Date: Fri, 14 Nov 1997 01:59:09 +0200
To: Recipient List Suppressed:;
From: Patrick Hublou <>
Subject: WHO defines 'normal birth'

World Health Organization defines 'normal childbirth''

High up in the Swiss Alps, at the borders of an idyllic lake, an international task force of fieldworkers investigated in the lap of the WHO what is meant with 'physiological birth'.

In preparation of the report 4 categories were defined that serve to catalog many methods and customs used in obstetrics:

1./ Methods and customs that are clearly effective and have to be stimulated
2./ Methods and customs that are clearly dangerous or ineffective and that
have to be abolished.
3./ Methods and customs where for not enough evidence exists to recommend and that have to be used with precaution while more research still have to take place.
4./ Methods and customs that are often improperly used.

A Dutch midwife and a Dutch gynecologist prepared the discussion texts together with midwives, gynecologists, pediatricians, epidemiologists and an economist of the WHO. Next six midwives coming from Gambia, Tanzania, Australia, Sweden, Malesia and Chile studied on the presented texts together with six gynecologists from Zambia, India, The Philippines, Lesotho, Egypt and Uruguay. It's unclear if there were Traditional Birth Attendants (TBA) involved in the creation of this report.

It appears that because in many countries no distinction is made between 'high risk' and 'low risk' births (nearly) all births happen in hospitals, with (ab)use of technology and under routine protocols. Unnecessary interventions are committed, the freedom of women to move around while in labor is made inferior to the speeding up, monitoring and drugging of the experience of giving birth. In extreme contrast to this is the situation in many third world countries where less as 20% of the women have access to hospital care and birth happens often at home but without professional conductment or having the option available to transfer.

The WHO finds midwives the best placed caregivers to conduct a normal pregnancy and states that midwives must be able to take decisions autonomously.

Certain tasks and skills that a midwife need to master or incorporate, are explicitly mentioned in the report. This provides a more solid base in the fight against criminalization of the work midwives in all diversity have been doing all over the planet since the beginning of time for men.

In the chapter "General aspects of care during the normal birth" attention is focused on useless or even harmful acts of routine. Denying a laboring woman food or to drink, insertion of infusions, limiting her freedom to move around and forcing her to labor and give birth lying on her back are just a few still often practiced examples of bad conductment. The use of epidural analgesia during normal births is seen as one of the most controversial interventions. The physiological birthing experience is due to epidural analgesia transformed into a medical proceeding.

With this report at hand women, parents, and their lawyers have good evidence to sue, if they can afford to do so, the hospital staff successfully if no appropriate care was provided.

To assess progression of labor in general one vaginal exam every four hours is considered sufficient. Cardio-tocography ('monitoring') is known to report many false positive results and thus to boost drastically medical interventions. The introduction of the partogram, a charted way to keep track of labor, is found positive and its use resulted in delaying with 8 hours intervention during latent stage. Also the number of unneeded transfers from home to hospital is reported to decline when a partogram is used.

The WHO advises to pierce only the membranes when there is a valid reason to do so. No indications are mentioned in the report. In 75% of the normal births membranes rupture spontaneously when total dilation is reached.

The guidelines for ruptured membranes without labor are different in different regions. When very hygienically conditions are available, and the woman is in good general condition, it is found OK to wait 48 hours when no vaginal exam is preformed.

The WHO recommends to come to regional guidelines regarding the conductment of labor during the period of dilation.

Encouraging the woman to push actively and long from the moment of total dilation raises the number of interventions. Better is it to wait until the woman feels the urge to push herself and then to encourage her to push shortly and spontaneously in a position she finds herself most comfortable in.

A rate of 10% of episiotomies is set as an aim. Expulsion for priming can take up to two hours while multiparticle should be allowed at least one hour to give birth.

The administration of oxitocin should only happen on indication. Indications mentioned in the WHO report are: twins, polyhydramnion, artificial stimulation of labor (drugged labor), low Hg, not progressing dilation and use of forceps or suction.

To obtain your copy of the guideline/report contact your local midwifery organization or write to:

WHO, 1211 Geneva 27, Switzerland
Phone: 41-22 791 21 11 Fax: 41-22 791 0746
Request: ------> Care in Normal Birth: a practical guide. Maternal and Newborn Health/Safe Motherhood Unit family and reproductive health.
World Health Organization, Geneva, Switzerland, 1997

Information based upon articles of the Dutch midwives Petra ten Hoope and Marianne Prins published in the Dutch periodical of midwives

(Tijdschrift voor Verloskunde),
October 1997, The Netherlands.
(Patrick Hublou) Gent, Flanders, November 1997 midwives on Usenet

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