What are the guidelines for a normal delivery based on the Philippines Clinical Practice Guidelines (CPG)?

Guidelines for Normal Delivery Based on Philippines Clinical Practice Guidelines

In the Philippines, normal delivery should be encouraged for women without medical or obstetric indications for cesarean section, with active management of the third stage of labor recommended for all women to reduce risk of postpartum hemorrhage.1

Antenatal Care and Preparation for Normal Delivery

• Pregnant women should receive regular antenatal care with initial visits ideally occurring in the first trimester to identify risk factors that may affect delivery planning 2
• Women with obesity (BMI ≥30) should be referred to an anesthesiologist for consultation during the antenatal period to discuss potential limitations and risks of anesthesia during delivery 1
• Fetal growth monitoring should be conducted throughout pregnancy, with increased vigilance for women with risk factors 1
• Low-dose aspirin is recommended for women at high risk of preeclampsia and should ideally be started by 16 weeks of gestation and taken in the evening to maximize efficacy 1

Labor Management

First Stage of Labor

• Clear liquids consumption is permitted throughout labor without volume limitation for patients at low risk of requiring general anesthesia 3
• Solid food consumption is not recommended during the active stage of labor 3
• A longer first stage of labor should be allowed before considering cesarean section for labor arrest, particularly when cervical dilation has not yet reached 6 cm 4
• Labor progress should be monitored using cervical dilation and fetal station measurements to create "labor curves" that provide diagnostic and prognostic information 5

Pain Management

• Regional analgesia (epidural) is recommended as the safest and most effective analgesic method for the mother and child when requested 3
• "Low-dose" regional analgesia that respects the experience of childbirth with patient-controlled epidural analgesia techniques is recommended 3
• There is no minimum cervical dilation required to allow epidural analgesia 3
• Epidural should not be discontinued before birth 3
• If regional analgesia is contraindicated, alternative analgesic options include entonox, nalbuphine, tramadol, or pudendal block, though their efficacy is moderate at best 3

Second and Third Stage of Labor

• Normal birth should be encouraged in the absence of obstetric or medical indications for intervention 1
• Active management of the third stage of labor is recommended for all women with a BMI ≥30 due to increased risk of postpartum hemorrhage 1
• Delayed cord clamping for at least 1 minute at term delivery and at least 30 seconds for preterm delivery is recommended 1
• Body temperature of the newborn should be maintained between 36.5°C and 37.5°C after birth 1

Immediate Postpartum Care

• Routine suctioning of the airway or gastric aspiration should be avoided and used only when secretions appear to be obstructing the airway 1
• Early initiation of breastfeeding should be encouraged with additional support provided as needed 1
• Hypertension may worsen after delivery, particularly between days 3 and 6 postpartum, requiring continued monitoring 1
• Antihypertensive medications should be continued postpartum if indicated, with methyldopa being switched to an alternative agent 1

Special Considerations

Hypertensive Disorders

• Magnesium sulfate is recommended for eclampsia treatment and prevention in women with severe preeclampsia or serious end-organ involvement 1
• For women with gestational hypertension, delivery is typically recommended at 37 weeks, to be discussed from 37 weeks, or by 39 weeks depending on clinical factors 1

Obesity

• Obesity alone is not an indication for elective cesarean section 1
• Women with obesity should have active management of the third stage of labor due to increased risk of postpartum hemorrhage 1
• Early establishment of venous access during labor is recommended for women with a BMI above 40 1
• Operating room staff should be alerted regarding any woman whose weight exceeds 120 kg to ensure adequate staffing and equipment availability 1

Postpartum Follow-up

• Lifestyle counseling and modification of risk factors should be provided, particularly for women with pregnancy complications such as hypertension 1
• Behavioral interventions including diet and exercise should be recommended for postpartum weight reduction 1
• Women should be advised that weight loss during breastfeeding through healthy diet and regular exercise does not impact the quantity or quality of milk production 1