Introduction of routine admission CTG might reduce equity if it leads to a cascade of unnecessary interventions that can only be accessed by more advantaged women and those in well resourced settings. In settings with high perinatal mortality rates, CTG interventions aimed at improving detection of the hypoxic fetus, with an appropriate increase in caesarean section, might increase equity by conferring greater benefit to the disadvantaged women.
In a review of qualitative studies exploring women's and providers' experiences of labour and childbirth, results suggest that some women find the use of CTG reassuring but feel restricted by the equipment and would prefer a more hands-on, woman-centred approach to care (low confidence in the evidence) (26).
Findings from a sub-study of the review (26) showed that staff felt that CTG is overused, that it leads to unnecessary interventions and, from a midwifery perspective, undermines traditional, womanfocused skills (high confidence in the evidence).
While some staff believe that the use of CTG offers reassurance, many do not trust the technology and feel pressured to use it in a defensive manner to temper organizational fears of litigation (high confidence in the evidence). In addition, some health care professionals do not feel sufficiently trained to interpret CTG tracings and acknowledge that understanding and interpretation can be inconsistent (high confidence in the evidence).
Findings also suggest that, where possible, health care professionals would prefer to use IA because they believe it offers more flexibility and leads to better outcomes (compared to CTG) (low confidence in the evidence).

# Additional considerations
Qualitative review findings are from HIC settings only.
In a qualitative systematic review exploring health care professionals' views (26), a sub-analysis on views on CTG and fetal monitoring showed that staff tend to believe that CTG is overused and may lead to unnecessary interventions (high confidence in the evidence). This is likely to have cost implications, which would reduce feasibility of responding to the findings in low-resource settings. Staff also believe that it is cheaper to use (compared with alternatives), but financial constraints often lead to poor maintenance and limited availability of accessories (low confidence in the evidence).

# Additional considerations
Qualitative review findings are from HIC settings only. In low-resource settings, other higher priority health resource needs will discourage investment in procuring CTG machines and training health care staff to use them.

# Routine perineal/pubic shaving prior to giving vaginal birth is not recommended. (Not recommended)
This recommendation has been integrated from the WHO recommendations for prevention and treatment of maternal peripartum infections (114), in which the GDG for that guideline determined it to be a conditional recommendation based on very low-quality evidence. This recommendation applies to all hair shavings around the female external genital area within the context of vaginal birth. It does not apply to women being prepared for caesarean section.
The decision regarding perineal/pubic shaving should be left to the woman and not the health care provider. In situations where a woman chooses to have perineal/pubic shaving prior to birth, she should be advised to arrange to be shaved wherever and by whomever she is most comfortable with (e.g. at home shortly before the time of labour and childbirth).
The evidence supporting this recommendation can be found in the source guideline document, available at: 

# Enema on admission

# RECOMMENDATION 15
Administration of an enema for reducing the use of labour augmentation is not recommended.
This recommendation has been integrated from the WHO recommendations for augmentation of labour (46), in which the GDG for that guideline determined it to be a strong recommendation based on very low-quality evidence. The GDG noted that the routine use of enema has neither been shown to reduce the duration of labour nor confer any other clinical benefits. It is considered invasive and associated with discomfort for women.
The GDG placed its emphasis on the feasibility of implementing this recommendation, the reduction in health care resource use and acceptability among caregivers and women, and therefore made a strong recommendation against this intervention. The evidence supporting this recommendation can be found in the source guideline document, available at: 

# Digital vaginal examination

# RECOMMENDATION 16
Digital vaginal examination at intervals of four hours is recommended for routine assessment of active first stage of labour in low-risk women. (Recommended)
This recommendation has been integrated from the WHO recommendations for prevention and treatment of maternal peripartum infections (114), in which the GDG for that guideline determined it to be a strong recommendation based on very low-quality evidence.
There is currently no direct evidence on the most appropriate frequency of vaginal examinations to prevent infectious morbidity in the mother and baby, and therefore this recommendation was based on consensus reached by the GDG, and it is in agreement with a similar recommendation in the 2014 WHO recommendations for augmentation of labour (46). Priority must be given to restricting the frequency and total number of vaginal examinations. This is particularly crucial in situations when there are other risk factors for infection (e.g. prolonged rupture of amniotic membranes and long duration of labour).
The GDG acknowledged that the frequency of vaginal examinations is dependent on the context of care and the progress of labour. The group agreed that vaginal examinations at intervals more frequent than specified in this recommendation may be warranted by the condition of the mother or the baby.

# Summary of evidence and considerations

# Effects of the intervention (EB Table 3.2.10)
The evidence was derived from a Cochrane systematic review comparing continuous CTG versus intermittent auscultation (IA) for assessment of fetal well-being during labour (115). For the purposes of this guideline, only evidence derived from the low-risk subgroup of the review was included. These low-risk subgroup data were derived from four trials conducted in Australia (989 women), Ireland (10 053 women), the United Kingdom (504 women) and the USA (14 618 women), which reported their findings between 1978 and 1986. The study conducted in Ireland also included women with high-risk pregnancies, but these data were excluded from this analysis. Three trials were individual RCTs and one was a quasi-RCT (the USA study), which alternated interventions for each month of the trial. The latter study was assessed as being at a high risk of bias. The method of IA varied across trials to include auscultation using a Pinard fetal stethoscope and/or Doppler ultrasound device. The absolute difference in effect was estimated at 1 event fewer per 1000 babies (from 0 to 2 fewer). There were no data in the review on cord blood acidosis or cerebral palsy for the low-risk subgroup.
Perinatal mortality: This evidence is of very low certainty, due to study design limitations and very few events.
Long-term infant outcomes: Studies of women with low-risk pregnancies did not report cerebral palsy or other long-term infant outcomes.

# Additional considerations
The evidence for the low-risk subgroup was consistent with the evidence for high-risk and mixed-risk subgroups. Very few clinically relevant neonatal outcomes were reported consistently in the trials (115). In addition, as long-term follow-up was not performed, the longterm effects of the reported neonatal seizures are not known.
The trials did not distinguish between nulliparous and parous women, or between women in spontaneous and induced labour. In addition, trials were relatively old and clinical practices used in them might differ from current practice; for example, in one trial, routine amniotomy was performed within an hour of admission in all women.
Continuous CTG compared with intermittent CTG was evaluated in an RCT conducted in Sweden among 4044 participants at low risk of complications (116). In the intermittent group, CTG was performed for 10-30 minutes every 2.0-2.5 hours during the first stage of labour, and stethoscope auscultation was performed every 15-20 minutes in the periods between CTG. All women were monitored continuously in the second stage of labour. The review authors found no significant differences in caesarean section for fetal distress (1.2% vs 1.0%, respectively) or other birth outcomes, and concluded that intermittent CTG was as safe as continuous CTG for monitoring low-risk labour.
Findings from a qualitative review of what matters to women during intrapartum care (23) indicate that most women want a normal childbirth, but acknowledge that medical intervention may sometimes be necessary to facilitate the birth of a healthy baby (high confidence in the evidence).
Where interventions are introduced, women would like to receive relevant information from technically competent health care professionals who are sensitive to their needs.
The findings also showed that women want to be in control of their birth process and would like to be involved in decision-making around the use of interventions (high confidence in the evidence).

# Additional considerations
Evidence from the same qualitative review suggests that women might place a higher value on avoiding the risk of additional interventions (e.g. caesarean section, instrumental birth and fetal blood sampling) that make birth abnormal and which override their control of the birth process, without necessarily improving outcomes for them and their babies (23).
In addition, continuous CTG during labour could negatively impact on a woman's sense of autonomy during the birth process, by increasing her discomfort and reducing her choices with regard to mobility and pain relief options.
No research evidence on relative costs or costeffectiveness of CTG compared with IA was found.

# Additional considerations
Auscultation with the Pinard fetal stethoscope is the least expensive method of fetal monitoring.
The evidence on beneficial effects of continuous CTG suggests that it might not be cost-effective when compared with IA since the only clear benefit is a small absolute reduction in neonatal seizures (with a rate of 1 fewer per 1000), and the longterm effects are unclear. Given that the use of CTG could also lead to moderate increases in costly labour interventions, such as caesarean section, instrumental vaginal birth and fetal sampling, which are associated with additional risks of morbidities for the mother and the baby, avoiding its use could lead to substantial cost savings. Health care costs related to procuring CTG equipment for the labour ward, with the associated maintenance costs, or use of ancillary resources such as pH monitoring, can instead be used to ensure access to other basic facilities. For instance, the cost of internal CTG monitoring as estimated in a Dutch study was 1316 per birth (117).
No evidence on the impact of CTG on equity was found.

# Additional considerations
Trials on the effects of continuous CTG compared with IA were conducted in HICs and the effect estimates may not be directly applicable to LMICs with high perinatal mortality rates. However, these effects of continuous CTG suggest that it could reduce equity if it leads to a cascade of unnecessary interventions.
WHO's 2015 State of inequality report indicates that women who are poor, least educated and residing in rural and remote areas have lower access to health intervention coverage than more advantaged women (33). In these settings, it is likely that electronic fetal heart rate (FHR) monitoring of any sort is highly inequitable, due to variable quality of care and a lack of basic resources. Studies report that adequate monitoring of labour progress is often lacking in such settings, and that the FHR may only rarely be auscultated (118)(119)(120). The introduction of continuous CTG into these settings could only further impact negatively on equity.
In a review of qualitative studies exploring women's and providers' experiences of labour and childbirth, results suggest that some women find the use of CTG reassuring but feel restricted by the equipment and would prefer a more hands-on, woman-centred approach (low confidence in the evidence) (26). In addition, findings from a qualitative review looking at what matters to women during intrapartum care suggest that women do not like to be left alone during labour and would prefer the presence of a sensitive and competent health care professional (high confidence in the evidence) (23).
The findings of the qualitative review of experiences of labour and childbirth also showed that some health care professionals feel CTG is overused, that it leads to unnecessary interventions and, from a midwifery perspective, undermines traditional, woman-focused skills (high confidence in the evidence) (26). While some staff believe that the use of CTG offers reassurance, many do not trust the technology and feel pressured to use it in a defensive manner to temper organizational fears of litigation (high confidence in the evidence).
In addition, some health care professionals do not feel sufficiently trained to interpret CTG tracings and acknowledge that understanding and interpretation can be inconsistent (high confidence in the evidence). Findings also suggest that, where possible, health care professionals would prefer to use IA because they believe it offers more flexibility and leads to better outcomes (compared with CTG) (low confidence in the evidence).

# Additional considerations
The qualitative findings were derived from HIC settings only (26). Findings from a USA-based study exploring midwives' attitudes towards the use of intermittent fetal monitoring found that among 145 midwives, 72.4% agreed that intermittent monitoring should be the standard of care and 87.0% stated that they would be willing to provide it. However, 53.9% indicated that nurse-patient ratios were a problem in providing this service (121).
In spite of the evidence indicating no clear clinical benefits, the views of some clinicians are that CTG is better at identifying at-risk babies than IA and that this justifies the additional risk of interventions, even in women without apparent risk factors for labour complications. However, CTG is likely to be particularly unacceptable for women and other health care professionals who believe that childbirth should be a natural, non-medicalized experience.
Findings from a qualitative systematic review of women's and health care providers' experiences of labour and childbirth suggest that women may find CTG irritating because it restricts their movement (low confidence in the evidence) (26).
The review findings also indicate that staff believe CTG tends to be overused and may lead to unnecessary interventions (high confidence in the evidence). They also believe that it is cheaper to use (compared to fetal monitoring techniques) but that financial constraints may lead to poor maintenance and limited availability of accessories. In addition, some health care professionals believe that workload pressures combined with poor staffing levels lead to CTG being used (continuously) as a "babysitter" and as an inadequate substitute for woman-centred care.

# Additional considerations
Qualitative findings are from HIC settings only. However, they suggest that women's views might impede the use of CTG in labour care settings whereas health care professionals' mixed views would impact its implementation differently depending on the context (26).
- Don't know - Varies - Reduced  Probably reduced - Probably no impact - Probably increased - Increased Acceptability - Don't know  Varies - No - Probably No - Probably Yes - Yes Feasibility - Don't know  Varies - No - Probably No - Probably Yes - Yes

# Intermittent fetal heart rate auscultation during labour

# RECOMMENDATION 18
Intermittent auscultation of the fetal heart rate with either a Doppler ultrasound device or a Pinard fetal stethoscope is recommended for healthy pregnant women in labour. (Recommended)
There is some evidence to suggest that intermittent auscultation (IA) with a handheld Doppler ultrasound device, cardiotocography (CTG), or strict monitoring with Pinard fetal stethoscope could increase the detection of fetal heart rate (FHR) abnormalities, which may in turn reduce hypoxiaischaemia outcomes. However, the impact on other substantive early and long-term infant outcomes is unclear.
The GDG stressed that IA of the FHR during labour is essential for intrapartum care, irrespective if the device used, with strict adherence to clinical protocols. The group noted that monitoring of the FHR during labour is inadequate in many low-and middle-income country (LMIC) settings, and this problem needs to be strongly addressed through quality improvement initiatives in these settings.
The GDG acknowledged the lack of evidence of comparative benefits of different IA protocols and variations in protocols across health care settings. However, the group agreed that standardization of protocol is important for health care planning and medico-legal purposes and, therefore, adopted the following protocol (113).
" " Interval: Auscultate every 15-30 minutes in active first stage of labour, and every 5 minutes in the second stage of labour.
" Duration: Each auscultation should last for at least 1 minute; if the FHR is not always in the normal range (i.e. 110-160 bpm), auscultation should be prolonged to cover at least three uterine contractions. Timing: Auscultate during a uterine contraction and continue for at least 30 seconds after the contraction.
" " Recording: Record the baseline FHR (as a single counted number in beats per minute) and the presence or absence of accelerations and decelerations.

# Summary of evidence and considerations

# Effects of the intervention (EB Table 3.2.11)
Evidence was derived from a Cochrane systematic review that included three RCTs conducted in Uganda, the United Republic of Tanzania and Zimbabwe, involving 6241 women in labour, but only two studies (excluding the one from the United Republic of Tanzania) were included in the metaanalysis (122).
The trial in Uganda (1987 women without risk factors) compared intermittent use of a Doppler ultrasound device with intermittent monitoring using a Pinard fetal stethoscope. Both methods were performed for 1 minute immediately after a contraction, and this was done every 30 minutes in the first stage, every 15 minutes in the second stage before bearing down, and every 5 minutes in second stage when bearing down.
The Zimbabwe trial (633 women) was a four-arm trial that compared intermittent cardiotocography (CTG), Doppler and two methods of Pinard FHR monitoring (strict and routine practice). In the CTG arm, an external transducer was applied for 10 minutes every half hour to monitor the FHR; it is unclear how consistently the transducer for contractions was applied. The Doppler and "strict" Pinard methods involved a research midwife auscultating the FHR for 1 minute during the last 10 minutes of every half hour, during and immediately after a contraction, whereas the midwives on duty performed auscultation in the "routine practice" arm. Women in this trial had obstetric or medical risk factors (excluding women with placental abruption or eclampsia) and were booked at or transferred to a referral hospital for childbirth. Where data from this trial were included in meta-analyses, the evidence was downgraded for indirectness.
Participants in both trials had term singleton pregnancies with cephalic presentation, and on admission they had cervical dilatation less than or equal to 7 cm and a FHR of 120-160 beats per minute.

# Perinatal mortality:
The evidence for this outcome is of very low certainty.
Long-term infant outcomes: These were not reported in the trials.

# Additional considerations
The evidence for most outcomes was based on data from a study among women described as having "high-risk" pregnancies. From the evidence, it is uncertain whether increased identification of early and late decelerations and increased caesarean section for fetal distress translate to improved early and long-term infant outcomes.
Findings from a review of qualitative studies looking at what matters to women during intrapartum care (23) indicate that most women want a normal childbirth with good outcomes for mother and baby, but acknowledge that interventions may sometimes be necessary. When interventions are being considered, women would like to be informed about the nature of the interventions and, where possible, given a choice (high confidence in the evidence). They also value receiving care and attention from technically competent health care providers who are sensitive to their needs (high confidence in the evidence).

# Additional considerations
The evidence on effects suggests that Doppler in LMICs may increase detection of FHR abnormalities, it probably increases subsequent caesarean section for fetal distress, and it may reduce perinatal hypoxia-ischaemia. Globally, women place a high value on avoiding severe newborn morbidity such as perinatal hypoxia-ischaemia and neonatal seizures and would be willing to have a healthy baby at the expense of increased caesarean section morbidity.
No research evidence on relative costs or costeffectiveness of Doppler compared with Pinard was found.

# Additional considerations
Pinard fetal stethoscope is the cheapest method of IA available.
No evidence on the impact of different types of fetal monitoring on equity was found.

# Additional considerations
WHO's 2015 State of inequality report indicates that women who are poor, least educated and residing in rural and remote areas have lower access and less health intervention coverage than more advantaged women (33). Studies report that adequate monitoring of labour progress is often lacking in such settings, and that the FHR may only rarely be auscultated (118)(119)(120). While Doppler fetal monitors are easier to apply, they are scarce in rural and remote health care facilities as a result of competing health resource needs. The introduction of Doppler monitoring into clinical practice may attract additional costs and therefore its use is more likely in facilities that provide care for more advantaged women.
In a review of qualitative studies exploring women's experiences of labour and childbirth, results suggest that women would prefer a more hands-on, womancentred approach to care and are likely to favour any technique that allows for this (high confidence in the evidence) (26).
Findings on health care professionals' experiences of labour and childbirth from the same review (26), show that staff like to use a Doppler device because it offers reassurance and potentially leads to better outcomes for women (compared with CTG) (low confidence in the evidence). In certain settings, health care professionals prefer to use a Pinard fetal stethoscope because it facilitates a more womancentred approach to care (low confidence in the evidence).

# Additional considerations
Qualitative findings from health care professionals were derived from high-income settings only.
Doppler also allows a woman to hear the fetal heartbeat, which provides reassurance and could add to its appeal over Pinard fetal monitoring.
A qualitative systematic review of women's experiences of labour and childbirth found no feasibility concerns relating to the use of Doppler (26).
The same review also explored health care professionals' views and found that staff believed that Doppler offers a more flexible approach to fetal monitoring and is less expensive to use compared with other similar monitoring equipment (low confidence in the evidence) (26). However, findings also suggest that in certain low-income settings the resources associated with using Doppler -in terms of initial purchase costs, training and ongoing maintenance -may be restrictive (low confidence in the evidence).

# Additional considerations
A Pinard fetal stethoscope is the least expensive option; however, Doppler is probably easier to use and therefore might be more feasible in settings with few midwives if the device is available and if equipment maintenance and a continuous supply of batteries is assured.
- Don't know - Varies - Reduced  Probably reduced - Probably no impact - Probably increased - Increased Acceptability - Don't know  Varies - No - Probably No - Probably Yes - Yes Feasibility - Don't know  Varies - No - Probably No - Probably Yes - Yes
Comparison 2: Intermittent cardiotocography (CTG) compared with routine Pinard fetal stethoscope Evidence was derived from the four-arm trial conducted in Zimbabwe, which for this comparison involved 633 women and babies. The "routine practice" Pinard group received "usual care" from the midwives on duty. As mentioned above, participants in this study were women with risk factors for complications; therefore, this evidence has been downgraded for indirectness.

# Maternal outcomes

# Birth experience:
There was no evidence on any element of maternal birth experience from this trial, including satisfaction, inability to adopt preferred position during labour, or perceived loss of control during labour.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: Low-certainty evidence suggests that intermittent CTG may reduce hypoxic-ischaemic encephalopathy (HIE) (RR 0.20, 95% CI 0.04-0.90) and neonatal seizures (RR 0.05, 95% CI 0.00-0.89). The absolute difference in HIE based on this limited data set is estimated at 25 fewer per 1000 (from 3 to 30 fewer). Evidence on Apgar scores of less than 7 at 5 minutes is of very low certainty. Cord blood acidosis was not reported in this trial.

# Perinatal mortality: Evidence on this outcome is of very low certainty.
Long-term infant outcomes: These were not reported in this trial.

# Additional considerations
The evidence for this comparison is based on data from a single study among women described as having "high-risk" pregnancies; therefore, the beneficial effects could be over-estimated. From the evidence, it is uncertain whether increased identification of early and late decelerations, and increased caesarean section for fetal distress, translated to improved early and long-term infant outcomes.
Findings from a review of qualitative studies looking at what matters to women during intrapartum care (23) indicate that most women want a normal childbirth with good outcomes for mother and baby, but acknowledge that interventions may sometimes be necessary. When interventions are being considered, women would like to be informed about the nature of the interventions and, where possible, given a choice (high confidence in the evidence).

# Additional considerations
The evidence on effects suggests that intermittent CTG in LMICs may increase detection of FHR abnormalities, and may reduce perinatal hypoxiaischaemia at the expense of subsequent caesarean section for fetal distress. Globally, women place a high value on avoiding severe newborn morbidity such as perinatal hypoxia-ischaemia and may be willing to have a healthy baby at the expense of caesarean section morbidity.
No research evidence on relative costs or costeffectiveness of different types of IA was found.
No evidence on the impact on equity was found.

# Additional considerations
WHO's 2015 State of inequality report indicates that women who are poor, least educated and residing in rural and remote areas have lower access to health intervention coverage than more advantaged women (33). Studies report that adequate monitoring of labour progress is often lacking in such settings, and that the FHR may only rarely be auscultated (118)(119)(120). Electronic fetal monitors are scarce in rural and remote health care facilities as a result of other competing health resource needs. An investment in CTG will likely attract additional costs for the women and for the facilities and therefore its use is more likely in facilities that provide care for more advantaged women. CTG might also reduce equity if it leads to a cascade of interventions that can only be afforded by more advantaged women and those in well resourced settings.
In a review of qualitative studies exploring women's and health care providers' experiences of labour and childbirth, results suggest that some women find the use of CTG reassuring but feel restricted by the equipment and would prefer a more hands-on, woman-centred approach (low confidence in the evidence) (26).
From the same review (26), findings show that staff feel CTG is overused and may lead to unnecessary interventions (moderate confidence in the evidence). From a midwifery perspective, staff believe that CTG undermines traditional, woman-focused skills (moderate confidence in the evidence) and may be used to "babysit" when staffing levels are low (low confidence in the evidence). While some staff believe that the use of CTG offers reassurance, many do not trust the technology and feel pressured to use it in a defensive manner to temper organizational fears of litigation (high confidence in the evidence). In addition, some health care professionals do not feel sufficiently trained to interpret CTG tracings and acknowledge that understanding and interpretation can be inconsistent (high confidence in the evidence).

# Additional considerations
Qualitative findings were derived from HIC settings only. New wireless methods of CTG may be more acceptable to women than existing CTG as they allow women to remain mobile during labour; these methods are undergoing evaluation for use in LMIC settings (123).
Findings from a qualitative systematic review of women's views and experiences of labour and childbirth suggest that CTG may restrict women's movement (low confidence in the evidence) (26).
The same review explored health care professionals' views and experiences of labour and childbirth; the findings indicate that many health care professionals believe CTG tends to be overused and might lead to unnecessary interventions (moderate confidence in the evidence). This is likely to have cost implications. Findings also suggest that, where possible, health care professionals prefer to use a Doppler device because of the greater flexibility it allows and because they believe it leads to better outcomes (compared with CTG). In addition, although health care professionals believe that CTG is cheaper to use (compared with other high-tech alternatives), they recognize that financial constraints may lead to poor maintenance and limited availability of accessories in certain contexts.

# Additional considerations
These qualitative findings were derived from HIC settings only. A Pinard fetal stethoscope is likely to be the cheapest option in low-resource settings. The need for ongoing maintenance and supplies with CTG reduces its feasibility in LMICs.
- Probably increased - Increased Acceptability - Don't know  Varies - No - Probably No - Probably Yes - Yes Feasibility - Don't know  Varies - No - Probably No - Probably Yes - Yes
Comparison 3: "Strict" (or intensive) monitoring compared with "routine" monitoring with Pinard fetal stethoscope Evidence for this comparison was derived from the Zimbabwe trial that included women with risk factors for complications (1 trial, 625 women and babies); therefore, it has been downgraded for indirectness.

# Maternal outcomes
Mode of birth: Low-certainty evidence suggests that there may be little or no difference between intensive and routine Pinard monitoring in terms of caesarean section for any indication (RR 0.71, 95% CI 0.46-1.08), caesarean section due to fetal distress (RR 0.70, 95% CI 0.35-1.38) and instrumental vaginal birth (RR 1.21, 95% CI 0.69-2.11).

# Birth experience:
There was no evidence on maternal birth experience from this trial, including satisfaction, inability to adopt preferred position during labour, or perceived loss of control during labour.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: Evidence on Apgar scores less than 7 at 5 minutes, neonatal seizures and hypoxic-ischaemic encephalopathy (HIE) is of very low certainty.
Fetal distress: Moderate-certainty evidence suggests that intensive Pinard monitoring probably increases the diagnosis of a FHR abnormality (RR 1.71, 95% CI 1.10-2.65), but may not do so for early and late FHR decelerations (RR 1.33, 95% CI 0.79-2.23) (low-certainty evidence).

# Perinatal mortality: Evidence on this outcome is of very low certainty.
Long-term infant outcomes: These were not reported in this trial.

# Additional considerations
From the evidence, it is uncertain whether increased identification of a FHR abnormality leads to improved birth and long-term infant outcomes.
Findings from a review of qualitative studies looking at what matters to women during intrapartum care (23) indicate that most women want a normal childbirth with good outcomes for mother and baby, but acknowledge that medical intervention or assessment may sometimes be necessary. Where this is the case, they would like to receive relevant information from technically competent health care providers who are sensitive to their needs (high confidence in the evidence).
No research evidence on resources was found.

# Additional considerations
The two study arms in the Zimbabwe study appear to reflect research-context (rigorous) practice versus typical daily (less-rigorous) practice. It is plausible that more rigorous fetal monitoring is more resource intensive in terms of staff time.

# Main resource requirements: See resource requirements in comparison 2 (Table 3.30).
WHO's 2015 State of inequality report indicates that women who are poor, least educated and residing in rural and remote areas have lower access to health intervention coverage than more advantaged women (33). In these settings, it is likely that FHR monitoring is less rigorous due to a lack of resources and poor quality of care. Studies report that adequate monitoring of labour progress is often lacking in such settings, and that the FHR may only rarely be auscultated (118)(119)(120). Addressing this fundamental quality of care issue with appropriate training, supervision and monitoring could have an impact on equity, irrespective of the method of intermittent auscultation.
Findings from a qualitative systematic review of women's and providers' experiences of labour and childbirth (26) indicate that women are likely to appreciate the more intimate connection with a health care professional that this strict or intensive monitoring approach enables, provided the practice is conducted by kind, competent staff who are sensitive to their needs (high confidence in the evidence). The review's findings also suggest that health care professionals like to deliver this kind of womancentred care provided there are enough resources (staff) to cover the more labour-intensive nature of this approach (high confidence in the evidence).

# Additional considerations
The qualitative evidence above suggests that if fetal monitoring were to be performed, women would prefer that competent staff perform it in such a way such that it detects fetal hypoxia in time to avert poor outcomes (26). Women may feel that they are better looked after if their health care providers are providing strict monitoring of the well-being of their baby.
A qualitative systematic review of women's experiences of labour and childbirth found no feasibility concerns relating to the intensive use of Pinard fetal stethoscope.
The same review also explored health care professionals' experiences of providing intrapartum care and found that staff sometimes lacked the time to conduct monitoring using this approach and felt that accurate monitoring required skill and experience that was sometimes difficult to achieve in time-pressured situations (low confidence in the evidence) (26).

# Epidural analgesia for pain relief

# RECOMMENDATION 19
Epidural analgesia is recommended for healthy pregnant women requesting pain relief during labour, depending on a woman's preferences. (Recommended)
The GDG agreed that while there is limited evidence on the impact of epidural analgesia compared with no epidural analgesia for pain relief during labour, epidural analgesia is a proven method for relieving pain related to surgery, including abdominal surgery, and chose to recommend it as a pain relief option.
Health care professionals should be aware that women's desire for epidural analgesia might be moderated by the clinical context in which they receive antenatal and intrapartum care, whether labour is spontaneous or not, and their access to and knowledge of a range of other forms of pain relief measures.
It is likely that the care context and the type of care provision and care provider have a strong effect on the need for labour pain relief, and on the kinds of choices women make in relation to this need. Both commonly used pharmacological options for pain relief during labour -epidural and opioid analgesic options -have advantages and disadvantages. Epidural analgesia appears to be the more effective pain relief option but compared with opioid analgesia it also requires more resources to implement and to manage its adverse effects, which are more common with epidural analgesia.
To avoid complications and preserve as much motor function as possible, the lowest possible effective concentration of local anaesthetic should be used when administering epidural analgesia (124).
For women with epidural analgesia in the second stage of labour, it is recommended that a birth position of the individual woman's choice be facilitated, including an upright birth position. For women with epidural analgesia in the second stage of labour, delaying pushing for one to two hours after full dilatation or until the woman regains the sensory urge to bear down is recommended.

# Summary of evidence and considerations

# Effects of the intervention (EB Table 3.2.12)
This evidence is derived from a Cochrane systematic review, to which 43 trials contributed data (125).

# Maternal outcomes
Pain relief: It is uncertain whether epidural analgesia compared with no analgesia reduces pain scores, pain intensity or the need for additional analgesia during labour because the certainty of the evidence for all of these outcomes is very low.

# Mode of birth:
Moderate-certainty evidence suggests that epidural analgesia probably leads to fewer women undergoing caesarean birth compared with no analgesia (5 trials, 578 women, RR 0.46, 95% CI 0.23-0.90). It is uncertain whether epidural has an effect on instrumental births because the certainty of this evidence is very low.

# Duration of labour:
It is not clear whether epidural analgesia makes any difference to the length of the first or second stages of labour compared with placebo, as the certainty of the evidence is very low.

# Augmentation of labour:
Low-certainty evidence suggests that epidural analgesia may make little or no difference to whether or not women receive oxytocin for labour augmentation (3 trials, 415 women, RR 0.89, 95% CI 0.63-1.24).
Birth experience: Low-certainty evidence from a single trial suggests that epidural may increase the proportion of women reporting they were satisfied or very satisfied with pain relief in labour (70 women, RR 1.32, 95% CI 1.05-1.65). Compared with no analgesia, it is uncertain whether epidural affects women's perceived feelings of poor control in childbirth because the certainty of this evidence is very low.
Side-effects: Review evidence on the relative effect of epidural compared with placebo or no intervention on hypotension, vomiting, fever, drowsiness or urinary retention is very uncertain.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: It is uncertain whether epidural analgesia has an effect on the number of babies born with Apgar scores of less than 7 at 5 minutes because the certainty of this evidence is very low.
Long-term outcomes: These were not reported in the included studies.
Mother-baby interaction and breastfeeding: These were not reported in any of the included trials.
In a review of qualitative studies looking at what matters to women during intrapartum care (23), findings suggest that most women, especially those giving birth for the first time, are apprehensive about childbirth (high confidence in the evidence), and in certain contexts and/or situations may welcome interventions that provide relief from pain (low confidence in the evidence). When interventions are being considered, women would like to be informed about the nature of the interventions and, where possible, given a choice (high confidence in the evidence).
A review of qualitative studies on women's experiences of the use of epidural analgesia when they request pain relief (from HICs only) highlights that women desire and value epidural analgesia when its use alleviates labour pain effectively, and they also value that it enables them to retain control over childbirth (moderate confidence in the evidence) (126). However, some women are fearful of receiving an epidural injection due to potential pain and complications, and there were mixed views on whether the pain relief provided was actually effective or ineffective in their experience (low confidence in the evidence). Some women perceive that epidural analgesia helped them to have a positive childbirth experience (moderate confidence in the evidence). Women value the opportunity to make a choice about this method of pain relief and value the support of professionals and family members for their decision on pain-relief (low confidence in the evidence).

# Additional considerations
All the included qualitative studies on the use of epidural analgesia were undertaken in high-income settings. Six were undertaken in the USA. It was not possible to identify, within the included studies, whether women had had augmentation, induction of labour or other forms of intervention that may have influenced how they valued the outcomes associated with this form of pain relief.
In some cultures, women might consider labour pain an integral part of childbirth and view physical expression of pain or discomfort as a sign of weakness. In addition, some women might view the use of epidural analgesia as an intervention that negatively impacts their sense of control during labour and childbirth.
No recent reviews on costs and cost-effectiveness were found; however, a 2002 USA review of the cost-effectiveness of epidural compared with opioid analgesia suggests that providing epidural analgesia for labour pain relief costs more than opioid analgesia (127). In the review, the mean cost of a hospital-based vaginal birth was US$ 3117, and the incremental expected cost of providing epidural analgesia was estimated at US$ 338 (1998 values), primarily due to higher costs for health care professionals (estimated at US$ 238) and increased costs associated with complications (estimated at US$ 120). The costs modelled for epidural analgesia assumed more instrumental vaginal births (14% vs 10%), fever (24% vs 6%), oxytocin augmentation (45% vs 35%), urinary retention (2.7% vs 0.13%), postural puncture headache (1.5% vs 0%), hypotension requiring treatment (30% vs 0%) and a longer duration of labour (7 hours versus 6 hours for the first stage, and 1.75 hours versus 1.5 hours for the second stage) than opioid analgesia, in addition to a higher rate of less-common complications. Opioid analgesia costs assumed a higher incidence of respiratory depression among women receiving opioids (14% vs 2%), a higher incidence of neonatal resuscitation due to respiratory depression (4.5% vs 0.5%) and more pruritis (14% vs 12%). Caesarean section was assumed to occur at the same rate for epidural and opioid analgesia (20%).

# Additional considerations
Findings from other studies suggest that costs per birth are substantially higher with epidural analgesia (128,129). For example, in an Australian study, epidural analgesia use alone was shown to increase the average cost of childbirth by up to 36% depending on the type of health care facility (129). For nulliparous women giving birth in a public health care facility, epidural analgesia increased birth costs by 20%, and when combined with labour augmentation it attracted an additional 24% increase in costs (i.e. 44% increase in total). Findings from a Dutch study comparing routine epidural analgesia with analgesia on request reported that birth costs were higher by 322 (60 to 355) with routine epidural analgesia, due to higher medication costs, a longer stay in hospital, and more caesarean sections and instrumental vaginal births (130).
The health care professionals required to administer and monitor epidural analgesia, and to perform instrumental births, are probably the main cost component of this intervention. In the Dutch study, costs attributed to the procedure itself were much higher for epidural analgesia (122) compared with opioid analgesia (15).
In many settings, women undergoing epidural analgesia cannot be managed in midwife-led birthing units but, rather, are managed at a higher level of care (i.e. hospital obstetric units), such that bed costs are also likely to be higher. Labour ward stays are also likely to be longer with epidural, due to the potential for longer duration of labour and postpartum monitoring.
No direct evidence was found on the impact of pain relief via epidural analgesia on equity. Indirect evidence from a review of facilitators and barriers to facility-based birth (8) indicates that "neglect and delays in receiving care" probably acts as a barrier to facility-based birth (moderate confidence in the evidence). Such neglect and delays might be applicable to labour pain management.
In addition, the review also highlights that many women in LMICs fear "unfamiliar and undesirable" birth practices, which are barriers to facility-based birth (high confidence in the evidence) (8). Some women could perceive epidural injections and other types of injections as unfamiliar and undesirable practices.

# Additional considerations
WHO's 2015 State of inequality report concluded that there are still large gaps in skilled birth attendance coverage (33). Epidural analgesia for pain relief is commonly used in HICs and among more advantaged women in LMICs. Due to its high resource implications, its availability within countries often varies between facilities and, for example, it is often not available in rural areas where women cannot afford it and the expertise is lacking (127). Limited findings from one USA study suggest that women with different sociodemographic characteristics might receive a different level of access to epidural analgesia and/or a different level of participation in decision-making in relation to epidural use (131).
Providing effective and timely labour pain relief to disadvantaged women might help to reduce inequalities in intrapartum care directly. Based on the evidence above, it might also impact equity indirectly, by encouraging more disadvantaged women to access facility-based care. However, particularly in LMIC settings, epidural analgesia might be perceived by some women as an unfamiliar and undesirable practice and could act as a barrier to facility-based birth, particularly for women who believe that labour and childbirth are natural processes that do not need intervention, and those who would prefer a traditional approach to pain management.
It has been argued that changing the attitudes of health care professionals and women surrounding labour pain and reducing the medicalization of labour discomfort could empower women to rediscover their innate birthing capabilities (132), which might positively impact equity by reducing epidural analgesia use in high-resource settings.
In a qualitative systematic review exploring women's experiences of epidural analgesia usage (126) there were mixed views. Views were influenced by the availability of epidural analgesia and by accounts of others (moderate confidence in the evidence). Some women expressed an a priori desire for an epidural analgesia to help with a pain-free labour, to alleviate a fear of pain and/or to remain in control during labour (moderate confidence in the evidence), while others requested an epidural as a last resort, when the level of pain and/or sense of control over the labour was overwhelming and unmanageable (low confidence in the evidence).
There was evidence that epidural analgesia could help to facilitate a positive labour and childbirth experience by helping women to relax, restore/ renew their energy levels and have a sense of control (moderate confidence in the evidence). However, although some women felt supported by health care professionals in their decision to use epidural analgesia, others felt pressurized or persuaded to do so (by health care professionals, through messages received via antenatal education or from family members) (low confidence in the evidence).
Some women who made a decision to receive an epidural analgesia had fears over the procedure and potential risks for themselves and/or their babies (low confidence in the evidence). They experienced negative physiological effects including pain and other complications associated with needle insertion (low confidence in the evidence). Some also felt disconnected from the baby and experienced a range of negative emotions including conflict, guilt, disappointment and a sense of failure (low confidence in the evidence). Some women reported restricted mobility following administration of epidural analgesia (low confidence in the evidence).
Pain relief afforded by epidural analgesia was considered effective for some, but not for all (low confidence in the evidence). Perceived lack of effectiveness was attributed to continuing pain, breakthrough pain and/or timing of administration (e.g. when it was administered too late for it to take effect).
Another qualitative systematic review on women's and health care professionals' experiences of labour and childbirth included health care professionals' views on epidural analgesia (26); however, the evidence was of very low confidence. The evidence suggests that some midwives feel that epidural analgesia is incongruous with the midwifery philosophy, and associate it with side-effects, disconnection from the baby and the potential for further intervention. Evidence also suggests that some health care professionals believe that, if it is used, it may be more appropriate for nulliparous women or for those with an abnormal labour.

# Additional considerations
The qualitative review findings on epidural analgesia (26,126) are all from studies conducted in HIC settings where epidural usage is common.
Findings from a qualitative systematic review exploring women's and providers' experiences of labour and childbirth (26) indicate that some health care professionals in HICs may encourage women to use epidural analgesia because of a heavy workload and a lack of time to provide supportive options (very low confidence in the evidence).
A perceived lack of effectiveness of epidural analgesia use reported by women in some studies in another qualitative systematic review (126) was partly attributed to late administration (low confidence in the evidence), suggesting that there might be logistical issues in implementing this pain relief method.

# Additional considerations
All of the findings on epidural analgesia in the qualitative reviews (26,126) came from HIC settings where epidural analgesia is widely available. In lower-resource settings, where it is not so widely used, there are likely to be financial implications as well as additional training considerations, which may negatively impact on the feasibility of implementing this intervention.  Bupivacaine or levobupivacaine was used for the epidural analgesia in most of the studies when reported. Bupivacaine was supplemented with fentanyl in 10 of the studies and with tramadol in one study. Levobupivacaine was supplemented with fentanyl in one study. Only four of the studies used the combined spinal-epidural technique. Epidural use was discontinued in the second stage of labour in three studies. Opioids compared included pethidine (17 trials, 6889 women), butorphanol (1 trial, 100 women), fentanyl (3 trials, 447 women) and remifentanil (9 trials, 3462 women), while other opioids were used in the remaining trials. Opioids were administered as patient-controlled intravenous analgesia in 19 trials, intravenous injection in 10 trials, and intramuscular injection in 5 trials (the route of administration was unclear in 1 trial).
- Don't know - Varies - Reduced  Probably reduced - Probably no impact - Probably increased - Increased Acceptability - Don't know  Varies - No - Probably No - Probably Yes - Yes Feasibility - Don't know  Varies - No - Probably No - Probably Yes - Yes

# Maternal outcomes
Pain relief: Low-certainty evidence suggests that epidural analgesia may reduce pain scores in women during labour compared with parenteral opioid analgesia (5 trials, 1133 women, standardized mean difference  -2.64, 95% CI -4.56 to -0.73; this equates to a difference of approximately 3 points lower on a 10-point scale). Low-certainty evidence suggests that women who receive epidural may be more likely than those receiving opioids to rate pain relief as excellent or very good (7 trials, 1911 women, RR 1.47, 95% CI 1.03-2.08). Low-certainty evidence suggests epidural may reduce the need for any additional analgesia (16 trials, 5099 women, RR 0.10, 95% CI 0.04-0.25).

# Mode of birth:
Low-certainty evidence suggests that epidural may increase instrumental vaginal birth, with 13.2% in the epidural analgesia group having an instrumental vaginal birth compared with 9.6% in the parenteral opioids group (31 trials, 10 343 women, RR 1.43, 95% CI 1.29-1.59). Moderatecertainty evidence suggests that epidural analgesia probably leads to little or no difference in the numbers of women undergoing caesarean birth (34 trials, 10 745 women, RR 1.07, 95% CI 0.97-1.19). Birth experience: Low-certainty evidence from a single trial suggests that epidural analgesia may make little or no difference to women's perception of poor control in childbirth (334 women, RR 1.17, 95% CI 0.62-2.21) or to the number of women reporting they were satisfied or very satisfied with their childbirth experience (332 women, RR 0.95, 95% CI 0.87-1.03).

# Duration of labour:
Low-certainty evidence suggests that epidural analgesia may increase the likelihood of hypotension, although there was considerable inconsistency across trials in the numbers of women reported to have hypotension (10 trials, 4212 women, RR 11.34, 95% CI 1.89-67.95). Moderatecertainty evidence suggests that epidural analgesia is probably associated with a reduced risk of respiratory depression requiring oxygen compared with opioids (5 trials, 2031 babies, RR 0.23, 95% CI 0.05-0.97). It is not clear whether, compared with opioid analgesia, epidural analgesia reduces nausea and vomiting, or maternal drowsiness, as the certainty of the evidence is very low. Low-certainty evidence suggests fever (temperature > 38 C) may be increased with epidural analgesia (10 trials, 4671 women, RR 2.60, 95% CI 1.82-3.73). Moderatecertainty evidence suggests that, compared with parenteral opioids, the risk of urinary retention is probably increased with epidural analgesia (4 trials, 343 women, RR 9.20, 95% CI 2.28-37.11).

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: Low-certainty evidence suggests that there is little or no difference in Apgar scores less than 7 at 5 minutes (23 trials, 9147 babies, RR 0.80, 95% CI 0.58-1.10). Moderatecertainty evidence suggests the number of babies with a cord arterial pH less than 7.2 is probably fewer with epidural analgesia than opioid analgesia (8 trials, 4783 babies, RR 0.81, 95% CI 0.69-0.94); however, low-certainty evidence suggests that there was little or no difference between groups for cord arterial pH less than 7.15 (3 trials, 480 babies, RR 1.17, 95% CI 0.64-2.14). Moderate-certainty evidence suggests that babies whose mothers received epidural analgesia rather than parenteral opioids are probably less likely to need naloxone administration (10 trials, 2645 babies, RR 0.15, 95% CI 0.10-0.23).
Long-term neonatal outcomes: These were not reported in any of the included trials.
Mother-baby interaction and breastfeeding: These were not reported in any of the included trials.
In a review of qualitative studies looking at what matters to women during intrapartum care (23), findings suggest that most women, especially those giving birth for the first time, are apprehensive about childbirth (high confidence in the evidence), and in certain contexts and/or situations may welcome interventions that provide relief from pain (low confidence in the evidence). When interventions are being considered, women would like to be informed about the nature of the interventions and, where possible, given a choice (high confidence in the evidence).
Findings from a review of qualitative studies on women's experiences during labour and childbirth (evidence derived from HICs only) highlights that women desire and value epidural analgesia when its use alleviates labour pain effectively, and they also value that it enables them to retain control over childbirth (moderate confidence in the evidence) (26). However, some women are fearful of receiving an epidural injection due to potential pain and complications, and expressed mixed views on whether the pain relief provided was actually effective or ineffective in their experience (low confidence in the evidence). Some women perceive that epidural analgesia helped them to have a positive childbirth experience (moderate confidence in the evidence).
Women value the opportunity to make a choice about this method of pain relief and value the support of professionals and family members for their decision on pain-relief (low confidence in the evidence).

# Additional considerations
All the included qualitative studies on the use of epidural analgesia were undertaken in high-income settings. Six were undertaken in the USA. It was not possible to identify, within the included studies, whether women had had augmentation, induction of labour or other forms of intervention that may have influenced how they valued the outcomes associated with this form of pain relief.
In some cultures, women might consider labour pain as an integral part of childbirth and view physical expression of pain or discomfort as a sign of weakness. In addition, some women might view the use of epidural analgesia as an intervention that negatively impacts their sense of control during labour and childbirth.
No recent reviews on costs and cost-effectiveness were found; however, a 2002 USA review of the cost-effectiveness of epidural compared with opioid analgesia suggests that providing epidural analgesia for labour pain relief costs more than opioid analgesia (127). In the review, the mean cost of a hospital-based vaginal birth was US$ 3117, and the incremental expected cost of providing epidural analgesia was estimated at US$ 338 (1998 values), primarily due to higher costs for health care professionals (estimated at US$ 238) and increased costs associated with complications (estimated at US$ 120). Costs modelled for epidural analgesia assumed more instrumental vaginal births (14% vs 10%), fever (24% vs 6%), oxytocin augmentation (45% vs 35%), urinary retention (2.7% vs 0.13%), postural puncture headache (1.5% vs 0.0%), hypotension requiring treatment (30% vs 0%), and a longer duration of labour (7 vs 6 hours for the first stage, and 1.75 vs 1.50 hours for the second stage) than opioid analgesia, in addition to a higher rate of less-common complications. Opioid analgesia costs assumed a higher incidence of respiratory depression among women receiving opioids (14% vs 2%), a higher incidence of neonatal resuscitation due to respiratory depression (4.5% vs 0.5%) and more pruritis (14% vs 12%). Caesarean section was assumed to occur at the same rate for epidural and opioid analgesia (20%).

# Additional considerations
Findings from other studies suggest that costs per birth are substantially higher with epidural analgesia (128,129). For example, in an Australian study, epidural analgesia use alone was shown to increase the average cost of childbirth by up to 36% depending on the type of facility (129). For primiparous women giving birth in a public health facility, epidural analgesia increased birth costs by 20%, and when combined with labour augmentation it attracted an additional 24% increase in costs (i.e. 44% increase in total). Findings from a Dutch study comparing routine epidural analgesia with analgesia on request reported that birth costs were higher by 322 (60 to 355) with routine epidural analgesia, due to higher medication costs, a longer stay in hospital, and more caesarean sections and instrumental vaginal births (130).
The health care professionals required to administer and monitor epidural analgesia, and to perform instrumental births, are probably the main cost component of this intervention. In the Dutch study, costs attributed to the procedure itself were much higher for epidural analgesia (122) compared with opioid analgesia (15).
In many settings, women undergoing epidural analgesia cannot be managed in midwife-led birthing units but, rather, are managed at a higher level of care (i.e. hospital obstetric units), such that bed costs are also likely to be higher. Labour ward stays are also likely to be longer with epidural, due to the potential for longer duration of labour and postpartum monitoring.
No direct evidence was found on the impact of pain relief via epidural analgesia on equity.
Indirect evidence from a review of facilitators and barrier to facility-based birth (8) indicates that "neglect and delays in receiving care" probably acts as a barrier to facility-based birth (moderate confidence in the evidence). Such neglect and delays might be applicable to labour pain management.
In addition, the review also highlights that many women in LMICs fear "unfamiliar and undesirable" birth practices, which are barriers to facility-based birth (high confidence in the evidence) (8). Some women could perceive epidural injections and other types of injections as unfamiliar and undesirable practices.

# Additional considerations
WHO's 2015 State of inequality report concluded that there are still large gaps in skilled birth attendance coverage (33). Epidural analgesia for pain relief is commonly used in HICs and among more advantaged women in LMICs. Due to its high resource implications, its availability within countries often varies between facilities and, for example, it is often not available in rural areas where women cannot afford it and the expertise is lacking (127). Limited findings from one USA study suggest that women with different sociodemographic characteristics might receive a different level of access to epidural analgesia and/or a different level of participation in decision-making related to epidural use (131).
Providing effective and timely labour pain relief to disadvantaged women might help to reduce inequalities in intrapartum care directly. Based on the evidence above, it might also impact equity indirectly, by encouraging more disadvantaged women to access facility-based care. However, particularly in LMIC settings, epidural analgesia might be perceived by some women as an unfamiliar and undesirable practice and could act as a barrier to facility-based birth, particularly for women who believe that labour and childbirth are natural processes that do not need intervention, and those who would prefer a traditional approach to pain management.
It has been argued that changing the attitudes of health care professionals and women surrounding labour pain (and reducing the medicalization of labour discomfort) could empower women to rediscover their innate birthing capabilities (132), which might positively impact equity by reducing epidural analgesia use in high-resource settings.
In a qualitative systematic review exploring women's intrapartum care experiences (126), there were mixed views of epidural analgesia usage. Views were influenced by the availability of epidural analgesia, and by accounts of others (moderate confidence in the evidence). Some women expressed an a priori desire for an epidural analgesia to help with a pain-free labour, to alleviate a fear of pain and/ or to remain in control during labour (moderate confidence in the evidence), while others requested an epidural as a last resort, when the level of pain and/or sense of control over the labour was overwhelming and unmanageable (low confidence in the evidence).
There was evidence that an epidural could help to facilitate a positive labour and childbirth experience by helping women to relax, to restore/renew their energy levels, and to have a sense of control (moderate confidence in the evidence). However, although some women felt supported by health care professionals in their decision to use epidural analgesia, others felt pressurized or persuaded to do so (by health care professionals, through messages received via antenatal education of from family members) (low confidence in the evidence).
Some women who made a decision to receive an epidural analgesia had fears over the procedure and potential risks for themselves and/or their babies (low confidence in the evidence). They experienced negative physiological effects including pain and other complications associated with needle insertion (low confidence in the evidence). Some also felt disconnected from the baby and experienced a range of negative emotions including conflict, guilt, disappointment and a sense of failure (low confidence in the evidence). Some women reported restricted mobility following administration of epidural analgesia (low confidence in the evidence).
Pain relief afforded by epidural analgesia was considered effective for some, but not for all (low confidence in the evidence). Perceived lack of effectiveness was attributed to continuing pain, breakthrough pain and/or timing of administration (e.g. when it was administered too late for it to take effect).
Another qualitative systematic review on women's and health care providers' experiences of labour and childbirth included health care professionals' views on epidural analgesia (26); however, the evidence was of very low confidence. The evidence suggests that some midwives feel that epidural analgesia is incongruous with the midwifery philosophy, and associate it with side-effects, disconnection from the baby and the potential for further intervention. Evidence also suggests that some health care professionals believe that, if it is used, it may be more appropriate for nulliparous women or for those with an abnormal labour.

# Additional considerations
The qualitative review findings (26,126) are all from studies conducted in HIC settings where epidural usage is common.
Findings from a qualitative systematic review of intrapartum care experiences (26) indicate that some health care professionals in HICs may encourage women to use epidural analgesia because of a heavy workload and a lack of time (very low confidence in the evidence).
A perceived lack of effectiveness of epidural analgesia use reported by women in some studies included in another systematic review (126) was partly attributed to late administration (low confidence in the evidence), suggesting that there might be logistical issues in implementing this pain relief method.

# Additional considerations
All of the findings on epidural use in the qualitative reviews (26,126) came from HIC settings where epidural analgesia is widely available. In lowerresource settings, where it is not so widely used, there are likely to be financial implications as well as additional training considerations, which may negatively impact on the feasibility of implementing this intervention.

# Opioid analgesia for pain relief

# RECOMMENDATION 20

# Parenteral opioids, such as fentanyl, diamorphine and pethidine, are recommended options for healthy pregnant women requesting pain relief during labour, depending on a woman's preferences. (Recommended)
Many women appreciate some form of pain relief in labour and would like a choice of options. The evidence suggests that opioids probably provide some relief from pain during labour, despite having some undesirable side-effects, such as drowsiness, nausea and vomiting. Despite being widely available and used, pethidine is not the preferred opioid option, as shorter-acting opioids tend to have fewer undesirable side-effects. Before use, health care providers should counsel women about the potential side-effects of opioids, including maternal drowsiness, nausea and vomiting, and neonatal respiratory depression, and about the alternative pain relief options available.
It is important that health care providers take care to ensure that the correct dosage is administered, as opioid overdose can have serious consequences.
Stakeholders should be aware that the care context and the type of care provision and care provider might have a strong effect on the need for labour pain relief, and on the kinds of choices women make in relation to this need. The GDG agreed that for women who suffer from current or previous opioid addiction, non-opioid methods of pain relief are preferred. Health care providers need to be trained to manage side-effects if they arise and must be aware that opioid medication should be securely stored with a register kept of its dispensing, to reduce the risk of abuse. Birth experience, mother-baby interaction, breastfeeding: These were not reported in any of the included trials.

# Summary of evidence and considerations

# Effects of the intervention (EB

# Fetal and neonatal outcomes

# Perinatal hypoxia-ischaemia (Apgar scores < 7):
The evidence is of very low certainty.
Long-term adverse infant outcomes: These were not reported in any of the included trials.

# Comparison 1.b. Pethidine (intravenous compared with placebo
One trial with 240 women conducted in Egypt compared IV pethidine with placebo.

# Maternal outcomes
Pain relief: Low-certainty evidence suggests that IV pethidine may reduce pain scores (1 trial, 240 women, MD -4.1, 95% CI -3.64 to -4.56).

# Mode of birth: Evidence of any effect on instrumental vaginal birth and caesarean section is of very low certainty.
Side-effects: Low-certainty evidence suggests that nausea and vomiting may be increased for women receiving IV pethidine (1 trial, 240 women, RR 2.43, 95% CI 1.05-5.64). No other side-effects were reported.
Birth experience, mother-baby interaction, breastfeeding: These were not reported in the included trial.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: This was not reported in the included trial.
Long-term neonatal outcomes: These were not reported in the included trial.
Comparison 1.c. Pentazocine (IM) compared with placebo
One three-arm trial conducted in Pakistan involving 150 women compared pentazocine (IM, 30 mg) with a saline placebo. The trial was published in 2016.

# Maternal outcomes
Pain relief: Low-certainty evidence suggests that IM pentazocine may make little or no difference to pain scores compared with placebo (1 trial, 89 women, MD -3.6, 95% CI -9.91 to 2.71).

# Mode of birth:
Low-certainty evidence suggests IM pentazocine may make little or no difference to caesarean or instrumental vaginal birth (1 trial, 89 women, RR 0.89, 95% CI 0.24-3.25 and RR 0.60, 95% CI 0.10-3.39, respectively).
None of the women in this trial reported vomiting. Other side-effects were not reported.
Birth experience, mother-baby interaction, breastfeeding: These were not reported in this trial.

# Fetal and neonatal outcomes
No fetal or neonatal outcomes were reported in this trial.

# Summary of the main findings for comparison 1
The evidence suggests that pethidine may provide labour pain relief but may also be associated with more side-effects (nausea, vomiting and drowsiness) compared with placebo. Pentazocine may make little difference to pain scores. Evidence on the effects of tramadol and fentanyl on pain relief in labour and other outcomes is of very low certainty.

# Additional considerations
The Cochrane systematic review (133) also included other comparisons -between different opioids, and between opioids and other analgesia (inhaled analgesia, transcutaneous electrical nerve stimulation  and complementary methods) -which were not presented in this framework; evidence on these options was predominantly from single studies and assessed in the review to be of low or very low certainty.
Evidence from another Cochrane systematic review (125) of epidural analgesia included a comparison of epidural analgesia with opioids (35 trials, 10 835 women). Findings suggest that epidural may be more effective in reducing pain during labour compared to parenteral opioids. With epidural analgesia, pain scores in women during labour may be reduced compared with parenteral opioid analgesia, women may be more likely to rate pain relief as excellent or very good, and the need for any additional analgesia may be reduced (all low-certainty evidence). However, epidural analgesia probably increases labour duration (moderate-certainty evidence) and may increase the need for interventions during labour (e.g. labour augmentation, instrumental vaginal birth) (lowcertainty evidence). There is probably little or no difference between the two pain relief options in relation to low Apgar scores (low-certainty evidence).
Repeated use of opioid analgesics is associated with the development of psychological and physical dependence. In view of worldwide drug addiction problems and associated adverse events, there have been recent concerns expressed about prescribing opioids for the relief of acute and chronic pain (134). These concerns are probably less applicable to use of opioids for pain relief in labour (135,136); however, the long-term effects of opioid analgesia on women and their offspring are not known.
In a review of qualitative studies looking at what matters to women during intrapartum care (23), findings suggest that most women, especially those giving birth for the first time, are apprehensive about childbirth (high confidence in the evidence), and in certain contexts and/or situations may welcome interventions that provide relief from pain (low confidence in the evidence). When interventions are being considered, women would like to be informed about the nature of the interventions and, where possible, given a choice (high confidence in the evidence).
A qualitative systematic review exploring women's experiences of opioid use during labour could only identify very low-confidence evidence (126). The findings suggest that some women value opioids to help them cope with intense and unmanageable labour pains. Mixed responses were identified in terms of whether the pain relief was effective or ineffective and whether it had a positive or negative impact on their labour and childbirth experience.
The data available for this qualitative review were very limited: only three studies, including two in HICs and one in an upper-middle-income country.
One study contained minimal data to inform the review, and one involved qualitative interviews with women involved in an RCT evaluating different opioid regimens. All participants were women who had requested pain relief.
It was not possible to identify, within the included studies, whether women had had augmentation, induction of labour or other forms of intervention that may have influenced their valuation of the outcomes associated with this form of pain relief.
No evidence on the relative cost or costeffectiveness of the different opioid analgesics was found. However, a USA review of the costeffectiveness of epidural analgesia compared with opioid analgesia found opioid analgesia to be more cost-effective than epidural analgesia, due to the higher costs of health care professionals associated with administering epidural, as well as higher costs associated with managing complications (127).
Opioid administration in a Dutch study published in 2016 was associated with an estimated unit cost of 15 (about US$ 18) per procedure (including staff costs) (130).

# Additional considerations
While in some high-resource settings parenteral opioid medicines are considered relatively inexpensive, these medicines may not be accessible in all settings, and in some LMICs they may not be affordable (136,137).
No direct evidence was found on the impact of pain relief with parenteral opioids on equity. Indirect evidence from a review of facilitators and barrier to facility-based birth (8) indicates that "neglect and delays in receiving care" probably acts as a barrier to facility-based birth (moderate confidence in the evidence). Such neglect and delays might be applicable to labour pain management.
The review also highlights that many women in LMICs fear "unfamiliar and undesirable" birth practices, which are barriers to facility-based birth (high confidence in the evidence). It is possible that some women might perceive injections to be unfamiliar and undesirable practices.

# Additional considerations
WHO's 2015 State of inequality report concluded that there are still large gaps in skilled birth attendance coverage (33). Providing effective and timely labour pain relief to disadvantaged women might help to reduce inequalities in intrapartum care directly. Based on the limited evidence above, it might also impact equity indirectly, by encouraging 1 British National Formulary website: / more disadvantaged women to access facility-based care. However, in LMIC settings, some women may perceive medical pain relief options as unfamiliar and undesirable, which could act as a barrier to facility-based birth, particularly for women who believe that labour and childbirth are natural processes that do not need intervention, and those who would prefer a traditional approach to pain management.
If women requesting pain relief are offered a choice of pharmacological and non-pharmacological (including traditional and cultural preferences) options, it might help to address inequalities in intrapartum care.
Women requesting pain relief should be informed of the effects (desirable and undesirable) of the respective pharmacological options and be empowered to participate in the decision-making processes relating to labour and childbirth, including pain management.
It has been argued that changing the attitudes of health care professionals and women surrounding labour pain (and reducing the medicalization of labour discomfort) could empower women to rediscover their innate birthing capabilities (132), which might positively impact equity by reducing the medicalization of childbirth among more advantaged women.
In a qualitative systematic review exploring women's experiences of opioid use for pain relief during labour, there were mixed views (126). Some women requested opioids due to intense and unmanageable labour pains (very low confidence in the evidence). Opioids were reported to be an effective (very low confidence in the evidence) or ineffective form of pain relief (very low confidence in the evidence). Women continued to experience pain due to the pain relief method being ineffective, being provided too late or wearing off too early (very low confidence in the evidence).
Some women experienced negative physiological (e.g. sickness, distorted cognitive processes, inability to achieve a physiological birth) and psychological (e.g. disappointment) impacts (very low confidence in the evidence). However, other review findings highlight that opioids increased women's enjoyment, shortened and reduced the intensity of the contractions, and aided them to achieve a physiological birth (very low confidence in the evidence).
Following opioid use, some women were disappointed due to an over-reliance on staff to administer the medication for them, and a lack of caregiver support (very low confidence in the evidence). Women were also not always fully aware of the route of administration or the risks of opioid use (very low confidence in the evidence).
In another review that included health care provider experiences (26), no qualitative accounts of health care professionals' views of opioid use in women during labour and childbirth were identified.

# Additional considerations
Overall, the review on women's experiences of pain relief options (126) highlights the lack of high-quality qualitative evidence. While confidence in the evidence is very low, the majority of negative comments were expressed towards IM pethidine use, whereas opinions on intranasal and subcutaneous fentanyl were generally far more positive.
It was not possible to identify, within the included studies, whether women valued the outcomes associated with opioids differently if they had had augmentation, induction of labour or other forms of intervention.
It has been suggested in other studies that the care context and the type of care provision and care provider have a strong effect on the need for labour pain relief, and on the kinds of choices women make in relation to this need (138,139).
In a qualitative systematic review exploring women's experiences of opioid use during labour (126), the lack of effectiveness of opioids to relieve pain was sometimes attributed to late administration (very low confidence in the evidence), which suggests the need for more timely and sensitive use of this pain relief method.

# Additional considerations
In low-resource settings, where opioids are not so widely available and used, there are likely to be financial implications as well as additional training requirements for their administration and for the management of potential maternal and neonatal side-effects.

# Maternal outcomes
Pain relief: Compared with pethidine, it is not clear whether IM meptazinol makes any difference to pain scores, or to the use of additional analgesia or epidural, as the certainty of the evidence is very low. Low-certainty evidence suggests there may be little or no difference between groups for rating pain relief as "poor" (more than 60% in both groups) (1 trial, 801 women, RR 1.01, 95% CI 0.91-1.12).

# Mode of birth:
Low-certainty evidence suggests there may be little or no difference in assisted vaginal birth (3 trials, 1266 women, RR 1.00, 95% CI 0.81-1.22), while it is not clear whether there is a difference between meptazinol and pethidine for caesarean birth, as the certainty of the evidence is very low.
Moderate-certainty evidence suggests vomiting is increased with meptazinol (3 trials, 1589 women, RR 1.25, 95% CI 1.06-1.47), while low-certainty evidence suggests there is little or no difference between groups for maternal drowsiness (3 trials, 1590 women, RR 0.55, 95% CI 0.28-1.07).

# Breastfeeding: It is not clear whether meptazinol affects breastfeeding, as the certainty of the evidence is very low.
Other maternal outcomes were not reported in the included trials.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: It is not clear whether meptazinol makes any difference to FHR changes or Apgar scores more than 7 at 5 minutes, as the certainty of the evidence is very low.

# Maternal outcomes
Pain relief: Low-certainty evidence suggests that compared with pethidine, tramadol may increase the number of women reporting poor pain relief (38.8% vs 25.4%) (4 trials, 243 women, RR 1.56, 95% CI 1.10-2.21). Compared with pethidine, it is not clear whether IM tramadol makes any difference to women's need for additional analgesia, as the certainty of the evidence is very low.

# Mode of birth:
The evidence on the effect of tramadol compared with pethidine on caesarean birth or assisted vaginal birth is of very low certainty.
Side-effects: Low-certainty evidence suggests that maternal sleepiness may be reduced with tramadol (5 trials, 409 women, RR 0.57, 95% CI 0.33-0.97), but it is unclear if the opioids are any different in terms of vomiting, as the certainty of the evidence is very low.
Other maternal outcomes were not reported in the trials.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: When compared with pethidine, it is not clear whether tramadol makes any difference to low Apgar scores at 5 minutes, as no events were reported in either group.
It is unclear whether tramadol makes any difference to neonatal respiratory distress, as the certainty of the evidence is very low. There were no neonatal resuscitation events in trials where tramadol was compared with pethidine.
Long-term adverse infant outcomes: These were not reported in the trials.

# Comparison 2.c. Tramadol (IM) with triflupromazine compared with pethidine (IM) with triflupromazine
A single trial with 40 women conducted in Germany which was published in 1992 compared IM tramadol with IM pethidine; both groups also received triflupromazine (an antipsychotic sometimes used as an anti-emetic).

# Maternal outcomes
Side-effects: It is not clear whether there is any difference between groups for vomiting or sleepiness, as the certainty of the evidence is very low.

# Other maternal outcomes were not reported in the trial

# Fetal and neonatal outcomes
Fetal/neonatal outcomes were not reported in the trial.

# Comparison 2.d. Morphine or diamorphine (IM) compared with pethidine (IM)

# Maternal outcomes
Pain relief: One trial involving 484 women in the United Kingdom which was published in 2014 compared IM diamorphine with pethidine. Highquality evidence suggests diamorphine probably slightly lowers maternal pain scores at 30 and 60 minutes compared with pethidine (MD -0.8, 95% CI -1.24 to -0.36 and MD -0.8, 95% CI -1.26 to 0.34, respectively, measured on a 10-point scale) and slightly increases the number of women satisfied with pain relief (RR 1.13, 95% CI 1.02-1.26). From another trial published in 1986 involving 135 women in Thailand, it is unclear whether IM morphine makes any difference to pain relief when compared with pethidine.
Moderate-certainty evidence suggests there is little or no difference in the need for additional analgesia between morphine or diamorphine compared with pethidine (2 trials, 574 women, RR 1.00, 95% CI 0.92-1.10).
Side-effects: Evidence on vomiting and sleepiness from the trial in Thailand with 135 women comparing IM morphine with pethidine is of very low certainty. Another trial in the United Kingdom with 161 women (133 analysed), published in 1999, examined diamorphine versus pethidine, with both groups receiving the anti-emetic prochlorperazine. Lowcertainty evidence suggests that IM diamorphine plus prochlorperazine may reduce vomiting compared with pethidine plus prochlorperazine (RR 0.39, 95% CI 0.17-0.86).

# Mode of birth:
Moderate-certainty evidence suggests there is little or no difference between the groups for caesarean birth (RR 0.94, 95% CI 0.66-1.35) or assisted vaginal birth (RR 1.28, 95% CI 0.91-1.80).
Other maternal outcomes were not reported in these trials.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: Moderate-certainty evidence suggests there is little or no difference between diamorphine or morphine compared with pethidine in neonatal resuscitation (2 trials, 574 babies, RR 0.96, 95% CI 0.66-1.41).

# Long-term adverse neonatal outcomes

# Maternal outcomes
Pain relief: The certainty of this evidence is very low.

# Side-effects: The certainty of evidence on vomiting and sleepiness is very low.
Other maternal outcomes were not reported in the trial.

# Fetal and neonatal outcomes
Fetal/neonatal outcomes were not reported in the trial.

# Comparison 2.f. Pentazocine (IM) compared with pethidine (IM)
Six trials compared pentazocine with pethidine (IM); all the trials except one are more than 40 years old -the most recent was published in 1980. The certainty of the evidence for all but one of the outcomes reported is very low.

# Maternal outcomes
Side-effects: Low-certainty evidence suggests nausea may be lower with pentazocine (3 trials, 391 women, RR 0.46, 95% CI 0.24-0.90).
Other maternal outcomes were not reported in the trials.

# Fetal and neonatal outcomes
Fetal/neonatal outcomes were not reported in the trials.

# Comparison 2.g. Nalbuphine (IM) compared with pethidine (IM)
Three trials with 430 women conducted in Argentina, Germany and the United Kingdom, and published between 1986 and 1999, are included in this comparison. The certainty of the evidence is very low for most of the outcomes reported.

# Maternal outcomes
Pain relief: Low-certainty evidence from a single trial with 72 women suggests maternal satisfaction with pain relief may be reduced with nalbuphine (RR 0.73, 95% CI 0.55-0.96). Low-certainty evidence suggests that nalbuphine makes little or no difference to the use of epidural as additional analgesia (1 trial, 307 women, RR 1.65, 95% CI 0.55-4.94)
Side-effects: Moderate-certainty evidence suggests nausea and vomiting is less frequent with nalbuphine (1 trial, 72 women, RR 0.41, 95% CI 0.18-0.94).

# Mode of birth:
Low-certainty evidence suggests there may be little or no difference between groups for caesarean birth (1 trial, 310 women, RR 0.45, 95% CI 0.12-1.69).

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: One study with 72 babies compared infant behavioural scores at 2-4 hours after birth and low-certainty evidence suggests slightly lower (worse) scores in infants whose mothers received nalbuphine (MD -3.7, 95% CI -1.26 to -6.14).

# Long-term adverse neonatal outcomes:

# Maternal outcomes
Pain relief: The certainty of the evidence is very low for use of epidural analgesia as additional intervention.
Side-effects: Low-certainty evidence suggests vomiting may be less frequent with phenazocine (RR 0.39, 95% CI 0.20-0.78).
Other maternal outcomes were not reported in the trial.

# Fetal and neonatal outcomes
Fetal/neonatal outcomes were not reported in the trial.

# Comparison 2.i. Butorphanol (IM) compared with pethidine (IM)
A single trial with 80 women conducted in Germany and published in 1978 is included in this comparison. It is not clear whether the medications have any differential effect on outcomes, as the certainty of the evidence is very low for all outcomes reported.

# Comparison 2.j. Fentanyl (IV) compared with pethidine (IV)
A single trial with 105 women conducted in the USA and published in 1989 is included in this comparison. The certainty of the evidence for most outcomes reported is very low.

# Maternal outcomes
Pain relief: Low-certainty evidence suggests women receiving fentanyl may need slightly more doses of the medication (MD 0.4 higher, 95% CI 0.14-0.66 higher), but may report slightly reduced maternal pain scores 1 hour after administration compared with pethidine (MD 0.20 lower, 95% CI 0.34-0.06 lower).
Side-effects: Low-certainty evidence suggests maternal sedation may be slightly less with fentanyl (RR 0.05, 95% CI 0.00-0.82).

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: Low-certainty evidence suggests that infant neurobehavioural scores at 1-2 hours after birth may be higher if mothers received fentanyl rather than pethidine (MD 1.30, 95% CI 0.15-2.45 higher).
Long-term adverse neonatal outcomes: These were not reported in the trial.
Comparison 2.k. Nalbuphine (IV) compared with pethidine (IV)
A single trial with 28 women conducted in the USA and published in 1995 examined this comparison.

# Maternal outcomes
Mode of birth: The certainty of the evidence is very low for caesarean birth.
No other relevant maternal outcomes were reported in this trial.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: There were no babies with low Apgar scores at 5 minutes.
Long-term adverse neonatal outcomes: These were not reported in the trial.

# Comparison 2.l. Phenazocine (IV) compared with pethidine (IV)
A single trial with 194 women conducted in the USA and published in 1964 examined this comparison. The certainty of the evidence is very low for all outcomes reported or there are no events. Most outcomes were not reported.

# Fetal and neonatal outcomes
Perinatal death: None were reported (low-certainty evidence).

# Comparison 2.m. Butorphanol (IV) compared with pethidine (IV)
Three studies with 330 women, all conducted in the USA and published between 1979 and 2005, compared IV butorphanol with IV pethidine.

# Maternal outcomes
Pain relief: Low-certainty evidence suggests that pain scores may be slightly lower and pain relief slightly higher for women in the butorphanol group (1 trial, 80 women, MD -0.6, 95% CI -1.02 to -0.18 and MD 0.67, 95% CI 0.25 to 1.09, respectively). The certainty of the evidence is very low for use of epidural analgesia or the need for further analgesia.

# Mode of birth:
The certainty of the evidence is very low for assisted vaginal birth and caesarean section.
Side-effects: Low-certainty evidence suggests vomiting may be reduced with butorphanol (1 trial, 200 women, RR 0.04, 95% CI 0.00-0.67).
No other relevant maternal outcomes were reported in these trials.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: The evidence regarding low infant Apgar scores at 5 minutes is of very low certainty.
Long-term adverse neonatal outcomes: These were not reported in the trials.

# Comparison 2.n. Morphine (IV) compared with pethidine (IV)
Two studies with 163 women conducted in Sweden (1996) and the USA (1961) provided data for this comparison.

# Maternal outcomes
Pain relief: Low-certainty evidence suggests that women may be slightly less satisfied with pain relief with morphine (1 trial, 141 women, RR 0.87, 95% CI 0.78-0.98), and may be more likely to require additional doses of analgesia (1 trial, 143 women, RR 3.41, 95% CI 1.90-6.12).

# Mode of birth:
In a study with 20 women, no women required caesarean section.
No other guideline outcomes were reported in these trials.

# Comparison 2.o. Alphaprodine (IV) compared with pethidine (IV)
A single USA trial published in 1958 with data for 395 women compared IV alphaprodine with IV pethidine.

# Maternal outcomes
Side-effects: Moderate-certainty evidence suggests vomiting is less frequent with alphaprodine (RR 0.38, 95% CI 0.22-0.66).
No other relevant maternal outcomes were reported in these trials.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: The evidence on neonatal resuscitation is of very low certainty.

# Long-term adverse neonatal outcomes

# Mode of birth:
Low-certainty evidence suggests that there may be little or no difference for assisted vaginal or caesarean births (2 trials, 97 women, RR 0.96, 95% CI 0.46-2.00 and RR 1.81, 95% CI 0.60-5.46, respectively).
Birth experience: Moderate-certainty evidence suggests that satisfaction with childbirth experience was slightly higher with remifentanil (1 trial, 68 women, MD 1.1, 95% CI 0.46-1.74).
Moderate-certainty evidence from a single trial with 105 women suggests that sleepiness is slightly increased with remifentanil (MD 0.4, 95% CI 0.14-0.66). Low-certainty evidence suggests there may be little or no difference between groups for nausea and vomiting (2 studies, 119 women, RR 0.95, 95% CI 0.61-1.49).

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: Low-certainty evidence suggests there may be little or no difference in Apgar scores at 5 minutes (1 trial, 17 infants, RR 0.13, 95% CI 0.01-2.16). The certainty of the evidence is very low for naloxone administration. Low-certainty evidence suggests there may be little or no difference in neurobehavioural scores in infants after 2 hours (1 trial, 56 infants, MD 0.6, 95% CI -0.66 to 1.86).

# Long-term adverse neonatal outcomes

# Maternal outcomes
Pain relief: Low-certainty evidence suggests that maternal pain scores in labour may be slightly reduced by PCA nalbuphine compared with PCA pethidine (MD -0.51, 95% CI -1.02 to 0). The relative effects of the interventions are unclear, as the certainty of the evidence is very low for all outcomes reported.
No other relevant maternal outcomes were reported in this trial.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: These outcomes were not reported in the trial.

# Maternal outcomes
Pain relief: Low-certainty evidence suggests there may be little or no difference between the interventions for maternal pain scores (MD -0.65, 95% CI -1.56 to 0.26). Moderate-quality evidence suggests that use of epidural analgesia is lower in women receiving PCA fentanyl (RR 0.44, 95% CI 0.21-0.92).

# Mode of birth:
Low-certainty evidence suggests there may be little or no difference between the interventions for assisted vaginal birth (RR 0.57, 95% CI 0.22-1.49) or caesarean birth (RR 0.25, 95% CI 0.03-2.34).
Low-certainty evidence suggests there may be little or no difference in maternal sleepiness scores (MD -0.16, 95% CI -0.25 to 0.13) or vomiting (RR 0.87, 95% CI 0.55-1.37).

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: Low-certainty evidence suggests little or no difference in infant neurobehavioral scores at 2 hours after birth (MD 0.5, 95% CI -1.95 to 0.95).

# Additional considerations
The data available for the qualitative review on women's experiences of opioid use during labour were very limited -they were obtained from just three studies (2 in high-income countries and 1 in an upper-middle-income country) (126). One of these studies contained minimal data to inform the review, and one involved qualitative interviews with women involved in an RCT of different opioid regimens. All participants were women who had requested pain relief.
It was not possible to identify, within the included studies, whether women had had augmentation, induction of labour or other forms of intervention that may have influenced their valuation of the outcomes associated with this form of pain relief.
No evidence on the relative cost or costeffectiveness of the different opioid analgesics was found. However, a USA review of the costeffectiveness of epidural analgesia compared with opioid analgesia found opioid analgesia to be more cost-effective than epidural analgesia, due to the higher costs of health care professionals associated with administering epidural, as well as higher costs associated with managing complications (127).
Opioid administration in a Dutch study published in 2016 was associated with an estimated unit cost of 15 (about US$ 18) per procedure (including staff costs) (130).

# Additional considerations
While in some high-resource settings parenteral opioid medications are considered relatively inexpensive, these medications may not be accessible in all settings and in some LMICs they may not be affordable (136,137).
A dose of pethidine or fentanyl can cost less than US$ 1; tramadol can cost about US$ 1.30; diamorphine and meptazinol can cost around US$ 3 per dose; and remifentanil can cost around US$ 6.50 per dose. Naloxone (to reverse respiratory depression) costs about US$ 6 per dose. 1
No direct evidence was found on the impact of pain relief with any parenteral opioids on equity.
Indirect evidence from a review of facilitators and barrier to facility-based birth (8) indicates that 1 British National Formulary website: / Long-term adverse neonatal outcomes: These outcomes were not reported in the trial.

# Comparison 2.t. PCA meptazinol compared with PCA pethidine
This comparison is examined in a single study of 10 women conducted in the United Kingdom. The certainty of all reported outcomes is very low.

# Summary of the main findings for comparison 2
Diamorphine is associated with slightly better pain relief than pethidine and may be associated with less nausea and vomiting. Fentanyl may be associated with slightly better pain relief than pethidine, less maternal sedation, less epidural use and slightly better infant neurobehavioural scores after birth. Remifentanyl is probably associated with less frequent use of epidural analgesia but more drowsiness than pethidine; it may lead to higher satisfaction with birth experience scores. Nalbuphine may lead to less maternal satisfaction with pain relief and lower infant behavioural scores after birth; however, it probably causes less nausea and vomiting than pethidine. Most evidence on other opioids compared with pethidine is of very low certainty.
Findings from a review of qualitative studies looking at what matters to women during intrapartum care (23) suggest that most women, especially those giving birth for the first time, are apprehensive about childbirth (high confidence in the evidence), and in certain contexts and/or situations may welcome interventions that provide relief from pain (low confidence in the evidence). When interventions are being considered, women would like to be informed about the nature of the interventions and, where possible, given a choice (high confidence in the evidence).
A qualitative systematic review exploring women's experiences of opioid use for pain relief during labour could only identify very low-confidence evidence (126). The findings suggest that some women appear to value opioids to help them cope with intense and unmanageable labour pains. Mixed responses were identified in terms of whether the pain relief was effective or ineffective and whether it had a positive or negative impact on their labour and childbirth experience.
"neglect and delays in receiving care" probably acts as a barrier to facility-based birth (moderate confidence in the evidence). Such neglect and delays might be applicable to labour pain management.
The review also highlights that many women in LMICs fear "unfamiliar and undesirable" birth practices, which are barriers to facility-based birth (high confidence in the evidence). It is possible that some women might perceive injections to be unfamiliar and undesirable practices.

# Additional considerations
If women requesting pain relief are informed about and offered a choice of pharmacological and nonpharmacological (including traditional and cultural preferences) options, it might help to address inequalities in intrapartum care, by giving women more control of their childbirth experience.
Women requesting pain relief should be informed of the effects (desirable and undesirable) of the respective available pharmacological options and be empowered to participate in the decision-making processes relating to labour and childbirth, including pain management.
Use of expensive opioid alternatives might have a negative impact on equity if these are preferentially used in high-resource settings and more advantaged populations.
It has been argued that changing the attitudes of health care professionals and women surrounding labour pain (and reducing the medicalization of labour discomfort) could empower women to rediscover their innate birthing capabilities (132), which might positively impact equity by reducing the medicalization of childbirth among more advantaged women.
In a qualitative systematic review exploring women's experiences of opioid use for pain relief during labour, there were mixed views (126). Some women requested opioids due to intense and unmanageable labour pains (very low confidence in the evidence). Opioids were reported to be an effective (very low confidence in the evidence) or ineffective form of pain relief (very low confidence in the evidence). Women continued to experience pain due to the pain relief method being ineffective, being provided too late or wearing off too early (very low confidence in the evidence). Some women experienced negative physiological (e.g. sickness, distorted cognitive processes, inability to achieve a physiological birth) and psychological (e.g. disappointment) impacts (very low confidence in the evidence). However, other review findings highlight that opioids increased women's enjoyment, shortened and reduced the intensity of the contractions, and aided them to achieve a physiological birth (very low confidence in the evidence).
Following opioid use, some women were disappointed due to an over-reliance on staff to administer the medication for them, and a lack of caregiver support (very low confidence in the evidence). Women were also not always fully aware of the route of administration or the risks of opioid use (very low confidence in the evidence).
In another review that included health care provider experiences (26), no qualitative accounts of health care professionals' views of opioid use were identified.

# Additional considerations
Overall, the review on women's experiences of pain relief options (126) highlights the lack of highquality qualitative evidence. While confidence in the evidence is very low, the majority of negative comments were expressed towards IM pethidine use, whereas opinions on intranasal and subcutaneous fentanyl were generally far more positive.
It has been suggested in other studies that the care context and the type of care provision and care provider have a strong effect on the need for labour pain relief, and on the kinds of choices women make in relation to this need (138,139).
In a qualitative systematic review exploring women's experiences of opioid use during labour (126), the lack of effectiveness of opioids to relieve pain was sometimes attributed to late administration (very low confidence in the evidence), which suggests the need for more timely and sensitive use of this pain relief method.

# Additional considerations
In lower-resource settings, where opioids are not so widely available and used, there are likely to be financial implications as well as additional training requirements for their administration and for the management of potential maternal and neonatal side-effects.
It is likely that the type of opioid used in different settings and countries would be influenced by the cost of the medication.

# Relaxation techniques for pain management

# RECOMMENDATION 21

# Relaxation techniques, including progressive muscle relaxation, breathing, music, mindfulness and other techniques, are recommended for healthy pregnant women requesting pain relief during labour, depending on a woman's preferences. (Recommended)
Most women desire some form of pain relief during labour, and qualitative evidence indicates that relaxation techniques can reduce labour discomfort, relieve pain and enhance the maternal birth experience.
Health care professionals should be aware that the care context and the type of care provision and care provider could have a strong effect on the need for labour pain relief, and on the kinds of choices that women make in relation to this need. Non-pharmacological pain relief options can vary widely within and across settings and contexts, which might favour other techniques that are not considered in this guideline, such as water immersion, hypnobirthing, acupuncture and cultural and traditional practices that women might find soothing.
Care providers should inform women that while relaxation techniques are unlikely to be harmful, the beneficial effects have very low certainty.

# Summary of evidence and considerations

# Effects of the intervention (EB

# Mode of birth:
It is unclear whether relaxation techniques have any effect on instrumental or caesarean birth, as the evidence is of very low certainty.

# Duration of labour:
It is unclear whether relaxation makes any difference to the duration of labour, as the evidence is of very low certainty.

# Augmentation of labour:
It is unclear whether relaxation makes any difference to labour augmentation, as this evidence is of very low certainty.
Birth experience: Low-certainty evidence suggests that relaxation techniques may make little or no difference to women's overall satisfaction with the experience of giving birth (3 trials, 1176 women, SMD 0.03, 95% CI -0.37 to 0.31) or their anxiety scores (1 trial, 140 women, MD 0.3, 95% CI -4.15 to 4.75). No studies reported on maternal sense of control.
Adverse effects, mother-baby interaction, breastfeeding: These were not reported in any of the included trials.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia and admission to special care: The evidence on these outcomes is of very low certainty.
Long-term infant outcomes: These were not reported in the trials.

# Maternal outcomes
Pain relief: Low-certainty evidence suggests that yoga may slightly reduce pain scores in labour (1 trial, 66 women, MD -6.12, 95% CI -0.47 to -11.7) and slightly increase satisfaction with pain relief (1 trial, 66 women, MD 7.88, 95% CI 1.51-14.25). It is unclear whether yoga has any effect on the use of pharmacological pain relief because the certainty of the evidence is very low.

# Mode of birth:
This was not reported in the trials.

# Duration of labour:
Low-certainty evidence suggests that yoga may reduce the duration of labour (1 trial, 66 women, MD -139.91 minutes, 95% CI -27.32 to -252.50).

# Augmentation of labour: Evidence on this outcome is of very low certainty.
Birth experience: Low-certainty evidence suggests that yoga may slightly improve women's overall childbirth satisfaction scores (1 trial, 66 women, MD 6.34, 95% CI 0.26-12.42).
Adverse effects, mother-baby interaction, breastfeeding: These were not reported in either of the included trials.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: The evidence on this outcome is of very low certainty.
Admission to special care and long-term adverse infant outcomes: These were not reported in the trials.

# Maternal outcomes
Pain relief, mode of birth, birth experience: The evidence on pain relief (pain intensity, use of epidural analgesia), mode of birth (instrumental vaginal, caesarean) and birth experience (maternal anxiety) is of very low certainty.
Maternal satisfaction and sense of control: These outcomes were not reported in the trials.

# Duration of labour, labour augmentation, adverse effects, mother-baby interaction, breastfeeding:
These outcomes were not reported in the trials.

# Fetal and neonatal outcomes
Admission to special care: The evidence on this outcome is of very low certainty.
Perinatal hypoxia-ischaemia and long-term adverse infant outcomes: These were not reported in the trials.

# Comparison 4: Audio-analgesia compared with control
One trial involving 25 women compared audio analgesia with a control group. The trial was conducted in the United Kingdom in 1965. The intervention group listened to "sea noise" set at 120 decibels in labour; the control group listened to the same sound set at 90 decibels.

# Maternal outcomes
Pain relief: It is unclear whether listening to the sound of waves during labour has any effect on satisfaction with pain relief because the certainty of the evidence is very low.
No other maternal outcomes were reported in the trial.

# Fetal and neonatal outcomes
No fetal or neonatal outcomes were reported in the trial.

# Maternal outcomes
Pain relief: It is unclear whether mindfulness training has an effect on the use of pharmacological pain relief because the certainty of the evidence is very low. Other pain outcomes were not reported in the trial.

# Mode of birth:
The evidence on instrumental vaginal birth and caesarean birth is of very low certainty.
Birth experience: Low-certainty evidence suggests that women's sense of control in labour may be improved with mindfulness training (1 trial, 26 women, MD 31.3, 95% CI 1.61-60.99); however, the evidence on satisfaction scores is of very low certainty. Anxiety was not reported in the trial.
Duration of labour, labour augmentation, adverse effects, mother-baby interaction, breastfeeding: These outcomes were not reported in the trial.

# Fetal and neonatal outcomes
No fetal or neonatal outcomes were reported in this trial.
Findings from a review of qualitative studies looking at what matters to women during intrapartum care (23) suggest that most women, especially those giving birth for the first time, are apprehensive about childbirth (high confidence in the evidence), and in certain contexts and/or situations may welcome interventions that provide relief from pain (low confidence in the evidence). When interventions are being considered, women would like to be informed about the nature of the interventions and, where possible, given a choice (high confidence in the evidence).
In a separate review of qualitative studies related to labour pain coping techniques (126), women valued the relief provided by relaxation techniques (moderate confidence in the evidence). Women using them felt relaxed and in control during labour, able to work effectively with their labour pains, and able to have a positive labour and childbirth experience (low confidence in the evidence). These methods also had a positive influence on postnatal well-being (moderate confidence in the evidence).

# Additional considerations
While findings were consistent across the studies in the qualitative review on pain relief, only eight studies were found for the women's qualitative review and only three for providers, none of which were undertaken in LMICs. It was not possible to identify, within the included studies, whether women had had augmentation, induction of labour or other forms of intervention that may have influenced their valuation of the outcomes associated with this form of pain relief.
It is likely that the care context and the type of care provision and care provider have a strong effect on the need for labour pain relief, and on the kinds of choices women make in relation to this need (138,139). For example, some of the findings related to relaxation techniques could be related to positive relationships formed with attending health care professionals and/or birth companionship.
No research evidence on the costs or costeffectiveness of these interventions was found. If non-pharmacological techniques reduce the use of pharmacological techniques, they might be costeffective; however, evidence of this effect is lacking.

# Additional considerations
Within the qualitative review on women's and providers' experiences (26), providers in HICs noted that equity in the delivery of complementary therapies was compromised due to a lack of resources (funds and midwives time) (very low confidence in the evidence). There is no evidence from this review on relaxation techniques and equity from LMICs.

# Additional considerations
If women requesting pain relief are offered a choice of pharmacological and non-pharmacological options, including traditional and cultural preferences, this might help to address inequalities in intrapartum care.
In a systematic review of qualitative studies exploring women's views of labour pain relief options (126), relaxation techniques were reported to be an acceptable and effective method of pain relief in HICs (moderate confidence in the evidence). Relaxation techniques facilitated a peaceful birthing environment and enhanced feelings such as safety, strength, control and connection, which contributed to a positive labour and childbirth experience (moderate confidence in the evidence). Some women also used them after the birth, to facilitate well-being (e.g. techniques to soothe the baby or to facilitate breastfeeding).
The review findings suggest that women valued having a range of taught techniques (during the antenatal period) that could be adapted according to their changing needs during labour and childbirth (low confidence in the evidence). Women also valued the techniques as a means of enhancing the participation of partners and caregivers (low confidence in the evidence).
The evidence on health care provider views on providing pain relief, from another review (26), is of very low confidence; however, it suggests that some health care providers believe that relaxation techniques increase women's ability to trust their bodies and promote a positive childbirth experience. The evidence from midwife respondents suggests that midwives may consider complementary therapies to be aligned with the woman-centred philosophy of midwifery.

# Additional considerations
Only eight studies were found for the qualitative review of women's experiences of pain relief options (126) and three for the providers' views (26), none of which were undertaken in LMICs.
It is possible that of the findings on acceptability of relaxation techniques could be related to positive relationships and labour companionship and not due to the relaxation techniques themselves. Two studies have suggested that the care context and the type of care provision and care provider have a strong effect on the need for labour pain relief, and on the kinds of choices women make in relation to this need (138,139).
In the qualitative systematic review that included health care professionals' views on providing pain relief (26), staff identified a number of barriers to the provision of relaxation techniques, including bureaucracy, lack of consensus among professionals, lack of an evidence base, and lack of regulation and training of complementary therapy practitioners (very low confidence in the evidence).

# Additional considerations
Relaxation techniques that can be provided by labour companions or that can be performed by the woman herself are plausibly more feasible to implement in settings where antenatal classes are already in place to facilitate maternal education/ preparation and labour companion training.
- Don't know - Varies - Reduced - Probably reduced - Probably no impact  Probably increased - Increased Acceptability - Don't know - Varies - No - Probably No  Probably Yes - Yes Feasibility - Don't know - Varies - No - Probably No  Probably Yes - Yes 111

# EVIDENCE AND RECOMMENDATIONS

# Manual techniques for pain management

# RECOMMENDATION 22
Manual techniques, such as massage or application of warm packs, are recommended for healthy pregnant women requesting pain relief during labour, depending on a woman's preferences. (Recommended)
Most women desire some form of pharmacological or non-pharmacological pain relief during labour, and qualitative evidence indicates that massage can reduce labour discomfort, relieve pain and enhance the maternal birth experience.
While the quantitative and qualitative evidence largely relates to massage, warm packs are unlikely to be harmful and some women might find these to be soothing.
Health care professionals should be aware that the care context and the type of care provision and care provider could have a strong effect on the need for labour pain relief, and on the kinds of choices women make in relation to this need. Non-pharmacological pain relief options can vary widely across settings and contexts, which might favour other techniques not considered in this guideline, such as water immersion, hypnobirthing, acupuncture, and cultural and traditional practices that women might find soothing.
Health care professionals should communicate to women the options available for pain relief in their birth facility, and discuss the advantages and disadvantages of these options as part of antenatal care. Care providers should inform women that while manual techniques for managing pain are unlikely to be harmful, evidence of the beneficial effects is of very low certainty.

# Summary of evidence and considerations

# Effects of the intervention (EB Table 3.2.15)
This evidence is derived from a Cochrane systematic review (141) Mode of birth: Low-certainty evidence suggests that massage may make little or no difference to instrumental vaginal birth (4 studies, 368 women, RR 0.71, 95% CI 0.44-1.13) and caesarean section (6 studies, 514 women, RR 0.75, 95% CI 0.51-1.09).

# Duration of labour:
This evidence is of very low certainty.

# Augmentation of labour:
This evidence is of very low certainty.
Birth experience: Low-certainty evidence suggests that more women may report satisfaction with their birth experience if they have massage (1 trial, 60 women, RR 1.90, 95% CI 1.07-3.38). Evidence on satisfaction scores was of very low certainty. Sense of control was reported in two studies using different measures: moderate-certainty evidence from one trial suggests that sense of control scores were increased for women receiving massage (1 trial, 124 women, MD 14.05, 95% CI 3.77-24.33); and low-certainty evidence from another trial also suggests that sense of control scores may be slightly better for the massage group (1 trial, 56 women, MD -6.10, 95% CI -11.68 to -0.52). Low-certainty evidence suggests that anxiety scores may be reduced in women receiving massage (1 trial, 60 women, MD -16.27, 95% CI -27.03 to -5.51).
Breastfeeding: This was not reported in the trials.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: Low-certainty evidence suggests that massage may make little or no difference to low Apgar scores (< 7) at 5 minutes (2 trials, 215 infants, RR 0.72, 95% CI 0.17-3.14).
Adverse effects: Low-certainty evidence suggests that fewer infants whose mothers receive massage may require resuscitation (2 trials, 231 infants, RR 0.43, 95% CI 0.23-0.79). Low-certainty evidence suggests that massage may make little or no difference to the risk of admission to the neonatal intensive care unit (2 trials, 231 infants, RR 0.71, 95% CI 0.31-1.62).
Long-term adverse infant outcomes: These are not reported in the trials.
Comparison 2: Warm packs compared with usual care (no warm packs)
Three trials involving 252 women compared warm pack application with usual care.
All three trials were conducted in hospitals in Iran and took place between 2009 and 2013. Two trials (192 women) applied the warm packs to the women's lower backs and abdomens in the first stage of labour, and to the perineum in the second stage. The other trial applied the pack to the sacral and perineal areas for at least 30 minutes; it was not clear at what stage the intervention was applied.

# Maternal outcomes
Pain relief (pain scores) during labour, duration of labour: The evidence on these outcomes, with the use of warm towels or packs, is of very low certainty.
Other maternal outcomes were not reported in the trials.

# Fetal and neonatal outcomes
These outcomes were not reported in the trials.
Findings from a review of qualitative studies looking at what matters to women during intrapartum care (23) suggest that most women, especially those giving birth for the first time, are apprehensive about childbirth (high confidence in the evidence), and in certain contexts and/or situations may welcome interventions that provide relief from pain (low confidence in the evidence). When interventions are being considered, women would like to be informed about the nature of the interventions and, where possible, given a choice (high confidence in the evidence).
In a separate review of qualitative studies related to labour pain coping techniques (126), women valued massage techniques as a form of pain relief when these techniques enabled them to relax and feel calm, and to retain control over childbirth (low confidence in the evidence). Benefits to women's overall well-being, such as feeling safe, reassured and less anxious, were also reported (low confidence in the evidence). However, while some women found that massage enabled them to effectively work with labour pain (low confidence in the evidence), others found it to be ineffective (very low confidence in the evidence).

# Additional considerations
Findings were consistent across the studies in the qualitative review, but only four studies were found, none of which were undertaken in LMICs (126).
It was not possible to identify, within the included studies, whether women had had augmentation, induction of labour or other forms of intervention that may have influenced their valuation of the outcomes associated with this form of pain relief.
No research evidence on the costs or costeffectiveness of these interventions for labour pain was found. However, indirect evidence from a review of the cost-effectiveness of complementary therapies for a range of other (non-pregnancyrelated) conditions found emerging evidence of cost-effectiveness and possible cost-savings across a number of therapies and clinical populations (142). The majority of studies included in this review pertained to the use of manipulative or body-based practices for the treatment of back pain.

# Additional considerations

# Manual techniques could be relatively low-cost interventions if performed by a labour companion.
Training costs would then be the main cost component, which could be integrated into antenatal classes where these are available, or into doula/ labour companion training. However, the cost of massage provided by professional massage therapists could be relatively high, depending on location and setting.
If non-pharmacological techniques reduce the use of pharmacological techniques, they might be costeffective; however, evidence of this effect is lacking.
Within a qualitative systematic review that included health care providers' views on different pain relief options (26), providers in HICs noted that equity in the delivery of complementary therapies was compromised due to a lack of resources (funds and midwives' time) (very low confidence in the evidence). The review found no evidence on manual techniques and equity from LMICs.

# Additional considerations
If women requesting pain relief are offered a choice of pharmacological and non-pharmacological options, including traditional and cultural preferences, it might help to address inequalities in intrapartum care.
A systematic qualitative review of women's experiences of pain relief in labour found that training in massage techniques enhanced participation of the women's birth partners (low confidence in the evidence), whereas massage carried out by midwives enhanced the mothermidwife relationship and women's sense of feeling cared for (low confidence in the evidence) (126).
In another systematic qualitative review that included health care professionals' views on providing pain relief, the evidence suggests that some health care professionals believe that massage techniques increase the potential for a positive childbirth experience (very low confidence in the evidence) (26). Midwife respondents felt that complementary therapies were a valued alternative to pharmacological pain relief and that they were aligned with midwifery's woman-centred philosophy, which values and facilitates active participation by each woman in her own labour and childbirth process (very low confidence in the evidence).

# Additional considerations
The qualitative review findings on women and providers' views (26,126) were all from studies conducted in HICs.
It is possible that the findings on acceptability of massage could be related to positive relationships and labour companionship, and not due to the massage itself. Two studies have suggested that the care context and the type of care provision and care provider have a strong effect on the need for labour pain relief, and on the kinds of choices women make in relation to this need (138,139).
In the qualitative systematic review that explored health care professionals' views on providing pain relief (26), staff indicated that barriers to the provision of massage or other manual techniques included bureaucracy, lack of consensus among professionals, lack of an evidence base, and lack of regulation and training for complementary therapy practitioners (very low confidence in the evidence).

# Additional considerations
Manual techniques that can be provided by labour companions are plausibly more feasible to implement in settings where antenatal classes are already in place to facilitate maternal education/ preparation and labour companion training.
- Don't know - Varies - Reduced - Probably reduced - Probably no impact  Probably increased - Increased Acceptability - Don't know - Varies - No - Probably No  Probably Yes - Yes Feasibility - Don't know  Varies - No - Probably No - Probably Yes - Yes

# Pain relief for preventing labour delay

# RECOMMENDATION 23
Pain relief for preventing delay and reducing the use of augmentation in labour is not recommended. (Not recommended)
This recommendation has been integrated from the WHO recommendations for augmentation of labour (46), in which the GDG for that guideline determined it to be a conditional recommendation based on very low-quality evidence. The GDG noted that there is no clear evidence to suggest that any form of pain relief is associated with reductions in labour duration or frequency of labour augmentation. The GDG acknowledged that pain relief may not necessarily reduce the need for labour augmentation but it has other substantial benefits that make it an essential component of good intrapartum care. The evidence supporting this recommendation can be found in the source guideline document, available at: 
Warm packs were also evaluated but most of the quantitative and qualitative evidence relates to massage.
This recommendation has been integrated from the WHO recommendations for augmentation of labour (46), in which the GDG for that guideline determined it to be a conditional recommendation based on very low-quality evidence.
Given that restriction of oral fluid and food intake has no beneficial effects on important clinical outcomes, including the use of labour augmentation, the GDG puts its emphasis on respect for the wishes of the woman and therefore made a positive recommendation.
The GDG noted that no cases of Mendelson's Syndrome (inhalation of food and drink from the stomach into the lungs during general anaesthesia -the most important safety concern limiting oral intake during labour -were reported in over 3000 women participating in the trials included in the systematic review.
The evidence supporting this recommendation can be found in the source guideline document, available at: 

# Maternal mobility and position

# RECOMMENDATION 25
Encouraging the adoption of mobility and an upright position during labour in women at low risk is recommended. (Recommended)
This recommendation has been integrated from the WHO recommendations for augmentation of labour (46), in which the GDG for that guideline determined it to be a strong recommendation based on very low-quality evidence. Although the evidence does not suggest that mobility and upright position in labour reduce the use of oxytocin augmentation, the GDG placed its emphasis on the clinical benefits in terms of reducing caesarean section.
The GDG noted that in many settings, traditional practices of enforcing bed rest for all women in labour are common, rather than allowing women's choices to be informed by their knowledge of the benefits of mobility and upright position. The GDG puts its emphasis on providing women with the choice of an intervention that is beneficial, cheap and easy to implement, and therefore made a strong recommendation for this intervention. This recommendation should inform and support women's choices on what position to adopt during the first stage of labour. The evidence supporting this recommendation can be found in the source guideline document, available at: 

# Vaginal cleansing

# RECOMMENDATION 26
Routine vaginal cleansing with chlorhexidine during labour for the purpose of preventing infectious morbidities is not recommended. (Not recommended)
This recommendation has been integrated from the WHO recommendations for prevention and treatment of maternal peripartum infections (114), in which the GDG for that guideline determined it to be a strong recommendation based on moderate-quality evidence. This recommendation was based on the lack of clinical benefits for the neonate and not on the potential effect of the intervention on group B Streptococcus (GBS)-related maternal infectious morbidity.
The GDG acknowledged the considerable variations in policies regarding the screening for GBS colonization in pregnant women. Therefore, the group agreed that this recommendation should be implemented within the context of local policy and guidance on screening for GBS colonization.
The evidence supporting this recommendation can be found in the source guideline document, available at: 

# Active management of labour

# RECOMMENDATION 27
A package of care for active management of labour for prevention of delay in labour is not recommended. (Not recommended)
This recommendation has been integrated from the WHO recommendations for augmentation of labour (46), in which the GDG for that guideline determined it to be a conditional recommendation based on low-quality evidence.
The GDG agreed that this package of interventions has potential benefits in terms of reducing the duration of labour and possible caesarean section rate. However, the group did not support its recommendation as it considered the approach to be highly prescriptive and interventional and one that could undermine women's rights, choices and autonomy as recipients of care. In addition, the intervention is considered to be a complex package that exerts considerable demands on health resources, which may not be feasible in many settings. The GDG chose not to recommend the package because the reported clinical benefits do not clearly outweigh these other considerations.
The GDG also noted that continuous one-to-one care is the only component of the package that has been shown to be beneficial, and is probably the component responsible for the benefits attributed to the package. Continuous support during labour as a separate intervention is recommended in the WHO recommendations for augmentation of labour.
Evidence supporting this recommendation can be found in the source guideline document, available at: 

# Routine amniotomy

# RECOMMENDATION 28
The use of amniotomy alone for prevention of delay in labour is not recommended. (Not recommended)
This recommendation has been integrated from the WHO recommendations for augmentation of labour (46), in which the GDG for that guideline determined it to be a conditional recommendation based on very low-quality evidence.
The GDG noted that in spite of the common use of amniotomy for prevention of labour delay in clinical practice, there is no clear evidence that the potential benefits outweigh the potential harms.
As early amniotomy may increase the risk of perinatal HIV transmission, this recommendation could be strengthened in settings where HIV infection is prevalent and women may present in labour with unknown HIV status.
The evidence supporting this recommendation can be found in the source guideline document, available at: 

# Early amniotomy and oxytocin

# RECOMMENDATION 29
The use of early amniotomy with early oxytocin augmentation for prevention of delay in labour is not recommended. (Not recommended)
This recommendation has been integrated from the WHO recommendations for augmentation of labour (46), in which the GDG for that guideline determined it to be a conditional recommendation based on very low-quality evidence.
The GDG noted that the variable reduction in the duration of the first stage of labour itself does not justify the intervention, given that no substantive differences were found in other important clinical outcomes.
The GDG noted the substantial overlap between this intervention and the other components of the active management of labour, and considered it as equally highly prescriptive and interventional. Like the package of active management of labour, the group placed much emphasis on its potential to undermine women's rights, choices and autonomy as recipients of care, and therefore did not recommend the intervention. Additionally, the intervention is not considered feasible in many settings, as it requires considerable health care resources to implement. The evidence supporting this recommendation can be found in the source guideline document, available at: 

# Oxytocin for women with epidural analgesia

# RECOMMENDATION 30
The use of oxytocin for prevention of delay in labour in women receiving epidural analgesia is not recommended. (Not recommended)
This recommendation has been integrated from the WHO recommendations for augmentation of labour (46), in which the GDG for that guideline determined it to be a conditional recommendation based on low-quality evidence. Augmentation with oxytocin should be performed when indicated as treatment of confirmed delay of labour progress in women receiving epidural analgesia.
The evidence supporting this recommendation can be found in the source guideline document, available at: 

# Antispasmodic agents

# RECOMMENDATION 31
The use of antispasmodic agents for prevention of delay in labour is not recommended.
This recommendation has been integrated from the WHO recommendations for augmentation of labour (46), in which the GDG for that guideline determined it to be a conditional recommendation based on very low-quality evidence.
The GDG noted that the available data were too heterogeneous with respect to the participants and interventions to permit wide applicability of the results. The shortening in the length of the first stage of labour by one hour was considered clinically inconsequential, as it did not translate into improvement in the other critical maternal or infant outcomes. The GDG placed high value on safety issues, which were poorly reported, and chose not to recommend the practice until new information demonstrating clinical benefits with minimal risks becomes available. The GDG considers the effectiveness of the use of antispasmodic agents for the treatment of labour delay as a research priority. The evidence supporting this recommendation can be found in the source guideline document, available at: 

# Intravenous fluids for preventing labour delay

# RECOMMENDATION 32
The use of intravenous fluids with the aim of shortening the duration of labour is not recommended. (Not recommended)
This recommendation has been integrated from the WHO recommendations for augmentation of labour (46), in which the GDG for that guideline determined it to be a strong recommendation based on very low-quality evidence. The GDG did not recommend this intervention on the basis of no clear evidence of benefits over harms. The group noted that the risk of maternal fluid overload, particularly when intravenous oxytocin infusion becomes indicated during the course of labour, might become accentuated.
The GDG agreed that low-risk women should be encouraged to drink fluids during labour.
The GDG acknowledged that intravenous (IV) fluid may become necessary for other indications and for supportive care in labour even for low-risk women.
The GDG placed its emphasis on the widespread and unnecessary use of routine administration of IV fluids for all women in labour and many health care facilities in low-, middle-and high-income settings that increases cost, has considerable impact on the resource use and reduces women's mobility, and therefore made a strong recommendation against this intervention. The evidence supporting this recommendation can be found in the source guideline document, available at: 

# Second stage of labour 3.3.1 Definition and duration of the second stage of labour

# RECOMMENDATION 33
The use of the following definition and duration of the second stage of labour is recommended for practice.
-The second stage is the period of time between full cervical dilatation and birth of the baby, during which the woman has an involuntary urge to bear down, as a result of expulsive uterine contractions. (Recommended)
-Women should be informed that the duration of the second stage varies from one woman to another. In first labours, birth is usually completed within 3 hours whereas in subsequent labours, birth is usually completed within 2 hours. (Recommended)
The description of the onset of the second stage based on research is an inexact science and the onset of the second stage of labour in clinical practice is often not precisely known. A woman may feel the urge to bear down before complete dilatation or she may not yet feel this urge at the moment when complete dilatation is diagnosed. If complete dilatation is found on vaginal examination, it remains uncertain for how long this cervical status has been present. Transportation from the labour room to a specific delivery room at the beginning of the second stage could be unpleasant to the woman and is unnecessary when labour is progressing normally. Birth attendants should be aware that a woman can feel the urge to bear down at a cervical dilatation earlier than 10 cm. A decision about curtailing the second stage of labour should be based on surveillance of the maternal and fetal condition, and on the progress of labour. When the woman's condition is satisfactory, the fetus is in good condition, and there is evidence of progress in the descent of the fetal head, there are no grounds for intervention. However, when the second stage has extended beyond the abovementioned standard durations, the chance of spontaneous birth within a reasonable time decreases, and intervention to expedite childbirth should be considered.

# Summary of evidence and considerations

# Duration of the second stage of labour
Evidence was derived from a systematic review of 37 studies evaluating the duration of labour in low-risk women with normal perinatal outcomes (52). The same review provided evidence for the duration of the first stage of labour. The included studies were conducted in 17 low-, middle-and high-income countries (China, Colombia, Croatia, Egypt, Finland, Germany, Israel, Japan, Republic of Korea, Myanmar, Nigeria, Norway, Taiwan Uganda, the United Kingdom, the USA and Zambia), involving over 200 000 women of different ethnic origins and socioeconomic status. The trials were published between 1960 and 2016. Twenty-one of the included studies reported data on the duration of the second stage of labour for nulliparous, and 17 reported data for parous women. Labour interventions such epidural analgesia and instrumental vaginal birth, which could impact the duration of the second stage, varied widely across studies.
In 13 of the studies reporting data for nulliparous women, no epidural analgesia was used; epidural use was not reported in five studies. One study subdivided the nulliparous population according to epidural use (groups with 0% and 100% epidural use) while three other studies reported 4.1%, 42.9% and 48.0% epidural use in the study populations.
Eleven of the studies did not clearly define the starting reference point for the second stage while others defined this as starting from 10 cm of cervical dilatation. Two studies defined the reference starting point as 10 cm of cervical dilatation or the urge to bear down. These studies were not pooled due to heterogeneity in population characteristics, interventions and definitions of the onset of the second stage of labour. Low-certainty evidence from 15 studies reporting data as a mean suggests that the mean duration of the second stage ranged from 6 to 30 minutes (0.1-0.5 hours), and the statistical ("maximum") limits were estimated as 16-78 minutes (0.3-1.3 hours).
There was no epidural use in eight of the studies, it was unreported in six studies, and epidural use was reported in 2.4%, 4.3% and 9.5% of women in three studies. Only four of these studies clearly reported the starting reference point for the second stage.
Sensitivity analysis excluding second stage interventions also reveals a similar range of values. It shows that nulliparous women are able to successfully complete the second stage within 20-78 minutes, with statistical limits ranging from 60 to 174 minutes (1.0-2.5 hours). For parous women, the duration of the second stage is shorter, ranging from 6 to 30 minutes (0.1-0.5 hours), with upper estimates ranging from 16 to 78 minutes (0.3 to 1.3 hours).
Findings from a review of qualitative studies looking at what matters to women during childbirth (23) indicate that most women want a normal childbirth with good outcomes for mother and baby, but acknowledge that medical intervention may sometimes be necessary.

# Additional considerations
Women generally place a high value on the total duration of labour, although the relative importance of how long or how short labour is may be context dependent. Evidence from other studies suggests that women are less likely (than health care providers) to recognize defined, time-bound phases of labour (54), and their ability to cope is more likely to be dependent on a variety of inter-related factors, including the level of pain experienced, the nature of the environment and their perceived level of support (55).
No review evidence on resource requirements relating to duration of the second stage of labour was found.

# Additional considerations
Application of limits for the duration of the second stage as informed by the respective 95th percentile thresholds as the benchmark for identifying unduly prolonged second stage of labour might be costeffective as it has the potential to reduce the use of interventions to hasten birth, especially with instrumental vaginal birth and caesarean section. However, it might increase costs associated with longer supportive care.
In certain middle-and high-income country settings where physicians attend to all women in labour, the use of limits for the duration of the second stage of labour based on 95th percentile thresholds for managing labour may likely result in an increase in health care resource use.
No evidence on the impact on equity was found.

# Additional considerations
An important indication for second stage caesarean section is prolonged second stage based on the expectation that the second stage should not last longer than 1 hour. However, caesarean section is a highly inequitable intervention (especially when used without a clear medical indication) as it is unlikely to be promptly received by disadvantaged women in resource-poor settings. Application of safe upper limits to all women has the potential to reduce inequity that is associated with overmedicalization of childbirth.
Findings from a review of qualitative studies looking at what matters to women during labour and
Sufficient beds in the labour ward to support women whose second stage might be slower than the average for their population

# Supervision and monitoring
Ongoing supervision and monitoring with regular audit and review of outcomes related to extending the upper limits to diagnose prolonged second stage, when fetal and maternal conditions are reassuring childbirth (23) indicate that most pregnant women would prefer a shorter labour (low confidence). However, when asked after childbirth, women are more likely to report a positive labour experience if they were able to "go with the flow" where the optimal length of labour was tailored to the individual regardless of standardized time limits (moderate confidence).

# Additional considerations
There is evidence to suggest that women are more likely to report both very short and very long labour in negative terms (72,73,91).
In a review of qualitative evidence looking at providers' experiences of delivering intrapartum care (26), the capacity to accommodate longer labours may be constrained by staff shortages and organizational time pressures (high confidence in the evidence). Local protocols and informal rules may also limit the ability of health care staff to provide personalized care (26).

# Additional considerations
Supporting women within the limits of the 95th percentile boundary for their parity group is unlikely to increase hospital stays or significantly increase staff workload, especially if unnecessary obstetric interventions, such as caesarean section (which could lead to longer hospital stays), can be avoided.

# Birth position for women without epidural analgesia

# RECOMMENDATION 34
For women without epidural analgesia, encouraging the adoption of a birth position of the individual woman's choice, including upright positions, is recommended. (Recommended)
The evidence suggests that upright birth positions during the second stage of labour might reduce episiotomy and instrumental vaginal births but might also be associated with increased risk of postpartum haemorrhage (PPH) and second-degree tears. However, most evidence is of low certainty and the GDG agreed that the difference in benefits and harms between upright and recumbent positions might not be clinically apparent.
It is important that any particular position is not forced on the woman and that she is encouraged and supported to adopt any position that she finds most comfortable.
The health care professional should ensure that the well-being of the baby is adequately monitored in the woman's chosen position. Should a change in position be necessary to ensure adequate fetal monitoring, the reason should be clearly communicated to the woman.
A practical approach to positioning in the second stage for women desiring an upright birth position might be to adapt to a semi-recumbent or all-fours position just before expulsion of the fetus, to facilitate perineal techniques to reduce perineal tears and blood loss.

# Summary of evidence and considerations

# Effects of the intervention (EB Table 3.3.2)
The evidence is derived from a Cochrane systematic review that included 32 individual RCTs conducted in low-, middle-and high-income countries (154).
Thirty trials involving 9015 women contributed data on upright compared with recumbent positions. Trial participants were nulliparous and/or parous women with uncomplicated singleton pregnancies at more than 36 weeks of gestation, except in two trials that included earlier gestations. Ten trials compared a birthing/squat stool, nine trials compared a birthing chair, and three trials compared a birth cushion with recumbent controls.
Comparison: Upright position compared with recumbent position in second stage of labour

# Maternal outcomes
Duration of labour: Evidence on the duration of labour from 19 trials (5811 women) is of very low certainty due to design limitations and high inconsistency across studies in the meta-analysis. However, on sensitivity analysis, whereby studies at high risk of bias were excluded, low-certainty evidence suggests that an upright birth position may make little or no difference to the duration of the second stage in minutes (10 trials, 2499 women, MD 4.34 fewer minutes, 95% CI 9.00 fewer to 0.32 more).

# Birth experience:
The review did not report on birth experience outcomes.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: The review did not report 5-minute Apgar score less than 7, cord blood acidosis, or hypoxic-ischaemic encephalopathy (HIE) outcomes.

# Additional considerations
A population-based study of 113 000 women conducted in Sweden of obstetric anal sphincter injury (OASI) and birth position found an increased risk of OASI with lithotomy position in nulliparous and parous women, a decreased OASI risk with a lateral birth position in nulliparous women, and no clear difference in risk with supine, kneeling, standing or all-fours positions (156). Squatting and birth seats were associated with an increased OASI risk in parous women but not in nulliparous women. Overall, 57% of nulliparous women and 26% of parous women underwent epidural analgesia in this study and findings were not reported separately according to its use.
A 2013 Cochrane systematic review found that the duration of labour with upright and ambulant positions compared with recumbent positions and bed care for the first stage of labour is probably about 1 hour and 22 minutes shorter (15 trials, 2503 women average MD -1.36 hours, 95% CI -2.22 to -0.51) (155). Findings also suggest that upright positions in the first stage probably reduce caesarean section (14 trials, 2682 women, RR 0.71, 95% CI 0.54-0.94) and epidural use (9 trials, 2107 women, RR 0.81, 95% CI 0.66-0.99). These effects did not occur in a comparison involving women with epidural analgesia.
Findings from a review of qualitative studies looking at what matters to women during intrapartum care (23) indicate that most women want a normal childbirth with good outcomes for mother and baby (high confidence in the evidence). Findings also suggest that women are aware of the unpredictability of labour and childbirth and are fearful of potentially traumatic events (including medical interventions and maternal and fetal morbidities), so they would value any technique that reduces their potential exposure to these kinds of outcomes (high confidence in the evidence).
Findings also suggest that women expect labour and childbirth to be painful but they would like to be in control of the labour process with the support of kind, caring staff who are sensitive to their needs. Women would also like to give birth in a safe, supportive environment that may include the freedom to move around (high confidence in the evidence).
No research evidence on resources was found.

# Additional considerations
Evidence on effects suggests that upright birth positions might reduce instrumental vaginal births and episiotomy but might increase second-degree tears and PPH, therefore, the cost-effectiveness is unclear. Health care professionals accustomed to supporting women to give birth in recumbent positions would require training on how to support women to give birth in an upright position. Upright positions do not necessarily require additional props (e.g. birth cushions).
down implementation even when a policy of offering upright birth options is in place. Safety concerns about the baby falling on the floor during an expulsive second stage would need to be addressed by appropriate training and provision of supportive birthing facilities.

# Birth position for women with epidural analgesia

# RECOMMENDATION 35
For women with epidural analgesia, encouraging the adoption of a birth position of the individual woman's choice, including upright birth positions, is recommended. (Recommended)
Evidence suggests that there might be little or no difference in most birth outcomes according to birth position among women with epidural analgesia. Having a choice of birth positions during the second stage of labour might positively impact maternal birth experience and improve equity. Upright positions with traditional epidural analgesia, which provides a dense neuroaxial block, might not be feasible; however, most epidural analgesia currently provided are "low dose" and "mobile" epidural analgesia, which should enable a choice of birth positions.
It is important that any particular position is not forced on the woman and that she is encouraged and supported to adopt any position that she finds most comfortable. The health care professional should ensure that the well-being of the baby can be adequately monitored in the woman's chosen position. Should a change in position be necessary to ensure adequate fetal monitoring, this should be effectively communicated to the woman.

# Summary of evidence and considerations

# Effects of the intervention (EB Table 3.3.3)
The evidence is derived from a Cochrane systematic review that included five individual RCTs conducted in the United Kingdom (4 trials) and France, involving 879 women (159). Participants were nulliparous and parous women with term singleton gestations and epidural analgesia for pain relief in labour. Three studies used mobile epidural analgesia, one study used traditional epidural analgesia, and the other study did not state the type of epidural used. Two studies reported that women with spontaneous and induced labour were included; however, it is unclear whether the other studies included women with induced labour.
Positions of the study groups varied between studies but all studies distinguished two groups that could be classified as upright or recumbent for the purpose of the review.
Upright positions included sitting (on a bed or a tilting bed more than 45 from the horizontal), squatting (unaided or using squatting bars or a birth cushion, semi-recumbent (with the main axis of the body 45 or more from the horizontal), and kneeling (upright, leaning on the head of the bed, or supported by a partner). Recumbent positions included lithotomy position, lateral position (left or right), Trendelenburg's position (head lower than pelvis), knee-elbow (all fours) position (with axis of the trunk horizontal), and semi-recumbent (with the main axis of the body less than 45 from the horizontal).
Comparison: Upright position compared with recumbent position in second stage of labour with epidural analgesia

# Fetal distress:
The evidence on abnormal FHR patterns requiring intervention is of very low certainty.
Perinatal mortality: Low-certainty evidence from one study suggests little or no difference in perinatal death (there was a single event, 3093 infants, RR 2.96, 95% CI 0.12-72.69).

# Additional considerations
A population-based study of 113 000 women conducted in Sweden of obstetric anal sphincter injury (OASI) and birth position found an increased risk of OASI with lithotomy position in nulliparous and parous women, a decreased risk of OASI with a lateral birth position in nulliparous women, and no clear difference in risk with supine, kneeling, standing or all-fours positions (156). Squatting and birth seats were associated with an increased risk of OASI in parous women but not in nulliparous women. Overall, 57% of nulliparous women and 26% of parous women underwent epidural analgesia in this study and findings were not reported separately according to its use.
Findings from a review of qualitative studies looking at what matters to women during intrapartum care (23) indicate that most women want a normal childbirth with good outcomes for mother and baby (high confidence in the evidence). Findings also suggest that women are aware of the unpredictability of labour and childbirth and are fearful of potentially traumatic events (including medical interventions and maternal and fetal morbidities) so would value any technique that reduces their potential exposure to these kinds of outcomes (high confidence in the evidence).
In addition, findings suggest that women expect labour and childbirth to be painful but would like to be in control of the labour process with the support of kind, caring staff who are sensitive to their needs. Women would also like to give birth in a safe, supportive environment that may include the freedom to move around (high confidence in the evidence).

# Additional considerations
Although the evidence on the effect of birth positions with epidural is limited, it suggests that birth position has little impact on outcomes for women with epidural. Therefore, based on the qualitative evidence above, women with epidurals may prefer the option of an upright birth position if it does not cause harm to them or their babies.
No research evidence was found on costs associated with birth positions.

# Additional considerations
As the evidence on effects suggests there might be little or no difference in the duration of the second stage and other birth outcomes, the choice of birth position for women with epidural analgesia might plausibly have little or no resource implications with regard to staff time and beds.
Health care professionals accustomed to supporting women with epidural analgesia to give birth in recumbent positions could require additional/ refresher training on how to support them to give birth in an upright position.
No research evidence on equity was found.

# Additional considerations
Having a choice of birth positions might have a positive impact on equity if it reduces unnecessary medical interventions among more advantaged women using epidural analgesia.
A systematic review of qualitative studies exploring women's experiences of intrapartum care (26) found that women wanted the freedom to adopt various positions during the second stage of labour (low confidence in the evidence). In most cases a non-supine position was perceived to be more empowering and less painful, and to facilitate an easier birth, although the supine position (on a bed) was still viewed as the more traditional approach to giving birth (low confidence in the evidence).
Findings on health care professionals' experiences from the same review showed that staff tried to be responsive to women's needs but tended to favour the supine position as it made monitoring, medical intervention and the birth process easier for them to manage (moderate confidence in the evidence) (26).

# Additional considerations
Data from cross-sectional surveys conducted in Africa (Malawi and Nigeria) showed that more than 90% of women were aware of the supine or semirecumbent positions for labour and birth but less than 5% were aware of alternative positions (e.g. squatting, kneeling, and on hands and knees). Data from the Nigerian study also showed that only 18.9% of women would have been prepared to adopt an alternative position if it had been suggested by a health care professional (157,158).
A systematic review of qualitative studies exploring women's experiences of intrapartum care (26) found that women generally wanted to move around during childbirth but the lack of space in some birth facilities prevented them from doing so (low confidence in the evidence). Findings also showed that women were sometimes unaware of non-supine positions and felt different options for birth positions should have been highlighted during antenatal care (low confidence in the findings).
Findings on health care professionals' experiences of intrapartum care (26) showed that providers were often unaware of or inexperienced in the use of nonsupine positions. Staff also raised safety concerns about women coming "off the bed" and in certain contexts (LMICs) felt that overcrowding in delivery rooms prevented women from adopting an upright position (low confidence in the evidence).

# Additional considerations
Upright birth positions might be more feasible to implement in settings where "walking" epidurals are available, as these are less restrictive than traditional epidurals. The adoption of upright positions will require additional training and practise, as many practising doctors and midwives may not be familiar with the method. Facilities employing a younger generation of doctors and midwives may not have experienced personnel on staff, which may slow down implementation even when a policy of offering upright birth options is in place. Safety concerns about the baby falling on the floor during an expulsive second stage would need to be addressed by appropriate training and provision of supportive birthing facilities. The cost-effectiveness domain was not judged because the desirable effects of the intervention were trivial.

# Summary of evidence and considerations

# Effects of the intervention (EB Table 3.3.4)
This evidence is derived from a Cochrane systematic review on pushing techniques (160). Eight RCTs involving 884 women compared spontaneous pushing with directed pushing. Most participants in these studies, which were conducted in Hong Kong Special Administrative Region, Iran, Turkey, the United Kingdom (1 study each) and the USA (3 studies), were nulliparous women with uncomplicated singleton vertex gestations at term. Sample sizes ranged from 32 to 320 participants. One trial (258 women) also included parous women and another comprised a proportion of women with epidural analgesia. The birth position of participants in the studies was not consistent across studies, with one study (72 women) managing the directed pushing group in a supine position, whereas women in the spontaneous group pushed in an upright position. Other aspects of the techniques differed slightly across studies but, in general, women in the spontaneous group were not given specific instructions on how to push and were encouraged, rather, to do what comes naturally.

# Comparison: Spontaneous pushing compared with directed pushing

# Maternal outcomes
Duration of labour: Evidence on duration of the second stage of labour and the duration of pushing is of very low certainty.

# Mode of birth:
High-certainty evidence shows that spontaneous pushing makes little or no difference to spontaneous vaginal birth (5 trials, 688 women, RR 1.01, 95% CI 0.97-1.05), and low-certainty evidence suggests that it may have little or no effect on instrumental vaginal birth (2 trials, 393 women,

# Method of pushing

# RECOMMENDATION 36
Women in the expulsive phase of the second stage of labour should be encouraged and supported to follow their own urge to push. (Recommended)
Qualitative evidence on what matters to women during intrapartum care shows that women want to feel in control of their birth process, with the support of kind, reassuring staff who are sensitive to their needs (23).
Health care providers should avoid imposing directed pushing on women in the second stage of labour, as there is no evidence of any benefit with this technique.
RR 0.56, 95% CI 0.06-5.10). Evidence on caesarean section is of very low certainty.
Perineal/vaginal trauma: Moderate-certainty evidence suggests there is probably little or no difference between spontaneous and directed pushing on perineal lacerations (1 trial, 320 women, RR 0.87, 95% CI 0.45-1.66). Evidence on episiotomy is of very low certainty.
Long-term morbidity: Low-certainty evidence suggests there may be little or no difference in postpartum urinary incontinence between spontaneous and directed pushing (1 trial, 128 women, RR 0.77, 95% CI 0.29-1.69). No studies reported perineal pain, dyspareunia or pelvic floor prolapse.
Birth experience: There may be little or no difference in maternal satisfaction between these techniques, measured on a visual analogue scale, however the evidence is of low certainty (1 trial, 31 women, MD 0.91 higher satisfaction score. Evidence on maternal fatigue after birth is of very low certainty and no studies reported on pain during the second stage.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: Low-certainty evidence suggests there may be little or no difference between spontaneous compared with directed pushing on 5-minute Apgar score less than 7 (1 trial, RR 0.

# Fetal distress:
The review did not report this outcome.
Perinatal mortality: The review did not report this outcome.

# Additional considerations
Evidence from other studies suggests that women are less likely (than health care providers) to recognize defined, time-bound phases of labour (54), and their ability to cope is more likely to be dependent on a variety of inter-related factors, including the level of pain experienced, the nature of the environment and their perceived level of support (55).
Findings from a review of qualitative studies looking at what matters to women during intrapartum care (23) indicate that most women want a normal childbirth with good outcomes for mother and baby (high confidence in the evidence). Some women also hope for a relatively quick labour but this is often based on the perception that the longer labour lasts the more likely they are to require medical intervention (low confidence in the evidence). Findings also suggest that women are aware of the unpredictability of labour and childbirth and are fearful of potentially traumatic events (including medical interventions and maternal and fetal morbidities) so they would value any technique that reduces their potential exposure to these kinds of outcomes (high confidence in the evidence).
Findings also suggest that women would like to "go with the flow" by being aware of and trusting their own physiological signals (including the urge to push), supported by kind, reassuring staff who are sensitive to their needs (high confidence in the evidence).

# Additional considerations
Evidence from other studies suggests that women are less likely (than health care providers) to recognize defined, time-bound phases of labour (54), and their ability to cope is more likely to be dependent on a variety of inter-related factors, including the level of pain experienced, the nature of the environment and their perceived level of support (55).
There is no review evidence on costs associated with these two pushing techniques.

# Additional considerations
If a pushing technique leads to a longer duration of second stage and/or more interventions, it would have cost implications in terms of staff time and other costs. However, this does not appear to be the case with spontaneous and directed pushing techniques, which, the review found, had little or no effect on the duration of labour and other birth outcomes. Therefore, although based on lowcertainty evidence overall, findings suggest that cost implications with these different techniques may be negligible.
No research evidence was found.

# Additional considerations
Encouraging women to use their own natural, physiological method of pushing in the second stage might help women to feel more in control of their childbirth experience and empower them to enjoy their reproductive rights.
A qualitative systematic review of women's experiences of labour and childbirth (26) found no direct evidence relating to women's views on pushing. Indirect evidence from this review suggests that in certain LMIC contexts women are more likely to experience disrespectful or abusive care when health care professionals adopt a directive approach to labour and childbirth (low confidence in the evidence). Findings also indicate that women like to feel "in control" of labour progress but welcome support and advice from reassuring health care professionals, provided it is consistent, coherent and in accord with their perceived physiological and psychological state (low confidence in the evidence).
The qualitative systematic review found no direct evidence on health care professionals' views relating to pushing (26).

# Additional considerations
Evidence from a review and case analysis study indicates that women do not like the conflicting internal and external messages, when their internal desire is to push but health care professionals tell them not to, or vice versa (161).
A qualitative systematic review of women's experiences of labour and childbirth found no direct evidence relating to women's views on pushing (26). Indirect evidence would suggest that there are unlikely to be any concerns around feasibility.
The qualitative systematic review found no direct evidence on health care professionals' views relating to pushing (26). Indirect evidence would suggest that organizational pressures relating to time and bed space may encourage health care professionals to favour directed pushing in certain contexts based on the perception that it shortens labour (very low confidence in the evidence).

# Additional considerations
The teaching of women, by health care professionals, to follow their own instincts to push when they feel the urge is more feasible than teaching women to perform the Valsalva manoeuvre. The cost-effectiveness domain was not judged because the desirable effects of the intervention were trivial.

# Method of pushing for women with epidural analgesia

# RECOMMENDATION 37
For women with epidural analgesia in the second stage of labour, delaying pushing for one to two hours after full dilatation or until the woman regains the sensory urge to bear down is recommended in the context where resources are available for longer stay in second stage and perinatal hypoxia can be adequately assessed and managed. (Context-specific recommendation)
Evidence on effects suggests that delaying pushing probably increases the likelihood of spontaneous vaginal birth after a slightly longer labour. The evidence that delaying pushing might increase the risk of low umbilical cord pH is of low certainty and the GDG agreed that the clinical importance of this limited evidence is very uncertain. Health care providers should avoid imposing immediate pushing on women in the second stage of labour, as there is no evidence of any benefit with immediate pushing and the practice might lead to further medical intervention.

# Summary of evidence and considerations

# Effects of the intervention (EB Table 3.3.5)
The evidence is derived from a Cochrane systematic review on pushing techniques (160). Twelve individual RCTs compared delaying pushing with immediate pushing in 2879 women with epidural analgesia in the second stage of labour. Sample sizes of these trials, which were conducted mainly in HICs (Canada, Ireland, Switzerland, United Kingdom  and the USA and one middle-income country (Malaysia), ranged from 37 to 1862 participants. Most participants were nulliparous women with uncomplicated singleton vertex gestations at term; however, two trials also included parous women. All participants had epidural analgesia, with dosing schemes and types of epidural analgesia (e.g. traditional or walking/ mobile) varying across the trials. Birth position of participants was reported in only five trials and most trials did not report whether women were encouraged to use a closed-glottis or spontaneous pushing technique for bearing down.
In general, women in the immediate pushing group began pushing as soon as full cervical dilatation was identified, whereas in the other group, the onset of pushing was delayed until the women experienced an irresistible urge to push, or for 1, 2 or 3 hours, depending on the individual trial protocols. In the largest trial of 1862 women, pushing was delayed for 2 hours in the intervention group, unless the woman had an irresistible urge to bear down, the fetal head was visualized on routine inspection of the perineum, or there was a medical indication to shorten the duration of labour. Birth experience: Low-certainty evidence suggests that delaying pushing may make little or no difference to maternal satisfaction (1 trial, 73 women, MD 0.4 higher, 95% CI 7.34 lower to 8.14 higher), as measured on a visual analogue scale.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: Low-certainty evidence suggests that delaying pushing might increase rates of low umbilical cord pH (arterial and/or venous pH as defined by trial authors) (4 trials, 2145 babies, RR 2.24, 95% CI 1.37-3.68).
The absolute risk difference might be approximately 25 more events per 1000 (from 7 to 53 more) with delaying pushing. Evidence on a 5-minute Apgar score less than 7 is of very low certainty. No trials reported hypoxic-ischaemic encephalopathy (HIE).
Fetal distress: This outcome was not reported in the review.
Perinatal mortality: This outcome was not reported in the review.
Findings from a review of qualitative studies looking at what matters to women during intrapartum care (23) indicate that most women want a normal childbirth with good outcomes for mother and baby (high confidence in the evidence). Findings also suggest that women are aware of the unpredictability of labour and childbirth and are fearful of potentially traumatic events (including medical interventions and maternal and fetal morbidities), so they would value any technique that reduces their potential exposure to these kinds of outcomes (high confidence in the evidence).
Some women also hope for a relatively quick labour, but this is often based on the perception that the longer labour lasts the more likely they are to require medical intervention (low confidence in the evidence).
Findings also suggest that women would like to "go with the flow" by being aware of and trusting their own physiological signals (including the urge to push), supported by kind, reassuring staff who are sensitive to their needs (high confidence in the evidence).

# Additional considerations
The qualitative evidence above suggests that women are likely to value the increased chance of spontaneous birth with delaying pushing, but would worry about the increase in cord pH if this translated into poor birth outcomes.
The Cochrane systematic review (160) included evidence on costs, with one large trial (1862 women) reporting this outcome (162).
No research evidence on equity was found.

# Additional considerations
Epidural analgesia is a technique for pain relief that, in healthy pregnant women, is mainly employed in well resourced settings and HICs.
Higher costs associated with the technique of delaying pushing might further reduce equity if women undergoing epidural analgesia require additional resources to accommodate delaying pushing in the second stage of labour.
A qualitative systematic review of women's experiences of labour and childbirth found no direct evidence relating to women's views on pushing (26). Indirect evidence from this review suggests that women like to feel in control of labour progress but welcome the support and advice from a reassuring health care professional, provided it is consistent, coherent and in accord with their perceived physiological and psychological state (low confidence in the evidence).
The same review also found no direct evidence on health care professionals' views relating to pushing (26).
A qualitative systematic review of women's experiences of labour and childbirth found no direct evidence relating to women's views on pushing (26). Indirect evidence would suggest there are unlikely to be any concerns around feasibility.
The qualitative systematic review also found no direct evidence on health care professionals' views relating to pushing (26). Indirect evidence would suggest that a lack of training in certain contexts may have an impact on practice (very low confidence in the evidence).

# Additional considerations
If delaying pushing leads to longer labour duration this might be less feasible in resource-constrained settings.

# Techniques for preventing perineal trauma

# RECOMMENDATION 38
For women in the second stage of labour, techniques to reduce perineal trauma and facilitate spontaneous birth (including perineal massage, warm compresses and a "hands on" guarding of the perineum) are recommended, based on a woman's preferences and available options. (Recommended)
Evidence suggests that perineal massage may increase the chance of the keeping the perineum intact and reduces the risk of serious perineal tears, that warm perineal compresses reduce third-and fourth-degree perineal tears, and that a "hands-on" approach (guarding) probably reduces firstdegree perineal tears. Most women accept these low-cost preventative perineal techniques and highly value the outcomes that they impact. Evidence on Ritgen's manoeuvre (using one hand to pull the fetal chin from between the maternal anus and the coccyx, and the other hand placed on the fetal occiput to control speed of birth) is very uncertain; therefore, this technique is not recommended.

# Summary of evidence and considerations

# Effects of the intervention (EB Table 3.3.6)
The evidence is derived from a Cochrane systematic review that included 22 individual RCTs (163). perineal massage compared with a "hands-off" approach or usual care; a "hands-off" compared with a "hands-on" approach; a warm compress compared with a "hands-off" approach or no warm compress; and Ritgen's manoeuvre compared with usual practice.
Other interventions assessed in the review that were associated with very limited evidence included cold compresses, delivery of the posterior shoulder first compared with the anterior shoulder, the application of petroleum jelly, enriched oil compared with liquid wax, and a perineal protection device. These interventions are not evaluated in this framework.
Comparison 1: Perineal massage compared with control ("hands off" approach or usual care)
Seven studies (2684 participants) from Australia, Iran and the USA contributed data to this comparison. In these studies, perineal massage in the second stage of labour was performed with a lubricant. It generally involved the midwife inserting two fingers into the vagina and applying mild, downward pressure to the vagina towards the rectum, while moving the fingers with steady strokes from side to side. Massage in some studies was performed only during contractions in the second stage and in others was continued during and between pushes.

# Maternal outcomes
Perineal/vaginal trauma: Low-certainty evidence suggests that perineal massage may increase the likelihood of having an intact perineum after giving birth (6 trials, 2618 women, RR 1.74, 95% CI 1.11-2.73). The absolute effect is estimated as 168 more women having an intact perineum per 1000 (from 25 to 393 more).
High-certainty evidence indicates that perineal massage reduces third-or fourth-degree perineal tears (5 trials, 2477 women, RR 0.49, 95% CI 0.25-0.94). The absolute effect is estimated as 5 fewer per 1000 (from 2 to 22 fewer). Evidence on first-and second-degree tears, episiotomy and the need for perineal suturing is of very low certainty.

# Long-term morbidity:
The review found no evidence on long-term outcomes.

# Birth experience:
The review found no evidence on maternal satisfaction or other outcomes related to birth experience.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: The review found no evidence on Apgar scores less than 7 at 5 minutes.
Birth trauma: The review did not include birth trauma as an outcome.
Findings from a review of qualitative studies looking at what matters to women during intrapartum care (23) indicate that most women want a normal childbirth with good outcomes for mother and baby (high confidence in the evidence). Findings also suggest that women are aware of the unpredictability of labour and childbirth and are fearful of potentially traumatic events (including medical interventions and maternal and fetal morbidities) that can occur during the birthing process (high confidence in the evidence). It is therefore likely that women will value any technique that may limit perineal trauma, particularly if it is offered by kind, competent health care professionals who are sensitive to their needs (high confidence in the evidence).
Qualitative evidence also shows that, when interventions are being considered, women would like to be informed about the nature of the interventions and, where possible, given a choice (high confidence in the evidence) (23).

# Additional considerations
Findings from a meta-synthesis of women's experiences of perineal trauma suggest that women may feel devalued, dismissed, depressed and have a sense of failure when their perineum is damaged following childbirth (164).
No review evidence was found.

# Additional considerations
Perineal techniques are a low-cost intervention for which in-service training would be the main cost.
If perineal massage increases the proportion of women with an intact perineum after childbirth and reduces third-and fourth-degree tears, it would logically be more cost-effective than usual care by reducing the costs associated with suturing supplies (e.g. suture materials, local anaesthetics, swabs) and health care professional time required to suture.
A 2002 study from Argentina reported an average provider cost saving of US$ 20.21 per birth with a change in episiotomy policy that led to fewer episiotomies being performed and a reduced need for suturing (165), which gives an indirect indication of possible cost savings that might occur per birth with reduced third-and fourth-degree tears and an increase in intact perineum.
No evidence on perineal techniques and equity was found.

# Additional considerations
If health care professionals could contribute to preserving the integrity of the perineum in the second stage of labour through simple perineal techniques, women in LMICs might be more inclined to use facility-based birth services, which could have a positive impact on equity.
A qualitative systematic review of women's experiences of labour and childbirth found no direct evidence relating to women's views on perineal massage techniques (26). Indirect evidence from this review suggests that, in certain contexts, some women may appreciate techniques that limit perineal trauma, provided they are applied by kind and sensitive health care professionals (low confidence in the evidence). In other contexts, women may find these techniques painful, uncomfortable or embarrassing (very low confidence in the evidence).
The qualitative systematic review also found no direct evidence on health care professionals' views on perineal techniques to prevent perineal trauma (26).

# Additional considerations
In a Canadian survey of women's views of prenatal perineal massage (n = 684), the authors found that women held positive views of the technique and would use it again in a subsequent pregnancy (166).
It is likely that women would appreciate any of the perineal techniques if there was evidence to suggest they might help or limit any of the potential long-term consequences of a damaged perineum (dyspareunia, sexual dysfunction, urinary or faecal incontinence).
A qualitative systematic review of women's experiences of labour and childbirth found no direct evidence relating to women's views on perineal techniques (26). Indirect evidence from this review would suggest that there are unlikely to be any concerns around feasibility.
The qualitative systematic review also found no direct evidence on health care professionals' views relating to perineal techniques (26). Indirect evidence would suggest that health care professionals in certain contexts may lack the training and/or experience to use some or all of the perineal techniques described (very low confidence in the evidence).

# Additional considerations
In a small survey of 54 Australian midwives taking part in an RCT on perineal massage during labour (167), the author found that midwives did not always apply the intervention for a variety of reasons, including: (i) women found it uncomfortable; (ii) labour progressed too quickly; (iii) there was fetal distress; (iv) they didn't have time and (v) they felt it was intrusive. After the trial, the number of midwives who felt the technique was "definitely beneficial" increased from 8 to 15.  Comparison 3: "Hands-off" compared with "hands-on" perineum approach Five studies (7317 participants) from Austria, Brazil, Iran and the United Kingdom contributed data to this comparison. The hands-off (or poised) approach was generally expectant and observational to the extent that light pressure could be applied to the baby's head in case of rapid expulsion, with the plan not to touch the head or perineum otherwise, and to allow spontaneous birth of the shoulders. A handson approach (or guarding) involved the midwife supporting the anterior and posterior perineum with both hands to protect/guard the perineum and maintain flexion of, and control, the expulsion of the fetal head.

# Maternal outcomes
Perineal/vaginal trauma: Moderate-certainty evidence suggests that use of the hands-off compared with the hands-on approach probably makes little or no difference to the likelihood of having an intact perineum after giving birth (2 trials, 6547 women, RR 1.03, 95% CI 0.95-1.12). Low-certainty evidence suggests that the handsoff approach may increase first-degree tears compared with the hands-on approach (2 trials, 700 participants, RR 1.32, 95% CI 0.99-1.77), however, the estimate of effect includes the possibility of no difference. The absolute effect is estimated as 58 more per 1000 (from 2 fewer to 139 more). Evidence on third-and fourth-degree tears, second-degree tears and episiotomy is of very low certainty.

# Long-term morbidity:
The review found no evidence on long-term outcomes.

# Birth experience:
The review found no evidence on maternal satisfaction or other outcomes related to childbirth experience.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: The review found no evidence on Apgar scores less than 7 at 5 minutes.

# Additional considerations
It is likely that women would appreciate any of the perineal techniques if there was evidence to suggest they might help or limit any of the potential long-term consequences of a damaged perineum (dyspareunia, sexual dysfunction, urinary or faecal incontinence).
A qualitative systematic review of women's experiences of labour and childbirth found no direct evidence relating to women's views on perineal  (26). Indirect evidence from this review would suggest that there are unlikely to be any concerns around feasibility.
The qualitative systematic review also found no direct evidence on health care professionals' views relating to perineal techniques (26). Indirect evidence would suggest that health care professionals in certain contexts may lack the training and/or experience to use some or all of the perineal techniques described (very low confidence in the evidence). Low-certainty evidence suggests that selective/ restrictive episiotomy may have little or no effect on perineal infection (3 trials, 1467 women, RR 0.90, 95% CI 0.45-1.82). Evidence on relative blood loss at birth is very uncertain.

# Long-term morbidity:
For long-term morbidity at 6 months or more after childbirth, low-certainty evidence suggests there may be little or no effect of selective/restrictive versus routine or liberal episiotomy on dyspareunia (pain during intercourse) (3 trials, 1107 women, RR 1.14, 95% CI 0.84-1.53). Evidence on other long-term morbidity is sparse and very uncertain (urinary incontinence, genital prolapse), or lacking (faecal incontinence, sexual dysfunction).

# Duration of the second stage of labour:
The review did not report this outcome.
Use of pain relief options: Use of pain relief options was not reported in the review but lowcertainty evidence suggests there may be little or no difference between selective/restrictive and routine or liberal episiotomy on perineal pain 10 days after birth (1 trial, 2587 women, RR 1.00, 95% CI 0.78-1.27).

# Birth experience:
According to the review, outcomes related to maternal birth experience, such as maternal satisfaction, were not reported in the trials.

# Fetal and neonatal outcomes
Perinatal hypoxia-ischaemia: Evidence on low Apgar scores (< 7 at 5 minutes) is of very low certainty, mainly because the sample size is small (2 trials, 511 babies) and no events occurred in either comparison group. Birth trauma: Birth trauma was not reported in the review.

# Additional considerations
The evidence on severe perineal/vaginal trauma was derived mainly from trials employing a mediolateral incision technique. Two trials involving 1143 women employed a midline episiotomy incision and statistical tests employed in the review suggest that the overall effect on perineal/vaginal trauma for this subgroup of trials is not different from medio-lateral incisions. However, the individual trials of midline incisions produced inconsistent results. In addition, severe perineal/vaginal trauma occurred more frequently in the trials of midline incisions than in trials of medio-lateral incisions (106/1143  vs 58/4834 respectively), suggesting that mediolateral incisions are safer than midline incisions.
The review did not evaluate any other outcomes according to the type of incision.
At the present time, there is no evidence corroborating the need for episiotomy in any situation. One small clinical trial (237 women) has published findings on the effects of selective/ restrictive use of episiotomy compared with no episiotomy and reported no difference with respect to any maternal and perinatal outcomes (169). There is an ongoing trial of selective/restrictive episiotomy compared with no episiotomy, with a target sample size of 6006 women.
Findings from a review of qualitative studies looking at what matters to women during intrapartum care indicate that most women want a normal childbirth with good outcomes for mother and baby, but acknowledge that medical intervention may sometimes be necessary (high confidence in the evidence) (23).
Women are scared of interventions like episiotomy (high confidence in the evidence), so they will invariably feel more anxious when they are introduced. However, in certain countries (e.g. Brazil) where episiotomy is liberally practised, there may be an expectation that its use will facilitate an easier birth (low confidence in the evidence).
When an episiotomy is indicated, women would like to receive relevant information about it, and for it to be performed by technically competent health care providers who are sensitive to their needs (high confidence in the evidence).

# Additional considerations
Given that a policy of selective/restrictive use of episiotomy is associated with less maternal morbidity than liberal use of episiotomy, it is unlikely that there is important uncertainty or variability in how much women value the outcomes related to episiotomy policies, as it stands to reason that most women would prefer not to sustain severe perineal or vaginal trauma.
No review evidence on the relative cost and costeffectiveness of these policies was found. However, a 2002 study from Argentina found that, for each low-risk vaginal birth, there was a potential average reduction in provider cost of US$ 20.21 and US$ 11.63, in two Argentinian provinces (170). This seems plausible, based on the effects evidence, as fewer procedures are performed and maternal morbidity might be reduced.

# Additional considerations
Fewer procedures means less provider time associated with episiotomy repair. This might be an important cost saving. Findings from a Cochrane review evaluating different episiotomy repair methods suggest that the average time required to suture an episiotomy with continuous or interrupted sutures is 21 and 25 minutes, respectively (171). Other costs, due to medical supplies (suture materials, anaesthetic agents, analgesics, etc.) and equipment for episiotomy repair, and those associated with wound complications, would logically also be lower with selective/restrictive compared with routine or liberal episiotomy policies.
Out-of-pocket costs to individual women might also be lower with selective/restrictive compared with routine or liberal episiotomy in settings where women incur additional birth costs for births in which episiotomy has been performed (172).
Routine or liberal use of episiotomy may be linked to over-medicalization based on ensuring financial profits for practitioners.
No direct evidence of the impact of the different episiotomy policies on equity was found. However, indirect evidence from a review of barriers and facilitators to facility-based birth indicates that many women have a "fear of cutting" (caesarean section and episiotomy) by health workers and this is probably a significant barrier to the uptake of facility-based birth by disadvantaged women in LMICs (moderate confidence in the evidence) (8).

# Additional considerations
WHO's 2015 State of inequality report indicates that women who are poor, least educated and residing in rural areas have lower health intervention coverage and worse health outcomes than the more advantaged women (33). Therefore, by reducing the "fear of cutting", with a clearly communicated policy of selective/restrictive episiotomy, the intervention might have a positive impact on health equity by increasing facility-based birth coverage among disadvantaged women.
A review of evidence-based practices suggests that some of the highest episiotomy rates occur in middle-income countries (173). This overuse might be a symptom of the obstetric transition, 1 with medicalization and more interventionist birth practices increasing with obstetric transition stage (174,175). Significant within-country differences in episiotomy coverage also exist (176). For example, in Brazil, public health care facilities have been reported to employ excessive use of episiotomy compared with private-sector facilities (177). Therefore, employing a restrictive policy of episiotomy in these settings could differentially improve the childbirth experience of disadvantaged women relative to more advantaged women, with a positive impact on equity.
Women in LMIC settings are often not informed about the risks of and reasons for interventions and are often not asked to give informed consent (173,(178)(179)(180)(181). Non-consented, invasive procedures are prevalent in LMICs and in the treatment of 1 Obstetric transition is the concept of a secular trend of countries as they shift from patterns of high maternal mortality to low maternal mortality through reductions in direct obstetric causes of mortality.

# Supervision and monitoring
Regular supervision and review by ward/clinic/facility lead disadvantaged pregnant women globally. Therefore, clinical protocols and provider training on episiotomy should emphasize the need for informed consent, to ensure that women's human rights are respected.
In a qualitative systematic review exploring women's and providers' views and experiences of intrapartum care, women felt they were poorly informed about the reasons for performing an episiotomy and were rarely asked for their permission (high confidence in the evidence) (26). Review findings suggest that women preferred to minimize the level of pain experienced from cutting and stitching, as well as the levels of discomfort experienced following episiotomy (high confidence in the evidence). In addition, they may be ill-prepared for the pain associated with the procedure or the potential short-and long-term consequences (perineal discomfort, difficulty performing normal day-to-day activities, aesthetic deformities, effect on sex life) (low confidence in the evidence). In some instances, women felt that their concerns were ignored or dismissed by staff, whom they perceived to be rude and insensitive (low confidence in the evidence).
The review findings also suggest that in certain countries (e.g. Brazil) women might hold the belief that an episiotomy facilitates a smoother birth (shorter labour, less pain) (low confidence in the evidence). This may be based on an established cultural acceptance of the procedure, largely generated by health care providers (low confidence in the evidence).
Review findings also showed that staff were generally aware of the recommendations for selective/restrictive use of episiotomy, but in some regions (South America, the Middle East, South-East Asia) they were reluctant to change established behaviour, particularly for primigravid women, where episiotomy was practised routinely (high confidence in the evidence). For primigravid women in these contexts, staff felt that an episiotomy was safer, more easily managed (by them) than a tear, and facilitated an "easier" birth (for them) (high confidence in the evidence).

# Additional considerations
Reluctance to change established behaviour in some settings might be financially motivated: a study of health care provider practice in Cambodia found that providers performed episiotomies to justify charging women a higher fee (172). From the above evidence, it seems that most women would find selective/ restrictive episiotomy more acceptable than routine or liberal episiotomy.
Acceptability among providers, in LMIC settings where episiotomy is routinely practised, might vary.
Findings from a qualitative systematic review exploring women's and providers views and experiences of intrapartum care suggest that a practice of selective/restrictive episiotomy would be easier to implement, especially in settings where resources may be limited (high confidence in the evidence) (26). However, in certain contexts, staff may have limited access to current research evidence (because of resource constraints) and subsequently have no clear policies or protocols to guide practice in this area (high confidence in the evidence). As a result, clinical practice is based on established, hierarchical, unwritten "rules" and/ or competence in performing the procedure (high confidence in the evidence).

# Additional considerations
Findings from a cluster RCT conducted in Mexico and Thailand of a multifaceted educational strategy to promote the use of the WHO Reproductive Health Library (RHL) on obstetric practices, including promotion of selective/restrictive over routine or liberal episiotomy, showed that implementing selective/restrictive episiotomy was feasible in Thailand and led to a reduction in episiotomy rates (182).
Shifting from a policy of routine or liberal to selective/restrictive use of episiotomy will require a change in organization culture, training, monitoring and continuous clinical practice audit.

# Fundal pressure

# RECOMMENDATION 40
Application of manual fundal pressure to facilitate childbirth during the second stage of labour is not recommended. (Not recommended)
The GDG had serious concerns about the potential for harm to mother and baby with this procedure. The panel is aware of an ongoing trial, the Gentle Assisted Pushing (GAP) trial (183), which could help to provide important evidence on the effects of applying fundal pressure according to a specific protocol.

# Summary of evidence and considerations

# Effects of the intervention (EB Table 3.3.8)
The evidence was derived from a Cochrane systematic review that included nine trials involving 3948 women (184)

# Fetal and neonatal outcome
Birth trauma: Evidence on birth trauma, including fractures and haematomas, is of very low certainty due to sparse data (small sample, no events).
Perinatal hypoxia-ischaemia: Evidence on low arterial cord pH and Apgar score less than 7 at 5 minutes is of very low certainty.

# Perinatal mortality:
No neonatal deaths occurred in the comparison groups (2 trials, 2445 neonates), therefore evidence on neonatal death is of very low certainty.

# Additional considerations
Concerns relating to the practice of fundal pressure are due to the possibility that serious harm might arise in the mother or the baby from the application of excessive uncontrolled force (185,186), including uterine and other organ rupture, and maternal and perinatal death; however, these occurrences might not often be reported in the literature.
Fundal pressure in the included trials was applied with the birth attendants' hands (i.e. not forearms or elbows); therefore, the evidence is not applicable to settings where other techniques of fundal pressure are applied.
The review also included studies on inflatable belts. A large multicentre trial is currently under way in South Africa to evaluate a new technique of fundal pressure, which is applied with the pregnant woman in an upright posture (183). The technique is called "gentle assisted pushing" whereby the health care professional applies "steady firm fundal pressure" with the palms of her hands, in the direction of the pelvis, taking care to use only the strength of her forearms and not to apply additional body weight. The health care professional is required to maintain the pressure for the full duration of each contraction or 30 seconds (whichever is shorter). The investigators hope that this trial, involving 1145 women, will establish whether or not a gentler form of fundal pressure can improve birth outcomes.
Findings from a review of qualitative studies looking at what matters to women during intrapartum care (23) indicate that most women want a normal childbirth with good outcomes for mother and baby, but acknowledge that medical intervention may sometimes be necessary. Most women, especially those giving birth for the first time, are apprehensive about childbirth (high confidence in the evidence) and fearful of some medical interventions, although in certain contexts and/or situations women welcome interventions to shorten labour or provide relief from pain (low confidence in the evidence). When interventions are introduced, women would like to receive relevant information from technically competent health care professionals who are sensitive to their needs (high confidence in the evidence). Findings also show that women desire to be in control of their birth process and would like to be involved in decision-making around the use of interventions (high confidence in the evidence).
There is no evidence on the costs or costeffectiveness of this practice.
No direct evidence of the impact of fundal pressure on equity was found. However, indirect evidence from a review of barriers and facilitators to facilitybased birth indicates that unfamiliar and undesirable birth practices by health workers in facilities, such as unfamiliar birth positions, are an important barrier to the uptake of facility-based birth by disadvantaged women in LMICs (high confidence in the evidence) (8).

# Additional considerations
WHO's 2015 State of inequality report indicates that women who are poor, least educated and residing in rural areas have lower health intervention coverage and worse health outcomes than the more advantaged women (33). Based on the research evidence above, if disadvantaged women consider fundal pressure an unfamiliar and undesirable practice, the intervention might have a negative impact on equity by contributing to low use of health care facilities by disadvantaged women. However, in the absence of specific evidence on fundal pressure,

# RECOMMENDATION 43
In settings where oxytocin is unavailable, the use of other injectable uterotonics (if appropriate, ergometrine/methylergometrine, or the fixed drug combination of oxytocin and ergometrine) or oral misoprostol (600 g) is recommended. (Recommended)
These recommendations have been integrated from the WHO recommendations for the prevention and treatment of postpartum haemorrhage (191), in which the GDG for that guideline determined them to be strong recommendations based on moderate-quality evidence. Available comparisons are limited, but a significant difference between the benefits of oxytocin and ergometrine is unlikely. These recommendations place a high value on avoiding the adverse effects of ergometrine and assume a similar benefit from using oxytocin and ergometrine for the prevention of PPH.
Caution should be exercised when opting for ergot derivatives for the prevention of PPH as these drugs have clear contraindications in women with hypertensive disorders. Thus, it is probably safer to avoid the use of ergot derivatives in unscreened populations. Oral misoprostol (600 g) was regarded by the GDG as an effective drug for the prevention of PPH. However, the GDG considered the relative benefits of oxytocin compared to misoprostol in preventing blood loss, as well as the increased adverse effects of misoprostol compared to oxytocin. The GDG acknowledged that there is no evidence to show that a 600-g dose of misoprostol provides greater efficacy over a 400-g dose. Lower doses have a lower side-effect profile but the efficacy of lower doses of misoprostol has not been evaluated sufficiently.
The recommendations concerning alternative uterotonics should not detract from the objective of making oxytocin as widely accessible as possible.
In view of past concerns regarding the community-level distribution of misoprostol and the potential for serious consequences of administration before birth, the
This recommendation has been integrated from the WHO Guideline: delayed cord clamping for improved maternal and infant health and nutrition outcomes (192), in which the GDG for that guideline determined it to be a strong recommendation based on moderate-quality evidence. Delayed cord clamping should be performed during the provision of essential newborn care. Some health care professionals working in areas of high HIV prevalence have expressed concern regarding delayed cord clamping as part of management of the third stage of labour. These professionals are concerned that during placental separation, a partially detached placenta could be exposed to maternal blood and this could lead to a micro-transfusion of maternal blood to the baby. It has been demonstrated that the potential for mother-to-child transmission of HIV can take place at three different points in time: micro-transfusions of maternal blood to the fetus during pregnancy (intrauterine HIV transmission), exposure to maternal blood and vaginal secretions when the fetus passes through the birth canal in vaginal deliveries (intrapartum transmission), and during breastfeeding (postnatal infection). For this reason, the main intervention to reduce the maternal-tochild transmission is the reduction of maternal viral load through the use of antiretroviral drugs during pregnancy, childbirth and postnatal period. There is no evidence that delaying cord clamping increases the possibility of HIV transmission from the mother to the newborn. Maternal blood percolates through the placental intervillous space throughout pregnancy with a relatively low risk of maternalfetal transmission before delivery. It is highly unlikely that separation of the placenta increases exposure to maternal blood, and it is highly unlikely that it disrupts the fetal placental circulation (i.e. it is unlikely that during placental separation the newborn circulation is exposed to maternal blood). Thus, the proven benefits of a 1-3 minute delay, at least, in clamping the cord outweigh the theoretical, and unproven, harms. Late cord clamping is recommended even among women living with HIV or women with unknown HIV status. The evidence supporting this recommendation can be found in the source guideline document, available at: 

# Uterine massage

# RECOMMENDATION 46
Sustained uterine massage is not recommended as an intervention to prevent postpartum haemorrhage (PPH) in women who have received prophylactic oxytocin. (Not recommended)
This recommendation has been integrated from the WHO recommendations for the prevention and treatment of postpartum haemorrhage (191), in which the GDG for that guideline determined it to be a conditional recommendation based on low-quality evidence.
There is a lack of evidence regarding the role of uterine massage for PPH prevention when no uterotonic drugs are used, or if a uterotonic drug other than oxytocin is used.
Although the GDG acknowledged that one small study reported that sustained uterine massage and clot expulsion were associated with a reduction in the use of additional uterotonics, there is lack of robust evidence supporting other benefits. However, the GDG considered that routine and frequent uterine tone assessment remains a crucial part of immediate postpartum care, particularly for the optimization of early PPH diagnosis.
Based on the most recent evidence, understanding about the contribution of each component of the active management of the third stage of labour package has evolved. The GDG considered that this package has a primary intervention: the use of a uterotonic. In the context of oxytocin use, CCT may add a small benefit, while uterine massage may add no benefit for the prevention of PPH. Early cord clamping is generally contraindicated. The evidence supporting this recommendation can be found in the source guideline document, available at:  3.5 Care of the newborn

# Routine nasal or oral suction

# RECOMMENDATION 47
In neonates born through clear amniotic fluid who start breathing on their own after birth, suctioning of the mouth and nose should not be performed. (Not recommended)
This recommendation has been integrated from the WHO Guidelines on basic newborn resuscitation (193), in which the GDG for that guideline determined it to be a strong recommendation based on high-quality evidence.
No further remarks were noted. The evidence supporting this recommendation can be found in the source guideline document, available at:  3.5.4 Haemorrhagic disease prophylaxis using vitamin K

# RECOMMENDATION 50
All newborns should be given 1 mg of vitamin K intramuscularly after birth (i.e. after the first hour by which the infant should be in skin-to-skin contact with the mother and breastfeeding should be initiated). (Recommended)
This recommendation has been integrated from the WHO Recommendations for management of common childhood conditions: evidence for technical update of pocket book recommendations (194), in which the GDG for that guideline determined it to be a strong recommendation based on moderatequality evidence.
No further remarks were noted.
The evidence supporting this recommendation can be found in the source guideline document, available at: 

# Bathing and other postnatal care of the newborn

# RECOMMENDATION 51
Bathing should be delayed until 24 hours after birth. If this is not possible due to cultural reasons, bathing should be delayed for at least six hours. Appropriate clothing of the baby for ambient temperature is recommended. This means one to two layers of clothes more than adults, and use of hats/caps. The mother and baby should not be separated and should stay in the same room 24 hours a day. (Recommended)
This recommendation has been integrated from the WHO recommendations on postnatal care of the mother and newborn (197), in which the GDG for that guideline determined it to be a strong situational recommendation based on GDG consensus. No further remarks were noted. The evidence supporting this recommendation can be found in the source guideline document, available at:  165

# EVIDENCE AND RECOMMENDATIONS
- 6 Care of the woman after birth 3.6.1 Uterine tonus assessment

# RECOMMENDATION 52
Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women. (Recommended)
This recommendation has been integrated from the WHO recommendations for the prevention and treatment of postpartum haemorrhage (191), in which the GDG for that guideline determined it to be a strong recommendation based on very low-quality evidence.
The GDG considered that routine and frequent uterine tone assessment remains a crucial part of immediate postpartum care, particularly for the optimization of early PPH diagnosis.
The evidence supporting this recommendation can be found in the source guideline document, available at: 

# Antibiotics for uncomplicated vaginal birth

# RECOMMENDATION 53
Routine antibiotic prophylaxis is not recommended for women with uncomplicated vaginal birth.
This recommendation has been integrated from the WHO recommendations for prevention and treatment of maternal peripartum infections (114), in which the GDG for that guideline determined it to be a strong recommendation based on very low-quality evidence.
The GDG was concerned about the potential public health implications of the high rate of routine use of antibiotics following vaginal birth without any specific risk factors in some settings. The group places emphasis on the negative impact of such routine use on the global efforts to contain antimicrobial resistance and, therefore, made a strong recommendation against routine antibiotic prophylaxis. "Uncomplicated vaginal birth" in this context connotes vaginal birth in the absence of any specific risk factor for, or clinical signs of, maternal peripartum infection.
Careful monitoring of all women after birth is essential to promptly identify any sign of endometritis and institute appropriate antibiotic treatment. Recommendations on antibiotic use for common intrapartum conditions or interventions that often raise concerns about increased risk of infection are available in the original WHO guideline. The evidence supporting this recommendation can be found in the source guideline document, available at: 

# Routine antibiotic prophylaxis for episiotomy

# RECOMMENDATION 54
Routine antibiotic prophylaxis is not recommended for women with episiotomy. (Not recommended)
This recommendation has been integrated from the WHO recommendations for prevention and treatment of maternal peripartum infections (114), in which the GDG for this guideline determined it to be a strong recommendation based on GDG consensus. This recommendation was based on a consensus of the GDG in view of a high rate of episiotomy and the potential impact of antibiotics, in the absence of clinical benefits for public health. The GDG places emphasis on avoidance of emerging antimicrobial resistance at the global level and, therefore, made a strong recommendation. This recommendation applies to the use of antibiotics before or immediately after episiotomy repair following vaginal birth. Antibiotics should only be administered when there are clinical signs of infection of an episiotomy wound. The GDG emphasized the need for health systems to adopt a policy of restrictive rather than routine use of episiotomy to reduce its potential complications and the use of additional resources for its treatment.
Second-degree perineal tear is anatomically similar to an episiotomy and does not warrant the use of prophylactic antibiotics.
In a situation where an episiotomy wound extends to become a third-or fourth-degree perineal tear, prophylactic antibiotics should be administered as recommended in the source guideline document (114).
The evidence supporting this recommendation can be found in the source guideline document,
After an uncomplicated vaginal birth in a health care facility, healthy mothers and newborns should receive care in the facility for at least 24 hours after birth. (Recommended)
This recommendation has been integrated from the WHO recommendations on postnatal care of the mother and newborn (197), in which the GDG for that guideline determined it to be a conditional recommendation based on low-quality evidence. An appropriate standard of care for mothers and newborns should be provided in health care facilities, in accordance with other existing WHO guidelines. For the newborn this includes an immediate assessment at birth, and a full clinical examination around one hour after birth and again before discharge. "Healthy mothers and newborns" are defined in the safe childbirth checklist that is to be used to assess mothers and newborns at the time of discharge (198). Before discharge, bleeding in the mother should be controlled, mother and baby should not have signs of infection, and baby should be breastfeeding well.
The evidence supporting this recommendation can be found in the source guideline document, available at: 

# Implementation of this guideline: introducing the WHO intrapartum care model
The aim of this guideline is to improve the quality of essential intrapartum care with the ultimate goal of improving maternal, fetal and newborn outcomes. The recommended practices need to be deliverable within an appropriate model of care that can be adapted to different countries, local contexts and the individual woman. With the contributions of the members of the Guideline Development Group (GDG), WHO reviewed existing models of delivering intrapartum care with full consideration of the range of recommended practices within this guideline (Section 3) and through a human rights lens.
First, the GDG emphasized the urgent need to improve the quality of care around labour and childbirth in all settings. Acknowledging the substantial variations that exist in the philosophies driving the organization and provision of labour and childbirth care in contemporary practice, and the fact that clinical outcomes and experience of care for the woman and her baby are largely determined by the prevailing model of care, the GDG reviewed how intrapartum care for healthy pregnant women should be delivered in terms of cross-cutting clinical and non-clinical interventions that should be received by all women irrespective of context. To achieve the much-needed improvements to the quality of intrapartum care, the GDG recognized that a key shift is required in the practical ways that intrapartum care is delivered globally. This key shift is informed by the importance of achieving the best possible physical, emotional and psychological outcomes for the woman and her baby, irrespective of the influence of generic policies that may exist within and across health systems and countries. The group agreed that attainment of these outcomes requires a model of care in which health care providers give priority to the implementation of critical components that have been shown to be effective in improving both clinically relevant outcomes and childbirth experience for the woman and her family.
To this end, WHO proposes a global model of intrapartum care that subscribes to all domains of the WHO quality of care framework for maternal and newborn health (12) and places the woman and her baby at the centre of care provision (Fig.

# Considerations for the implementation of the WHO intrapartum care model
Health policy considerations A firm government commitment to increasing coverage of maternity care for all pregnant women giving birth in health care facilities is needed, irrespective of social, economic, ethnic, racial or other factors. National support must be secured for the whole package of recommendations, not just for specific components.
To set the policy agenda, to secure broad anchoring and to ensure progress in policy formulation and decision-making, representatives of training facilities and professional societies should be included in participatory processes at all stages.
To facilitate negotiations and planning, situation-specific information on the expected impact of the new intrapartum care model on service users, providers and costs should be compiled and disseminated.
To be able to adequately ensure access for all women to quality maternity care, in the context of universal health coverage (UHC), strategies for raising public funding for health care will need revision. In low-income countries, donors could play a significant role in scaling up implementation.

# Organizational or health-system-level considerations
Long-term planning is needed for resource generation and budget allocation to address the shortage of skilled midwives, to improve facility infrastructure and referral pathways, and to strengthen and sustain good-quality maternity services. Introduction of the model should involve training institutions and professional bodies so that preservice and in-service training curricula can be updated as quickly and smoothly as possible.
Standardized labour monitoring tools, including a revised partograph, will need to be developed to ensure that all health care providers (i) understand the key concepts around what constitutes normal and abnormal labour and labour progress, and the appropriate support required, and (ii) apply the standardized tools. A F F The national Essential Medicines Lists will need to be updated (e.g. to include medicines to be available for pain relief during labour). Development or revision of national guidelines and/or facility-based protocols based on the WHO intrapartum care model is needed. For health care facilities without availability of caesarean section, context-or situation-specific guidance will need to be developed (e.g. taking into account travel time to the higher-level facility) to ensure timely and appropriate referral and transfer to a higher level of care if intrapartum complications develop. Good-quality supervision, communication and transport links between primary and higher-level facilities need to be established to ensure that referral pathways are efficient. Strategies will need to be devised to improve supply chain management according to local requirements, such as developing protocols for obtaining and maintaining stock of supplies. Consideration should be given to care provision at alternative maternity care facilities (e.g. on-site midwife-led birthing units) to facilitate the WHO intrapartum care model and reduce exposure of healthy pregnant women to unnecessary interventions prevalent in higher-level facilities. Behaviour change strategies aimed at health care providers and other stakeholders could be required in settings where non-evidence-based intrapartum care practices are entrenched. Successful implementation strategies should be documented and shared as examples of best practice for other implementers.

# User-level considerations
Community-level sensitization activities should be undertaken to disseminate information about:
" respectful maternity care (RMC) as a fundamental human right of pregnant women and babies in facilities; " facility-based practices that lead to improvements in women's childbirth experience (e.g. RMC, labour and birth companionship, effective communication, choice of birth position, choice of pain relief method); and " unnecessary birth practices that are not recommended for healthy pregnant women and that are no longer practised in facilities (e.g. liberal use of episiotomy, fundal pressure, routine amniotomy).

# Research implications
During the guideline development process, the Guideline Development Group (GDG) identified important knowledge gaps that need to be addressed through primary research. Where the certainty of available evidence was rated as "low" or "very low", the GDG considered whether further research should be prioritized, based on whether such research would contribute to improvements in the childbirth experience of women, be likely to promote equity, and be feasible to implement. GDGprioritized research gaps are listed below. What is the effectiveness of a reference line (such as the "alert line") as a tool for triaging women for referral from peripheral to higher-level settings, in terms of improved birth outcomes? What is the impact of facilitating longer labour on health outcomes and health service utilization?

# Care throughout labour and birth

# Labour ward admission policy
For healthy pregnant women in early labour, does delayed labour ward admission compared with direct labour ward admission improve birth outcomes?

# Clinical pelvimetry on admission
In remote or rural facilities without caesarean section availability, is routine clinical pelvimetry at labour admission a useful assessment for triaging women at risk of cephalo-pelvic disproportion?

# Routine cardiotocography (CTG) on admission
For women classified to be low risk in LMICs and any setting with inadequate antenatal care provision, can routine CTG on labour admission improve birth outcomes?

# Continuous CTG during labour
What are the effects of mobile continuous CTG on birth outcomes for women without risk factors?
- RESEARCH IMPLICATIONS 6. DISSEMINATION
This guideline will be available online for download and also as a printed publication. Online versions will be available via the websites of the WHO Departments of Reproductive Health and Research (RHR) and Maternal, Newborn, Child and Adolescent Health (MCA), and through the WHO Reproductive Health Library (RHL). 1 Print versions will be distributed to WHO regional and country offices, ministries of health, WHO collaborating centres, NGO partners and professional associations, using the same distribution list that was developed for the antenatal care guideline: WHO recommendations on antenatal care for a positive pregnancy experience (35). This guideline will be accompanied by an independent critical appraisal based on the AGREE instrument (Appraisal of Guidelines for Research & Evaluation) (199). Technical meetings will be held within the WHO RHR and MCA Departments to share the recommendations and derivative products, which will include a practical manual for implementation of the new WHO intrapartum care model, with the teams responsible for policy and programme implementation.
Two sets of evidence briefs will be developed: one set for policy-makers and programme managers and the other set for health care professionals. These evidence briefs, which will highlight the recommendations and implementationrelated contextual issues, will be developed and disseminated in collaboration with USAID, FIGO and ICM.
The executive summary and recommendations from this publication will be translated into the six UN languages for dissemination through the WHO regional and country offices and during meetings organized by, or attended by, staff of the WHO RHR and MCA Departments.
In addition to online and print versions of this guideline, an interactive web-based version is planned, which will be developed by a professional content communication and design firm that specializes in infographics. This will facilitate the dissemination and uptake of the guideline recommendations by making them available online in a user-friendly format, and will allow a platform for cross-referenced recommendations to be updated or added on an ongoing basis to ensure that the recommendations are up to date and comprehensive. Furthermore, this would allow for 1 RHL is available at: / focused activities and products to be developed. English, French, Portuguese and Spanish (the latter in collaboration with the WHO Regional Office for the Americas/Pan American Health Organization web-based versions are planned and have been budgeted for.
The guideline will also be launched on the WHO RHR departmental website as part of the monthly HRP News. This site currently has over 4500 subscribers including clinicians, programme managers, policy-makers and health service users from all around the world. In addition, a number of articles presenting the recommendations and key implementation considerations will be published, in compliance with WHO's open access and copyright policies. Relevant WHO clusters, departments and partnerships, such as the Partnership for Maternal, Newborn & Child Health (PMNCH), will also be part of this dissemination process.
In an effort to increase dissemination of WHO guidelines on sexual and reproductive health and rights, a search function with the ability to search the database of WHO guidelines and recommendations has been created and recently launched by the RHR Department. 2 The intrapartum care guideline recommendations will be made available via this search function.
The Maternal and Perinatal Health and Preventing Unsafe Abortion team of the RHR Department, in collaboration with the MCA Department and other partners, will support national and subnational working groups to adapt and implement the guideline. This process will include the development or revision of existing national guidelines or protocols in line with the WHO guideline. The GREAT Network (Guideline-driven, Research priorities, Evidence synthesis, Application of evidence, and Transfer of knowledge) will be used to bring together relevant stakeholders to identify and assess the priorities, barriers and facilitators to guideline implementation, and to support the efforts of stakeholders to develop adaptations and guideline implementation strategies tailored to the local context (200). This includes technical support for local guideline implementers in the development of training manuals, flow charts and quality indicators, as well as participation in stakeholder meetings.
This can be accessed at: search.optimizemnh.org 7. Applicability issues Various strategies for addressing these barriers and facilitating implementation are provided in the lists of implementation considerations in Section 4 and Annex 4.

# Monitoring and evaluating the impact of the guideline
The implementation and impact of these recommendations will be monitored at the healthservice, regional and country levels. The WHO publication Standards for improving quality of maternal and newborn care in health facilities (201) provides lists of prioritized input, output and outcome measures, which can be used to define quality of care criteria and indicators with locally agreed targets. In collaboration with the monitoring and evaluation teams of the WHO Departments of Reproductive Health and Research (RHR) and Maternal, Newborn, Child and Adolescent Health (MCA), data on country-and regional-level implementation of the recommendations will be collected and evaluated in the short to medium term to evaluate their impact on national policies of individual WHO Member States. Interrupted time series, clinical audits or criterion-based audits could be used to obtain the relevant data on the practices contained in this guideline.

# UPDATING OF THE GUIDELINE

# Updating of the guideline
In accordance with the process for updating WHO maternal and perinatal health guidelines, a systematic and continuous process of identifying and bridging evidence gaps following guideline implementation will be employed. An Executive Guideline Steering Group (GSG) for maternal and perinatal health recommendations will convene annually to review WHO's current portfolio of maternal and perinatal health recommendations, and to prioritize new and existing questions for recommendation development and updating. Accordingly, the recommendations included in this guideline will be regularly reviewed and prioritized as needed by the Executive GSG. In the event that new evidence (that could potentially impact the current evidence base for any of the recommendations) is identified, the recommendation will be updated. If no new reports or information are identified for a particular recommendation, the recommendation will be revalidated.
The WHO Steering Group will continue to monitor the research developments in the area of intrapartum care, particularly for those questions for which no evidence was found and those that are supported by low-quality evidence, where new recommendations or a change in the published recommendations may be warranted, respectively. Any concern about the validity of any recommendation will be promptly communicated via the website for the guideline, 1  Mechanisms should be put in place to ensure that all women, and particularly those from disadvantaged backgrounds, are made aware of (i) their right to RMC and (ii) the existence of a mechanism for raising and addressing complaints (e.g. an audit and feedback mechanism that integrates women's complaints and ensures that responses are provided). RMC policies should be tailored to the context of each different setting to ensure that subgroups of women at particular risk of mistreatment and those with special needs (e.g. poor awareness of their rights, language difficulties) are targeted for more intensive efforts to promote RMC, especially where maternity care experiences among these subgroups are very poor. Implementers should be aware that shifts in health system infrastructure (e.g. reorganization of staffing, increasing workload) could disrupt implementation; therefore, any infrastructural changes need close monitoring to ensure and evaluate the feasibility and sustainability of RMC practices. Implementers should be aware that a commitment to providing the necessary physical and staff resources and supporting staff well-being/morale is needed for successful implementation and sustainability of RMC. In addition, ensuring a visible, sustained and participatory intervention process, with committed facility leadership, management support and staff engagement, is important. b Implementers should be aware of the general principals of the Human Rights Council's Technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce preventable maternal morbidity and mortality. c a This annex refers only to implementation considerations for the new recommendations. Implementation considerations related to integrated recommendations can be found in the original guideline documents and accessed via the links provided in the respective "remarks" sections.
197 Integration of the lay companion (including male partners/husbands and female relatives) into antenatal care visits, childbirth education classes, etc., might empower companions with knowledge about the process of labour, familiarity with the health care facility structure, and the skills and confidence to better support the woman, while additionally providing the woman herself with information about how the companion will be able to support her throughout labour and birth.

# FIRST STAGE OF LABOUR

# Definitions of the latent and active first stages of labour
Guidance and protocols for health care facilities without availability of caesarean section will need to be developed that are context-and situation-specific. Introduction of these new definitions and concepts should involve pre-service training institutions and professional bodies, so that training curricula for intrapartum care can be updated as quickly and smoothly as possible.
Labour monitoring tools will need to be updated and/or developed to facilitate the new approach. Practice manuals and labour ward protocols will need to be updated and disseminated.

# Duration of the first stage of labour 3.2.3 Progress of the first stage of labour 3.2.4 Labour ward admission policy
This recommendation requires a well functioning health system with a sufficient number of trained health care professionals.
It is important that health care professionals clearly communicate the reason for delaying admission to women in latent labour, and provide them with encouragement, support and advice on how to manage uncomfortable contractions, how to recognize active labour and, if a woman chooses to go home, when to return to the hospital.

# Clinical pelvimetry on admission
In settings where clinical pelvimetry is routinely performed among healthy pregnant women on admission in labour, health care providers need to be aware that there is insufficient evidence to support this practice.

# Routine assessment of fetal well-being on labour admission
In settings where cardiotocography (CTG) is performed routinely on admission for labouring women with no risk factors for adverse outcomes, it is important to inform health care professionals and other stakeholders that this practice is not evidencebased and increases the risk of unnecessary medical interventions. Policy-makers and relevant stakeholders need to consider how records from auscultation can be validated for use in the defence against potential litigation claims, instead of reliance on admission CTG for this purpose.

# Continuous cardiotocography during labour
The GDG panel is aware that in some countries and settings, continuous CTG is used to protect against litigation. In such settings, health care professionals and women should be advised that this practice is not evidence-based and does not lead to better outcomes. Clinicians might be better protected against litigation by keeping good medical notes and records, which clearly indicate findings of intermittent auscultation (IA), than by relying on continuous CTG tracings. In low-resource settings, Pinard fetal stethoscope would be the most feasible method for intermittent auscultation (IA) as it is not associated with ongoing costs related to supplies and equipment maintenance, and has no infrastructural requirements (e.g. power supply).
A practical approach in low-resource settings might be to firstly ensure widespread availability and competence of health care providers to conduct IA with the Pinard fetal stethoscope. Then, as resources become available, the Doppler ultrasound device could be introduced with appropriate pre-service and in-service training.
In settings with a high prevalence of litigation, policy-makers and relevant stakeholders need to consider whether records from non-electronic fetal monitoring (and IA in general) would be valid in the defence against potential litigation claims.

# Epidural analgesia for pain relief
Policy-makers need to determine which pain relief measures are most feasible and acceptable in their settings.
Facilities offering epidural analgesia need to have staff with the appropriate specialist skills (anaesthetists, obstetricians) as well as equipment and systems in place to monitor, detect and manage any undesirable effects of the procedure during and after labour to ensure the safety of mother and baby. Epidural analgesia should not be introduced in settings where these resources are not consistently available.
Systems should be in place to ensure adherence to standardized protocols for epidural analgesia, including correct drugs, doses, techniques, staffing levels and other resource requirements.
Oxygen, resuscitation equipment and appropriate drugs for resuscitation should be readily available in labour and postnatal wards where women who have undergone epidural analgesia are cared for.
Health care providers and women should be aware that epidural analgesia is a significant procedure that can lead to serious complications. The benefits and risks associated with epidural analgesia should be clearly explained to women considering this method of pain relief. Signed informed consent is necessary for all women undergoing epidural analgesia. Setting-specific protocols for assessing a woman's need for pain relief and for providing a range of pharmacological and non-pharmacological options should be developed to guide clinical management, to support women's decision-making, and to ensure safe and equitable provision of pain relief. Health care professionals should communicate to women the pain relief options available for labour and birth at their facility, and should discuss the advantages and disadvantages of these options, as part of antenatal care education and counselling. A woman's choice of pain relief during labour, if pain relief is required, should be confirmed on admission in labour. In addition, she should be free to change her mind about the type of pain relief she would like if she feels the need to do so. Health care facilities providing pharmacological options for pain relief, including epidural analgesia, should ensure that they have adequately trained staff, clear protocols and the necessary equipment to manage complications, should they arise. Mechanisms should be in place at facilities offering pharmacological pain relief options to ensure that the necessary drugs are kept in stock and can be dispensed when needed. Health care facilities offering epidural analgesia during labour should conduct regular audit and feedback procedures to ensure adherence to clinical protocols and to monitor complications.
Opioid analgesia for pain relief Policy-makers need to determine which pain relief measures are most appropriate (feasible and acceptable) in their settings, in consultation with health care professionals and the women using their facilities. Opioid analgesia is not suitable in settings where women and babies cannot be adequately monitored due to staff shortages, or where resuscitation skills, equipment and supplies (oxygen, appropriate drugs) are lacking. Setting-specific protocols for assessing a woman's need for pain relief and for providing a range of pharmacological and non-pharmacological options should be developed to guide clinical management, to support women's decision-making, and to ensure safe and equitable provision of pain relief. Health care facilities providing opioid analgesia should ensure that personnel skilled in performing resuscitation are among the staff on duty at all times. Health care facilities should monitor adherence to clinical protocols and complications related to opioid use (particularly maternal and neonatal respiratory depression) to reduce iatrogenic outcomes.
Health care professionals should communicate to women the pain relief options for labour and birth available at their facility, and should discuss the advantages and disadvantages of these options, as part of antenatal care education and counselling. Health care facilities providing pharmacological options for pain relief, including opioid analgesia, should ensure that they have adequately trained staff, clear protocols and the necessary equipment to manage complications, should they arise. Mechanisms should be in place at facilities offering pharmacological pain relief options to ensure that the drugs are kept in stock and can be dispensed when needed.
Opioid medication needs to be securely stored and a register kept of its dispensing, to reduce the risk of abuse.
Relaxation techniques for pain management

# Manual techniques for pain management
Health care professionals should communicate to women the pain relief options for labour and birth available at their facility, and should discuss the advantages and disadvantages of these options as early as possible in labour, and ideally as part of antenatal care education and counselling.
Training institutions could cover these techniques in health care professionals' pre-service and in-service training. For lay companions, basic training in these techniques could be facilitated during the antenatal period.

# SECOND STAGE OF LABOUR

# Definition and duration of the second stage of labour
Same as considerations for 3.2.1-3.2.3.

# Birth position (for women without epidural analgesia)
In settings where women usually give birth in recumbent positions, policy-makers should ensure that (i) health care professionals receive in-service training on how to support women to give birth in upright positions and (ii) the necessary facilities that can be used to support alternative upright positions for women are provided. Health care professionals should advise women about their options with regard to choice of birth positions; this should be done during antenatal care contacts as part of antenatal education and counselling.

# Birth position (for women with epidural analgesia)
Same implementation considerations as for item 3.3.2 (previous row).

# Method of pushing
In settings where health care professionals are accustomed to using directed pushing techniques, clinical protocols, pre-service and in-service training content should be updated to support spontaneous pushing.

# Method of pushing (for women with epidural analgesia)
Clinical protocols, pre-service and in-service training content should be updated to support delayed pushing in the second stage of labour for women with epidural analgesia.

# Techniques for preventing perineal trauma
Policy-makers should liaise with professional bodies, societies and training institutions to ensure that pre-service training of health care professionals includes training in techniques for preventing perineal trauma. Professional bodies, societies and health care facilities should update their training and guidance on supporting women in the second stage of labour to include these different options for preventing perineal trauma: perineal massage, warm compresses and a "hands-on" guarding approach.
Stakeholders can consider which techniques are most feasible in their settings.
Health care professionals should communicate to women the different options available for preventing perineal trauma; this should be done during antenatal care contacts as part of BPCR counselling, and the woman's preferences for her care during the second stage of labour should be noted.

# Episiotomy policy
To secure broad support and to ensure that health workers receive appropriate training and support, policy-makers should include representatives of training facilities and professional bodies in participatory processes. Guidelines of professional societies and health care facility protocols should be updated to reflect the recommendation that episiotomy is not to be used liberally and that only selective use of episiotomy is permissible.
In settings where routine or liberal use of episiotomy has been employed, and in settings with low utilization of health care facilities for childbirth, women and health care providers should be informed that the use of episiotomy is now restricted. All stakeholders should be aware of the need for a woman to give informed consent for episiotomy. Episiotomy indications and protocols should be clearly displayed in maternity facilities.
Policy-makers, health care managers and administrators for both public and private health care facilities should ensure that any financial and other incentives to perform episiotomy are removed.

# Fundal pressure
Health care providers should be made aware that this practice is not recommended and can lead to adverse birth outcomes. Stakeholders could consider undertaking implementation research to determine how best to reduce unnecessary childbirth practices in their settings.