Improving Quality: Labor & Delivery Care
Ensuring Quality Intrapartum Care for Mothers and Newborns
T
he World Health Organization (WHO) defines intrapartum care as the care provided to women and their newborns during labor and childbirth. This phase is a critical window of opportunity – not only for safeguarding maternal and newborn survival, but also for ensuring a positive and respectful childbirth experience.
High-quality labor and delivery care must prioritize both the physical and emotional well-being of the mother, the safety of the newborn, and the dignity of the birthing process. This includes timely identification and management of complications, effective pain relief, respectful maternity care, and continuous monitoring of maternal and fetal well-being. Skilled birth attendance and evidence-based clinical practices – such as the use of the partograph, active management of the third stage of labor, and immediate newborn care – are fundamental to preventing maternal and neonatal deaths.
Investing in quality intrapartum care strengthens trust in the health system and supports the broader goals of Universal Health Coverage and Sustainable Development Goal 3: Ensuring healthy lives and promoting well-being for all at all ages.
This section provides practical guidance for local government leaders, facility managers, and healthcare providers to improve the quality of labor and delivery services through structured interventions, monitoring tools, and capacity-building strategies.
What Are the Benefits of Delivering Quality Intrapartum Care?
How to Implement
Steps for Providing Quality Labor & Delivery Care:
1. Practice Respectful Maternity Care
- Treat every woman with dignity and respect.
- Offer continuous emotional and physical support throughout labor and childbirth.
2. Promote Informed Decision-Making
- Share clear, accurate information about labor progress and available options.
- Support women in making informed choices about their care.
3. Monitor Labor Progress and Well-Being
- Use a partograph to track labor progress.
- Regularly check the mother’s vital signs and fetal heart rate.
4. Offer Pain Relief Options
- Provide non-medical options like breathing exercises, massage, or warm baths.
- Offer pharmacological pain relief when requested or needed.
5. Encourage Supportive Labor Practices
- Allow the woman to choose comfortable labor positions.
- Provide reassurance and encouragement throughout labor.
6. Avoid Unnecessary Interventions
- Do not perform routine episiotomy or instrumental delivery unless medically indicated.
- Support spontaneous pushing unless directed pushing is necessary.
7. Actively Manage the Third Stage of Labor
- Give a uterotonic drug (e.g., oxytocin) immediately after birth.
- Perform controlled cord traction and uterine massage after placenta delivery.
Steps for Preventing and Managing Postpartum Hemorrhage (PPH):
1. Prevent PPH through Active Management of the Third Stage
- Administer a uterotonic drug such as oxytocin.
- Use controlled cord traction to deliver the placenta.
- Perform uterine massage after placenta expulsion.
2. Use Uterotonics Appropriately
- Prioritize oxytocin for prevention; if unavailable, use misoprostol or ergometrine.
- Delay cord clamping by at least one minute while initiating newborn care.
3. Respond Quickly if PPH Occurs
- Assess the woman’s condition, estimate blood loss, and check vital signs.
- Begin IV fluids to maintain blood pressure and prevent shock.
4. Administer Additional Medications
- Give additional uterotonics if bleeding persists.
- Use tranexamic acid if available as a supportive treatment.
5. Apply Non-Medical Measures
- Perform uterine massage and compression.
- Use bimanual uterine compression for ongoing bleeding.
6. Escalate to Surgical Intervention if Needed
- Refer to a higher-level facility for advanced procedures if bleeding does not stop.
- Consider options like uterine balloon tamponade or surgical repair.
7. Use Blood Transfusion When Available
- Â Offer transfusion to women with severe blood loss, based on clinical signs and availability.
8. Monitor and Follow Up
- Continue checking vital signs and overall condition.
- Provide follow-up care to ensure recovery and manage any complications.
Key Indicators
Maternal Health Indicators
- Maternal Mortality Ratio (MMR): The number of maternal deaths per 100,000 live births.
- Severe Maternal Morbidity (SMM): The incidence of severe complications during labor and childbirth.
Neonatal Health Indicators
- Neonatal Mortality Rate (NMR): The number of neonatal deaths (within the first 28 days of life) per 1,000 live births.
- Apgar Score: The percentage of newborns with a low Apgar score (less than 7) at 5 minutes after birth.
- Use of Partograph: The percentage of labor cases monitored using a partograph.
- Uterotonic Administration: The percentage of women receiving a uterotonic drug within 1 minute of birth.
- Skilled Birth Attendance: The percentage of births attended by skilled health personnel.
Quality of Care Indicators
- Respectful Maternity Care: The percentage of women reporting respectful and dignified care during labor and childbirth.
- Timely Interventions: The percentage of timely interventions for complications such as postpartum hemorrhage or obstructed labor.
Facility-Based Indicators
- Availability of Essential Supplies: The availability of essential drugs, equipment, and supplies for intrapartum care.
- Staff Training and Competency: The percentage of healthcare providers trained in evidence-based intrapartum care practices.
Patient Satisfaction Indicators
- Patient Satisfaction: The percentage of women reporting satisfaction with the care received during labor and childbirth.
- Feedback Mechanisms: The presence of mechanisms for collecting and addressing patient feedback.
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Looking for practical guidance on delivering MNCH services? Visit the MNCH Service Delivery Toolkit for step-by-step instructions on Labor & Delivery Care. Â
Tips
- Strengthen Leadership and Governance: Ensure clear policies, standards, and accountability mechanisms are in place to guide intrapartum care. Coordinate resources and personnel effectively to support service delivery.
- Build Provider Capacity Continuously: Invest in ongoing training, mentorship, and simulation-based learning to equip healthcare providers with evidence-based skills for safe and respectful childbirth care.
- Implement Quality Improvement Initiatives: Use proven tools like the WHO Safe Childbirth Checklist and local quality collaboratives to monitor and enhance service delivery regularly.
- Strengthen Data for Decision-Making: Improve data collection and management systems to generate timely, reliable insights. Use this data to track performance and guide improvements.
- Engage Communities in Care: Involve communities in the design and delivery of services. Raise awareness about respectful, high-quality intrapartum care to increase demand and trust.
- Adapt Interventions to Local Contexts: Tailor interventions to reflect national guidelines and community realities. Ensure flexibility to increase acceptability, relevance, and impact.
Challenges
- Address Resource Constraints: Advocate for increased funding and improve budget allocation for maternal health services. Strengthen supply chain systems to ensure consistent availability of essential medical supplies, equipment, and drugs.
- Manage Human Resource Challenges: Recruit and retain skilled healthcare workers and implement workload management strategies to reduce burnout and support staff well-being.
- Strengthen Training and Capacity Building: Provide continuous professional development through updated guidelines and evidence-based training. Incorporate simulation-based learning to enhance clinical preparedness and skill retention.
- Address Sociocultural Barriers: Collaborate with community leaders to challenge harmful cultural practices. Promote women’s empowerment and support their informed decision-making during childbirth.
Key Resources
- Recommendations: Intrapartum Care for a Positive Childbirth Experience. WHO 2018
- Toolkit for Implementation of the WHO Intrapartum Care and Immediate Postnatal Care Recommendations in Health-Care Facilities. WHO 2023
- Improving Quality of Intrapartum and Immediate Postpartum Care in Public Facilities: Experiences and Lessons from Rajasthan State, India. BMC Pregnancy and Childbirth 2021
- Implementing an Intrapartum Package of Interventions to Improve Quality of Care to Reduce the Burden of Preterm Birth in Kenya and Uganda. Implementation Science Communications 2021
- WHO Recommendations for the Prevention and Treatment of Postpartum Haemorrhage. WHO 2012
- WHO Guidelines for the Management of Postpartum Haemorrhage and Retained Placenta. WHO 2009
