioning can lead to n. vagus stimulation, causing bradycardia and the development of apnea. In addition, the procedure may cause damage to the upper airway mucosa and secondary infection [93].
Recommended early initiation of breastfeeding for all newborns who are able to receive breast milk independently, if their condition is stable and both mother and baby are ready for feeding [3, 94].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comment: There is compelling evidence that early initiation of breastfeeding (within the first hour after birth) and exclusive breastfeeding during the first month of life have significant benefits in reducing neonatal mortality and morbidity [95, 96].
Not recommended routine washing of the newborn in the first 24 hours after birth [97].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comment: The newborn's skin is covered with vernix caseosa (vernix caseosa), which protects the skin during intrauterine development. If the baby's skin is soiled with blood or meconium, it should be gently washed off with warm tap water.
Recommended prophylactic ocular antimicrobial administration shortly after birth for all newborns to prevent eye infections [164].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Comment: In the Russian Federation, for the prevention of eye infections during initial newborn care, it is recommended to use erythromycin 10,000 IU/g eye ointment (in individual packaging). The eye ointment is applied in sterile gloves behind the lower eyelid as a 1 cm long strip, without touching the eye or eyelids with the tube. Excess ointment can be removed after one minute using a sterile swab.
3.3. Management of the third stage of labor
Recommended parenteral administration of oxytocin** in the third stage of labor for the prevention of postpartum hemorrhage [98–102].
GPP ALOE 1Grade of Recommendation A (Level of Evidence – 1).
Comment: Oxytocin** is administered intramuscularly into the lateral thigh in a dose of 2 ml (10 IU) or intravenously in a dose of 5 IU in 50 ml of normal saline at a rate of 16.2 ml/h using a syringe pump; if oxytocin cannot be administered, the oxytocin agonist carbetocin** is administered intramuscularly or slowly intravenously at a dose of 100 mcg/ml [103].
Recommended in order to reduce the risk of postpartum hemorrhage, active management of the third stage of labor should be applied (administration of oxytocin** or carbetocin**, clamping and cutting the umbilical cord between the 1st and 3rd minutes after birth, spontaneous delivery of the placenta or its expulsion by external maneuvers within 30 minutes) [104], [31].
GPP ALOE 1Grade of Recommendation A (Level of Evidence – 1).
Comment: The placenta may be delivered by controlled cord traction, which should only be performed by trained medical personnel attending the birth. If the medical personnel lack these skills, it is necessary to wait for signs of placental separation and deliver the placenta using external methods. Performing controlled cord traction reduces the risk of retained placenta and manual removal of the placenta, but increases the risk of umbilical cord rupture [105–107].
For patients who received medical prophylaxis of postpartum hemorrhage in the third stage of labor, it is not recommended to routinely perform uterine massage for the prevention of postpartum hemorrhage [108].
Level of Evidence BLevel of Confidence 2Level of recommendation B (level of evidence – 2).
Comment: Uterine massage after vaginal delivery is not associated with a reduced risk of postpartum hemorrhage in patients who received oxytocin** and underwent controlled cord traction for the prevention of postpartum hemorrhage [108].
Recommended assessment of uterine tone after delivery by palpation for the early diagnosis of uterine hypotonia [98, 109, 110].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
3.4. Monitoring the mother's condition in the first 2 hours postpartum
To assess blood loss volume, it is recommended to use the gravimetric method – direct blood collection in graduated measuring containers combined with weighing blood-soaked soft materials [111, 112].
GPP ALOE 1Grade of Recommendation A (Level of Evidence – 1).
Comment: Physiological blood loss in vaginal delivery is <10% of circulating blood volume or <0.5-0.7% of body weight, or <5 ml/kg (<500.0 ml) [111].
Recommended to perform a postpartum inspection of the placenta (postpartum placental examination) for the timely diagnosis of structural integrity compromise and retained placental tissue in the birth canal [113].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
Recommended after delivery to inspect the vagina, perineum, and cervix using a speculum for the timely diagnosis of lacerations of the perineum, vagina, and cervix, and to perform surgical repair of the tears [12].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
It is recommended to monitor the patient's condition every 15 minutes during the first two hours after delivery: blood pressure, heart rate, uterine tone, uterine fundal height, character and volume of bloody vaginal discharge, condition of sutures (presence or absence of edema, hyperemia, hematomas); before transferring the patient to the postnatal ward, assess her condition, including body temperature control and bladder emptying [12].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Not applicable.
5. Prevention and Dispensary Observation
Comprehensive birth preparation is recommended to reduce anxiety and fear of childbirth [114], and to increase the likelihood of successful vaginal delivery and breastfeeding [115–117].
GCR BLEL 2Grading of Recommendations Assessment, Development and Evaluation — Recommendation Grade B (Level of Evidence – 2).
Comment: Childbirth preparation increases maternal satisfaction with labor, even if complications develop and medical interventions are required [118].
6. Organization of Medical Care
Medical care for normal childbirth can be provided in level 1, 2, and 3 obstetric healthcare facilities.
7. Additional Information
Not applicable.
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Yes/No |
|---|---|---|
1. | Upon admission to the inpatient facility, the gestational age and expected date of confinement were determined based on the last menstrual period and fetal ultrasound data. | Yes/No |
2. | The partogram was completed. | Yes/No |
3. | Parenteral administration of oxytocin** was performed after delivery of the fetus (in the absence of medical contraindications). | Yes/No |
4. | Delayed umbilical cord clamping was performed (no earlier than 1 minute and no later than 3 minutes after the birth of the child). | Yes/No |
5. | Placental delivery was performed within 30 minutes after the birth of the child. | Yes/No |
6. | Postpartum inspection of the placenta was performed. | Yes/No |
7. | Following delivery, examination of the vagina, perineum, and cervix using specula was performed, and lacerations were sutured. | Yes/No |
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Appendix A1. Working Group Composition
Oleg R. Baev – MD, PhD, Professor, Honored Doctor of the Russian Federation, Head of the 1st Maternity Ward, Head of the Department of Obstetrics and Gynecology at the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.
Roman G. Shmakov – MD, PhD, Professor, Professor of the RAS, Director of the Moscow Oblast Research Institute of Obstetrics and Gynecology named after Academician V.I. Krasnopolsky, Chief Freelance Specialist in Obstetrics of the Russian Ministry of Health (Moscow). No conflict of interest.
Sergey V. Martirosyan – PhD, Expert at the National Institute of Quality of Roszdravnadzor, Obstetrician-Gynecologist, Associate Professor at the Department of Obstetrics and Gynecology, Faculty of Fundamental Medicine, Lomonosov Moscow State University (Moscow). No conflict of interest.
Nataliia V. Dolgushina – MD, PhD, Professor, Deputy Director for Research at the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health, Chief Freelance Specialist in Women's Reproductive Health of the Russian Ministry of Health (Moscow). No conflict of interest.
Oksana V. Avdeeva – Chief Nurse at the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.
Baranov Igor Ivanovich – D.Sc. (Medicine), Professor, Head of the Department of Scientific and Educational Programs, Department of Research Organization, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health. There is no conflict of interest.
Kseniia A. Gorina – PhD, Obstetrician-Gynecologist at the Pregnancy Pathology Department, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health. No conflict of interest.
Dmitrii N. Degtyarev – MD, PhD, Professor, Deputy Director for Research at the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health, Head of the Department of Neonatology at the N.F. Filatov Clinical Institute of Child Health, Sechenov First Moscow State Medical University (Sechenov University), Chief Freelance Neonatologist of the Russian Ministry of Health in the Central Federal District (Moscow). No conflict of interest.
Viktor V. Zubkov – MD, PhD, Professor, Director of the Institute of Neonatology and Pediatrics, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.
Vladimir A. Klimov – PhD, Head of the Medical Care Organization and Information Service, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.
Elena N. Minakova – Deputy Chief Physician for Nursing and Medical Personnel, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.
Anastasiia V. Nikolaeva – PhD, Chief Physician, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.
Tatiana V. Priputnevich – MD, PhD, Director of the Institute of Microbiology, Antimicrobial Therapy and Epidemiology, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health, Chief Freelance Specialist in Medical Microbiology of the Russian Ministry of Health (Moscow). No conflict of interest.
Andrey Yu. Romanov – PhD, Head of the Department of Planning and Support of Scientific Projects, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.
Vladimir N. Serov – Academician of the RAS, MD, PhD, Professor, Honored Scientist of the RF, President of the Russian Society of Obstetricians and Gynecologists, Chief Researcher at the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.
Natalia V. Artymuk – MD, PhD, Professor, Head of the Department of Obstetrics and Gynecology named after Professor G.A. Ushakova, Kemerovo State Medical University of the Russian Ministry of Health, Chief Freelance Specialist in Obstetrics, Gynecology, and Women's Reproductive Health of the Russian Ministry of Health in the Siberian Federal District (Kemerovo). No conflict of interest.
Nadezhda V. Bashmakova – MD, PhD, Professor, Chief Researcher at the Ural Research Institute of Maternity and Infancy Welfare of the Russian Ministry of Health, Chief Freelance Specialist in Obstetrics, Gynecology, and Women's Reproductive Health of the Russian Ministry of Health in the Ural Federal District (Yekaterinburg). No conflict of interest.
Vitaly F. Bezhenar – D.Sc. (Medicine), Professor, Head of the Departments of Obstetrics, Gynecology and Neonatology/Reproductology, Head of the Clinic of Obstetrics and Gynecology, Academician I.P. Pavlov First Saint Petersburg State Medical University of the Russian Ministry of Health, Chief Freelancer Specialist in Obstetrics and Gynecology of the Healthcare Committee of the Government of Saint Petersburg (Saint Petersburg). No conflict of interest.
Tatiana Belokrinitskaya Evgenyevna – D.Sc. in Medicine, Professor, Head of the Department of Obstetrics and Gynecology, Faculty of Advanced Training and Professional Retraining of Healthcare Specialists, Chita State Medical Academy of the Russian Ministry of Health, Honored Doctor of the Russian Federation, Chief freelance specialist in obstetrics, gynecology, and women's reproductive health for the Far Eastern Federal District, Ministry of Health of Russia (Chita). No conflict of interest.
Akim Bykov – Ph.D. in Medicine, Anesthesiologist-Resuscitator, Yekaterinburg Clinical Perinatal Center (Yekaterinburg). No conflict of interest.
Uliana Vagushchenko – Obstetrician-Gynecologist, Organizational and Methodological Department, Yekaterinburg Clinical Perinatal Center, Assistant at the Department of Obstetrics and Gynecology, Faculty of Medicine and Preventive Care, Ural State Medical University (Yekaterinburg). No conflict of interest.
Kirill Desyatnik – Obstetrician-Gynecologist, Head of the Department of Pregnancy Pathology, Perinatal Center, Vorohobov City Clinical Hospital No. 67, Moscow Healthcare Department, Obstetrician (Moscow). No conflict of interest.
Irina Koltasheva – Head of the Quality Management and Medical Safety Department, Yekaterinburg Clinical Perinatal Center (Yekaterinburg). No conflict of interest.
Igor Kostin – D.Sc. in Medicine, Professor, Department of Obstetrics and Gynecology with a Course in Perinatology, Peoples' Friendship University of Russia (RUDN University) of the Ministry of Science and Higher Education of the Russian Federation (Moscow). No conflict of interest.
Olga Ksenofontova – Ph.D. in Medicine, Deputy Chief Medical Officer, Yekaterinburg Clinical Perinatal Center (Yekaterinburg). No conflict of interest.
Kulikov Alexander Veniaminovich – D.Sc. (Medicine), Professor at the Department of Anesthesiology, Intensive Care and Transfusiology of the Faculty of Advanced Training and Professional Retraining, Ural State Medical University of the Russian Ministry of Health (Yekaterinburg). Member of the Board of the Federation of Anesthesiologists and Intensivists and the Association of Obstetric Anesthesiologists-Intensivists. There is no conflict of interest.
Galina Malgina – D.Sc. in Medicine, Professor, Honored Doctor of the RF, Leading Researcher, Ural Research Institute of Maternity and Infancy Care of the Russian Ministry of Health (Yekaterinburg). No conflict of interest.
Anna Malyshkina – D.Sc. in Medicine, Professor, Director of the Gorodkov Ivanovo Research Institute of Maternity and Childhood of the Russian Ministry of Health, Head of the Department of Obstetrics and Gynecology and Medical Genetics, Faculty of Medicine, Ivanovo State Medical Academy of the Russian Ministry of Health, Chief freelance specialist in obstetrics, gynecology, and women's reproductive health for the Central Federal District, Ministry of Health of Russia (Ivanovo). No conflict of interest.
Anton Mikhailov – D.Sc. in Medicine, Professor, Chief Medical Officer, Maternity Hospital No. 17, Professor at the Department of Obstetrics and Gynecology, Mechnikov North-Western State Medical University of the Russian Ministry of Health, and the Department of Obstetrics, Gynecology, and Perinatology, Pavlov First Saint Petersburg State Medical University of the Russian Ministry of Health, Chief freelance specialist in obstetrics and gynecology for the North-Western Federal District, Ministry of Health of Russia (Saint Petersburg). No conflict of interest.
Tatiana Oboskalova – D.Sc. in Medicine, Professor, Head of the Department of Obstetrics and Gynecology, Faculty of Medicine and Preventive Care, Ural State Medical University (Yekaterinburg). No conflict of interest.
Anton Olenev – Ph.D. in Medicine, Chief freelance specialist in obstetrics, Moscow Healthcare Department, Head of the Perinatal Center Branch, City Clinical Hospital No. 24, Moscow Healthcare Department, Associate Professor at the Department of Obstetrics and Gynecology with a Course in Perinatology, Medical Institute of RUDN University. No conflict of interest.
Olga Perevozkina – Ph.D. in Medicine, Head of the Clinical and Expert Review Department, Perinatal Center, Vorohobov City Clinical Hospital No. 67, Moscow Healthcare Department, Obstetrician-Gynecologist, Assistant at the Department of Obstetrics and Gynecology, Faculty of Fundamental Medicine, Lomonosov Moscow State University (Moscow). No conflict of interest.
Victoria Popandopulo – D.Sc. in Medicine, Professor, Head of the Department of Obstetrics and Gynecology, Maykop State Technological University, Professor at the Department of Obstetrics and Gynecology, Faculty of Medicine, Astrakhan State Medical University of the Russian Ministry of Health, Chief Medical Officer, Kuban Medical Center LLC, Chief freelance specialist in obstetrics, gynecology, and women's reproductive health for the Southern Federal District, Ministry of Health of Russia (Krasnodar). No conflict of interest.
Pyregov Aleksey Viktorovich – D.Sc. (Medicine), Professor, Deputy Chief Physician for Anesthesiology and Intensive Care, Moscow Regional Perinatal Center, Chairman of the Committee on Anesthesiology and Intensive Care in Obstetrics and Gynecology, Association of Anesthesiologists-Intensivists (Moscow). There is no conflict of interest.
Viktor Radzinsky – Corresponding Member of the Russian Academy of Sciences, D.Sc. in Medicine, Professor, Honored Scientist of the Russian Federation, Head of the Department of Obstetrics and Gynecology with a Course in Perinatology, Peoples' Friendship University of Russia (RUDN University) of the Ministry of Science and Higher Education of the Russian Federation (Moscow). No conflict of interest.
Olga Sevostyanova – D.Sc. in Medicine, Chief Specialist Obstetrician-Gynecologist, Healthcare Administration of the City Administration of Yekaterinburg (Yekaterinburg). No conflict of interest.
Pavel Troshin – Anesthesiologist-Resuscitator, Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health (Moscow). No conflict of interest.
Ildar Fatkullin – D.Sc. in Medicine, Professor, Honored Scientist of the Republic of Tatarstan, Honored Doctor of the Republic of Tatarstan, Head of the Prof. V.S. Gruzdhev Department of Obstetrics and Gynecology, Kazan State Medical University of the Russian Ministry of Health, Chief freelance specialist in obstetrics and gynecology for the Volga Federal District, Ministry of Health of Russia (Kazan). No conflict of interest.
Larisa Fatkullina – Ph.D. in Medicine, Associate Professor at the Prof. V.S. Gruzdhev Department of Obstetrics and Gynecology, Kazan State Medical University, Head of the Obstetric and Gynecological Clinic, Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan, Perinatal Center, Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan (Kazan). No conflict of interest.
Oleg Filippov – D.Sc. in Medicine, Professor, Professor at the Department of Obstetrics and Gynecology, Faculty of Advanced Training for Physicians, Yevdokimov Moscow State University of Medicine and Dentistry of the Russian Ministry of Health, Deputy Director of the Department of Medical Care for Children and Obstetrics Services, Russian Ministry of Health (Moscow). No conflict of interest.
Elena Sheshko – Ph.D. in Medicine, Director of the Department of Medical Care for Children, Obstetrics Services, and Public Health, Russian Ministry of Health (Moscow). No conflict of interest.
Efim Shifman – D.Sc. in Medicine, Professor at the Department of Anesthesiology and Critical Care Medicine, Faculty of Advanced Medical Training, Vladimirsky Moscow Regional Research Clinical Institute (MONIKI), President of the Association of Obstetric Anesthesiologists-Resuscitators, Honored Doctor of the Republic of Karelia, Expert in Anesthesiology and Critical Care Medicine, Federal Service for Surveillance in Healthcare (Moscow). Member of the Presidium of the Federation of Anesthesiologists and Intensivists. No conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
Obstetricians-gynecologists.
Obstetrician-gynecologist residents.
Midwives.
Table 1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for assessing levels of evidence (LE) for methods of prevention, treatment, and medical rehabilitation, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)
LoE | Definitions |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for evaluating levels of confidence for recommendations (LCR) regarding methods of prevention, diagnosis, treatment, and medical rehabilitation, including those based
on the use of natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitation interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Appendix A3. Reference Materials
Rules for completing the partograph [156].
Patient information: full name, parity, medical record number, date and time of onset of labor, date and time of onset of the active phase of labor, date and time of amniotic fluid rupture, significant risk factors.
Indicate the actual time. For convenience, it is best to record in increments of 30 minutes, e.g., 13:00 or 13:30.
Hours 1, 2, 3, etc., correspond to the course of the active phase of the 1st and 2nd stages of labor and must not be altered in the table.
Fetal heart rate: the baseline rate is recorded every half hour in numbers. Note the presence of decelerations (early - E, variable - V, late - L).
Amniotic fluid: if the fetal membranes are intact or the fluid is clear and light, record every 4 hours; if meconium or blood is present, record every hour.
Ц (Intact) – fetal membranes are intact
С (Clear) – amniotic fluid is light and clear
М (Meconium) – fluid with meconium (any staining intensity)
К (Blood) – admixture of blood in the fluid
Fetal presentation: assessed every 4 hours in the first stage of labor and every hour in the second stage.
А – anterior position
P – posterior position
Т – transverse arrest of the sagittal suture
Caput succedaneum: assessed upon vaginal examination
0 – absent
+ mild
++ moderate
+++ large caput succedaneum
Fetal skull molding: assessed upon vaginal examination.
0 – no molding
+ bones are approximated at the sutures
++ bones overlap at the sutures but can be easily repositioned by pressure
+++ bones overlap at the sutures and cannot be repositioned
Pulse, blood pressure, body temperature, and maternal urination: assessed every 4 hours.
Frequency and duration of contractions: assessed every 30 minutes in the first stage of labor and every 15 minutes in the second stage. Pushing efforts are marked with the letter P on the line below the duration of contractions.
Cervical dilation: assessed during every vaginal examination and marked with a cross (x).
Descent of the fetal head: head descent is assessed via abdominal examination followed by vaginal examination. In the 1st stage of labour every 4 hours, in the 2nd stage every hour, and plotted on the graph with a circle in the corresponding cell. On abdominal palpation:
5 – entire head above the pelvic brim
4 – 4/5 of the fetal head is palpable - engaged at the pelvic brim
3 – 3/5 of the fetal head is palpable above the pubic symphysis (most of the head is above the pubic symphysis)
2 – 2/5 of the fetal head is palpable above the pubic symphysis (minor part of the head is above the pubic symphysis)
1 – a minimal part of the head is palpable above the pubic symphysis
0 – head is not palpable above the pubic symphysis (entirely in the pelvis)
Time: marked to the left of the line. For convenience, it is best to record in increments of 30 minutes, e.g., 13:00 or 13:30.
Oxytocin: when prescribed, record the dosage and infusion rate (plotted every 30 minutes).
Medication orders: record any additional medication orders.
Intravenous infusions: indicate the drug and dose in mL
Non-pharmacological methods of pain relief in labor
Birth ball. Promotes relaxation of the pelvic floor and provides freedom of movement [119]. When used in a sitting position, the ball exerts painless pressure on the perineum, which can block part of nociceptive reception at the spinal cord level and thereby reduce the sensation of pain.
Massage [3]. May reduce discomfort during labor, relieve pain, and increase maternal satisfaction with childbirth [3, 38]. It is a simple, inexpensive, and safe option for pain relief.
Acupressure [120, 121]. Limited data suggest the benefits of acupressure [122–124]. There are no known risks of using acupuncture when performed by trained personnel using disposable needles.
Application of warm packs [3]. Heat is usually applied to the woman's back, lower abdomen, groin, or perineum. Possible sources of heat include: hot water bottles, a sock filled with heated rice, a warm compress (towels soaked in warm water and wrung out), an electric heating pad, or a warm blanket. Caution should be exercised to avoid burns. The caregiver should test the heat source on their own skin and place one or two layers of fabric between the woman's skin and the hot pack. In addition to being used for pain relief, heat is also applied to relieve chills or shivering, reduce joint stiffness, decrease muscle spasm, and increase connective tissue extensibility [125–127].
Cold [128]. Cold packs may be applied to the lower back when the woman experiences back pain. Potential sources of cold include: a bag or surgical glove filled with ice, a frozen gel pack, a plastic bottle filled with ice, or ice-chilled cans of carbonated beverages. It is necessary to place one or two layers of fabric between the woman's skin and the cold pack. Cold compresses to the perineum may be used intermittently for several days postpartum [129].
Relaxation techniques, including progressive muscle relaxation and breathing techniques [3]. Yoga techniques for relaxation, breathing, and positioning used during the antenatal period reduce anxiety regarding childbirth [130, 131]. The use of yoga during labor may reduce pain and increase satisfaction with childbirth [39].
Shower [132] or water immersion in the first stage of labor [133, 134]. To avoid increasing the woman's core body temperature and potentially increasing fetal risk, the water temperature should be equal to human body temperature or slightly higher (no more than 37 °C) [135]. Prolonged immersion (more than two hours) prolongs labor and slows uterine contractions by inhibiting oxytocin production [136]. Medical contraindications to water immersion include: fever, suspected infection, abnormal fetal heart rate patterns, vaginal bleeding, and any conditions requiring continuous fetal monitoring. Evidence of the benefits of water immersion in the second stage of labor is limited. At the same time, there is no evidence of increased adverse outcomes for the newborn or the woman from water birth [133, 134]. A woman insisting on a water birth should be informed that the benefits and risks of this choice have not been sufficiently studied [134].
Audio analgesia (music, white noise, or ambient sounds) [39, 137]. Contributes to increased satisfaction with childbirth and a reduced risk of postpartum depression [138].
Aromatherapy [139, 140], [141]. Essential oils are potent substances and can be potentially harmful if used incorrectly [139–141]. Pregnant women should avoid blending their own essential oils. The use of aromatherapy should be supervised by specially trained personnel. Hospital staff should be informed about the use of aromatherapy to protect against allergic reactions in individuals sensitive to essential oils.
Hypnosis. May reduce the use of pharmacological methods of pain relief during labor. No effect on pain reduction satisfaction was identified [142]. Hypnosis is a focused form of concentration. Self-hypnosis is a form of hypnosis in which a certified specialist teaches an individual to induce an altered state of consciousness. The main goal of using self-hypnosis in labor is to help the woman maintain control by managing anxiety and discomfort, inducing a targeted state of relaxation [143]. It should be noted that hypnosis is contraindicated in individuals with a history of severe psychological disorders or psychosis. There are no other obvious risks or disadvantages to using hypnosis in labor.
Intradermal or subcutaneous injections of sterile water for back pain or any other labor pain [144]. Water injections typically consist of four intradermal or subcutaneous injections of 0.05 to 0.1 mL of sterile water. The first two points are located over the posterior superior iliac spines (where the right and left dimples of Michaelis are located). Two other points are located 3 cm inferior and 1 cm medial to the first two. After wiping the injection site with an alcohol swab, sterile water is injected, forming four small papules. Injections should be given quickly to reduce the duration of pain from the injections themselves. The patient should be warned that she will experience a burning sensation from the injections for 30–60 seconds. Pain relief occurs after 2 minutes and lasts for 1–2 hours [145]. No side effects have been reported other than temporary pain at the injection site.
Neuraxial analgesia in labor
Indications for neuraxial analgesia in labor [146], [147].
Arterial hypertension of any etiology (preeclampsia, essential hypertension, symptomatic arterial hypertension).
Labor in women with certain types of somatic disorders (e.g., essential hypertension, heart defects (not all), respiratory diseases - bronchial asthma, renal diseases - glomerulonephritis, high degree of myopia, increased intracranial pressure, etc.).
Labor in women with antenatal fetal death (in this case, the psychological state of the woman is a primary aspect).
Labor in women with current or past venous or arterial thrombosis.
Young parturients (under 18 years of age).
Intolerable pain experienced by the parturient during contractions (when assessing this indication, the visual analogue scale of pain intensity can be used).
Labor abnormalities (the obstetrician-gynecologist must consider the effect of epidural analgesia on the course of the second stage of labor).
Premature labor.
Epidural analgesia is preferable to opioid analgesics for pain relief in preterm labor due to greater efficacy and lower toxicity.
Contraindications to neuraxial analgesia in labor:
Severe hypovolemia (hemorrhagic shock, dehydration).
Coagulation disorders skewed toward hypocoagulation (activated partial thromboplastin time increased > 1.5 times, international normalized ratio increased > 1.5 times) and thrombocytopenia – < 70x109/L, acquired or congenital coagulopathies. With thrombocytopenia from 70 to 100x109/L and in the absence of hypocoagulation, only spinal analgesia may be used (use of small-gauge needles – 27-29 G is mandatory).
Purulent skin lesions at the puncture site.
Intolerance to local anesthetics (intolerance, as well as anaphylaxis to amide local anesthetics, is extremely rare).
Presence of a fixed cardiac output in female patients with a cardiac pacemaker, aortic valve stenosis, coarctation of the aorta, or severe mitral stenosis. In this situation, the feasibility of regional analgesia is assessed individually and agreed upon with the cardiovascular surgeon, as the degree of compensation for hemodynamic disorders caused by the valvular defect is of great importance.
Severe hepatic impairment (coagulation disorders and altered metabolism of local anesthetics).
Demyelinating diseases of the nervous system and peripheral neuropathy (evaluated on an individual basis).
Tattoo at the puncture site.
The decision on the possibility of labor pain relief using neuraxial analgesia methods, and subsequently the tactics of its management at all stages of labor, is determined exclusively jointly by the obstetrician-gynecologist and the anesthesiologist-resuscitator, taking into account all risk factors, the specifics of the course of labor, and the condition of the fetus. Neuraxial analgesia is performed by an anesthesiologist-resuscitator.
Physical activity and the upright position of the woman during the first stage of labor reduce the overall duration of labor, lower the risk of cesarean section, and are not associated with adverse effects for the mother and fetus. This is achieved by using local anesthetic solutions at the minimum concentration that provides an analgesic effect (differential block phenomenon) [148], [149].
Neuraxial methods of labor analgesia may be accompanied by a prolongation of the second stage of labor [150], [151], [152] due to a pronounced motor block, and the following techniques are used to prevent this complication:
In the absence of acute fetal hypoxia, delivery is not expedited until the degree of motor block decreases.
Continuous infusion of a local anesthetic into the epidural space is used.
The concentration of the local anesthetic is decreased (which may result in a weakening of the analgesic effect) [148].
After delivery, the puerpera must remain in a supine position for two hours; getting up and walking is permitted only when accompanied by medical staff. This is due to the potential residual effect of the motor block and the development of orthostatic hypotension.
For the safe use of epidural analgesia, as well as other methods of neuraxial analgesia, it is necessary to be guided by the following principles recommended by the American Society of Anesthesiologists.
Neuraxial analgesia/anesthesia must be performed in facilities equipped for resuscitation and intensive care.
Neuraxial analgesia/anesthesia must be performed by a properly trained anesthesiologist-resuscitator.
The patient must be examined prior to the procedure, and the condition of the woman and fetus must be assessed jointly with the obstetrician-gynecologist.
Ensuring the availability of infusion therapy (venous catheterization, ready-to-use solutions).
Monitoring of the mother's and fetus's condition must be provided.
Personnel must be prepared to perform neonatal resuscitation.
The anesthesiologist-resuscitator must monitor the woman throughout the entire period of neuraxial analgesia/anesthesia and in the postpartum period.
All necessary equipment and medications for treating complications following neuraxial analgesia/anesthesia must be available.
The safety of neuraxial labor analgesia for the woman and fetus is determined by the following factors:
The competence of the anesthesiologist-resuscitator regarding the specifics of performing neuraxial labor analgesia.
The competence of the obstetrician-gynecologist regarding the course of labor under epidural analgesia.
Modern technical equipment (needles, catheters, dispensers, monitors).
Modern local anesthetics (bupivacaine**, ropivacaine**).
Continuous monitoring of the mother's and fetus's condition.
The safety of patients receiving anticoagulants (heparin group, ATC: B01AB) and/or antiplatelet agents (antiplatelet agents other than heparin, ATC: B01AC) during neuraxial anesthesia and invasive procedures (surgery) in a scheduled setting depends on adherence to the time intervals from the last administration to the start of the procedure. In an emergency, methods to inactivate the effects of anticoagulants and antiplatelet agents must be used [153].
Systemic pharmacologic analgesia
Systemic opioids provide minor to moderate pain relief during labor. Pain relief is incomplete, temporary, accompanied by sedation, and is more effective at the onset of active labor. Opioids may be ineffective after cervical dilation exceeds 7 cm. Despite their limitations, temporary relief of labor pain after opioid administration can be a useful and satisfactory pain management strategy for many laboring women.
Inhalation analgesia
Inhalation analgesia is the administration of subanesthetic doses of inhalation anesthetics for pain relief in labor. Although inhalation methods provide some level of analgesia, it is insufficient for adequate labor pain relief in the majority of women. These methods can be used as an adjunct in failed neuraxial blockades or when the latter are contraindicated. Inhalation analgesia can be administered intermittently (during contractions) and continuously. Inhalation methods can be used for patient-controlled analgesia, but under the supervision of an anesthesiologist-resuscitator to monitor the level of consciousness and the correct use of equipment.
The N2O/O2 50:50 mixture has been used for many years both as a mono-anesthetic and as an adjuvant in regional methods of labor analgesia. Associated side effects include dizziness, nausea, apathy, and reduced responsiveness. The maximum analgesic effect occurs 45-60 seconds after the start of inhalation. Therefore, it is very important that the laboring woman starts inhalation at the very first signs of a contraction and stops it after the peak of uterine contraction. The lack of scavenging systems for expired gases in pre-labor wards theoretically exposes medical staff to the risk of prolonged exposure to excessive concentrations of exhaled anesthetics. It has been found that inhaling a 50:50 nitrous oxide-oxygen mixture does not affect the functions of the liver, kidneys, cardiovascular, or respiratory systems. The analgesic effect of nitrous oxide is dose-dependent, which provides some efficacy in labor pain relief.
#Sevoflurane** is also used for pain relief in labor. An inspired concentration of 0.8% is acceptable for effective labor analgesia. #Sevoflurane, compared to the N2O/O2 50:50 mixture, provides a higher level of analgesia, but against the background of more pronounced sedation. It does not exhibit prominent side effects and is convenient for laboring women [154], [155]. The use of volatile anesthetics in labor is limited by central nervous system depression, unpleasant odor, and high cost. The main hazard when using volatile anesthetics is accidental overdose resulting in loss of consciousness and loss of airway-protective reflexes.
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
What is normal labor?
Normal labor is term labor (at 370 – 416 weeks of gestation) with a single fetus, starting spontaneously, with a low risk of obstetric complications at the onset of labor (in the absence of preeclampsia, fetal growth restriction, fetal compromise, placenta previa, and other complications), proceeding without complications, resulting in the spontaneous birth of the infant in a cephalic presentation, and followed by a satisfactory condition of both the patient and the newborn.
Can labor be normal in the presence of pre-existing obstetric complications?
In rare cases, labor may be considered normal in the presence of certain pre-existing obstetric complications, such as preeclampsia, fetal growth restriction without fetal compromise, etc.
How does labor progress?
Labor consists of 3 stages.
The first stage of labor is the time from the onset of labor until full cervical dilation. This stage of labor consists of a latent phase and an active phase. The latent phase is characterized by mild uterine contractions (sometimes painful) and slow cervical dilation up to 5 cm. This phase can last up to 20 hours in primiparous women and up to 14 hours in multiparous women. The active phase is characterized by regular painful uterine contractions and cervical dilation up to complete dilation. The duration of the active phase typically does not exceed 12 hours in the first labor and 10 hours in subsequent labors. Contractions during the active phase occur every 2-3 minutes.
The second stage of labor is the time from full cervical dilation to the birth of the baby. During this stage, the patient feels a strong urge to push (expulsive efforts), which occur every 2-5 minutes. The duration of the second stage of labor in first-time mothers is usually no more than 3 hours, and in multiparous mothers no more than 2 hours, but when epidural analgesia is used, the duration may be one hour longer.
The third stage of labor is the time from the birth of the baby to the delivery of the placenta. Usually, the third stage of labor is completed within 15-30 minutes.
How should I behave during labor?
In the absence of contraindications, physical activity and assuming a comfortable position are recommended during labor, especially in the first stage. A free, comfortable position is also encouraged during the second stage (pushing), provided it does not interfere with monitoring the fetus's condition and providing obstetric care.
Can my partner be present during delivery?
The presence of a partner during delivery is encouraged, provided they have prepared to assist and are present at the birth.
Will I experience pain during labor?
Labor is typically accompanied by painful sensations during contractions (lasting approximately 60 seconds) followed by relaxation. Proper breathing and remaining calm are necessary to minimize discomfort.
Will pain relief be provided during labor?
Initially, non-pharmacological methods of pain relief are recommended, such as proper breathing techniques, the use of a birth ball, massage, warm compresses, cold packs on the back in case of lower back pain, and others, which prove effective in the majority of cases. If non-pharmacological methods are ineffective, at your request, in the absence of contraindications, and if available at the medical facility, epidural analgesia may be performed. You should be aware that epidural analgesia is associated with an increased risk of prolonged labor.
Do I need to shave my perineum before childbirth?
No, shaving the perineal hair is not mandatory and is done solely at your request.
Will I be given an enema before childbirth?
No, a cleansing enema is not mandatory and may be administered solely at your request.
What interventions will be performed by medical personnel during labor?
A venous catheter will be placed (typically in the antecubital vein) to allow for rapid intervention in the event of bleeding. Vaginal examinations will also be performed upon admission to the hospital, then every 4 hours during the active phase of the first stage of labor, every hour during the second stage (pushing), as well as when indicated (e.g., prior to epidural analgesia or upon rupture of membranes), and postpartum to assess the integrity of the birth canal and suture any lacerations if identified. Additionally, fetal palpation (assessing fetal position through the abdominal wall) and fetal auscultation (listening to the fetal heart rate) using an obstetric stethoscope will be performed, with cardiotocography (CTG) utilized if any abnormalities are detected. Ultrasound examination of the fetus may be required if fetal distress occurs or to confirm presentation. Immediately after birth, uterotonics will be administered via the venous catheter to prevent postpartum hemorrhage.
Can I eat and drink during labor?
Fluid intake and, in the absence of contraindications, light food are recommended during labor. However, solid food is not recommended.
Will I be able to use the restroom during labor?
You should urinate regularly during labor, and you may use the restroom and shower if available at the medical facility. Otherwise, an individual bedpan will be provided.
How can perineal and birth canal tears be prevented?
To prevent perineal and vaginal tears, digital perineal massage with gel and warm compresses applied to the perineum using cloths soaked in warm water (43°C) can be used during the second stage of labor, which may be performed by the midwife if available.
What happens when the baby is born?
When your baby is born, in the absence of complications, they will be placed on your abdomen for skin-to-skin contact, covered, and initiated to the breast as early as possible. All subsequent neonatal procedures (weighing, eye drops, wiping, neonatal examination) will be performed later in the delivery room.
When will the umbilical cord be clamped?
In the absence of contraindications, delayed cord clamping is indicated — no earlier than 1 minute and no later than 3 minutes after birth.
How long will I stay in the delivery room after childbirth?
Observation in the delivery room typically does not exceed 2 hours, after which you and your baby will be transferred to the postpartum ward.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Not applicable.