cephalic presentation in marathi

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cephalic - Meaning in Marathi

Adjective .

• डोक्यासंबंधी +1

Definitions and Meaning of cephalic in English

Cephalic adjective, antonyms of cephalic.

A head is the part of an organism which usually includes the ears, brain, forehead, cheeks, chin, eyes, nose, and mouth, each of which aid in various sensory functions such as sight, hearing, smell, and taste. Some very simple animals may not have a head, but many bilaterally symmetric forms do, regardless of size.

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What is cephalic meaning in Marathi, cephalic translation in Marathi, cephalic definition, pronunciations and examples of cephalic in Marathi.

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INTRODUCTION

Diagnosis and management of face and brow presentations will be reviewed here. Other cephalic malpresentations are discussed separately. (See "Occiput posterior position" and "Occiput transverse position" .)

Prevalence  —  Face and brow presentation are uncommon. Their prevalences compared with other types of malpresentations are shown below [ 1-9 ]:

● Occiput posterior – 1/19 deliveries

● Breech – 1/33 deliveries

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Cephalic presentation

October 14, 2016

A cephalic presentation or head presentation or head-first presentation is a situation at childbirth where the fetus is in a longitudinal lie and the head enters the pelvis first; the most common form of cephalic presentation is the vertex presentation where the occiput is the leading part (the part that first enters the birth canal). All other presentations are abnormal (malpresentations) which are either more difficult to deliver or not deliverable by natural means.

The movement of the fetus to cephalic presentation is called head engagement. It occurs in the third trimester. In head engagement, the fetal head descends into the pelvic cavity so that only a small part (or none) of it can be felt abdominally. The perineum and cervix are further flattened and the head may be felt vaginally. Head engagement is known colloquially as the baby drop, and in natural medicine as the lightening because of the release of pressure on the upper abdomen and renewed ease in breathing. However, it severely reduces bladder capacity, increases pressure on the pelvic floor and the rectum, and the mother may experience the perpetual sensation that the fetus will “fall out” at any moment.

The vertex is the area of the vault bounded anteriorly by the anterior fontanelle and the coronal suture, posteriorly by the posterior fontanelle and the lambdoid suture and laterally by 2 lines passing through the parietal eminences.

In the vertex presentation the occiput typically is anterior and thus in an optimal position to negotiate the pelvic curve by extending the head. In an occiput posterior position, labor becomes prolonged and more operative interventions are deemed necessary. The prevalence of the persistent occiput posterior is given as 4.7 %

The vertex presentations are further classified according to the position of the occiput, it being right, left, or transverse, and anterior or posterior:

Left Occipito-Anterior (LOA), Left Occipito-Posterior (LOP), Left Occipito-Transverse (LOT); Right Occipito-Anterior (ROA), Right Occipito-Posterior (ROP), Right Occipito-Transverse (ROT);

By Mikael Häggström – Own work, Public Domain  

Cephalic presentation. (2016, September 17). In Wikipedia, The Free Encyclopedia . Retrieved 05:18, September 17, 2016, from https://en.wikipedia.org/w/index.php?title=Cephalic_presentation&oldid=739815165

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Fetal Presentation, Position, and Lie (Including Breech Presentation)

, MD, Children's Hospital of Philadelphia

Variations in Fetal Position and Presentation

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Presentation refers to the part of the fetus’s body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.

Position refers to whether the fetus is facing backward (occiput anterior) or forward (occiput posterior). The occiput is a bone at the back of the baby's head. Therefore, facing backward is called occiput anterior (facing the mother’s back and facing down when the mother lies on her back). Facing forward is called occiput posterior (facing toward the mother's pubic bone and facing up when the mother lies on her back).

Lie refers to the angle of the fetus in relation to the mother and the uterus. Up-and-down (with the baby's spine parallel to mother's spine, called longitudinal) is normal, but sometimes the lie is sideways (transverse) or at an angle (oblique).

For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not be possible.

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

The fetus has a birth defect Overview of Birth Defects Birth defects, also called congenital anomalies, are physical abnormalities that occur before a baby is born. They are usually obvious within the first year of life. The cause of many birth... read more .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

In occiput posterior position (sometimes called sunny-side up), the fetus is head first (vertex presentation) but is facing forward (toward the mother's pubic bone—that is, facing up when the mother lies on her back). This is a very common position that is not abnormal, but it makes delivery more difficult than when the fetus is in the occiput anterior position (facing toward the mother's spine—that is facing down when the mother lies on her back).

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards. The neck being bent backward increases the width required for delivery as compared to when the head is angled forward with the chin tucked, which is the position that is easiest for delivery. Thus, the baby’s body may be delivered and then the head may get caught and not be able to pass through the birth canal. When the baby’s head is caught, this puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among breech babies than among those presenting head first.

Breech presentation is more likely to occur in the following circumstances:

Labor starts too soon (preterm labor).

Sometimes the doctor can turn the fetus to be head first before labor begins by doing a procedure that involves pressing on the pregnant woman’s abdomen and trying to turn the baby around. Trying to turn the baby is called an external cephalic version and is usually done at 37 or 38 weeks of pregnancy. Sometimes women are given a medication (such as terbutaline ) during the procedure to prevent contractions.

Other presentations

In face presentation, the baby's neck arches back so that the face presents first rather than the top of the head.

In brow presentation, the neck is moderately arched so that the brow presents first.

Usually, fetuses do not stay in a face or brow presentation. These presentations often change to a vertex (top of the head) presentation before or during labor. If they do not, a cesarean delivery is usually recommended.

In transverse lie, the fetus lies horizontally across the birth canal and presents shoulder first. A cesarean delivery is done, unless the fetus is the second in a set of twins. In such a case, the fetus may be turned to be delivered through the vagina.

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What Is Cephalic Position?

The ideal fetal position for labor and delivery

• Why It's Best

Risks of Other Positions

• Determining Position
• Turning a Fetus

The cephalic position is when a fetus is head down when it is ready to enter the birth canal. This is one of a few variations of how a fetus can rest in the womb and is considered the ideal one for labor and delivery.

About 96% of babies are born in the cephalic position. Most settle into it between the 32nd and 36th weeks of pregnancy . Your healthcare provider will monitor the fetus's position during the last weeks of gestation to ensure this has happened by week 36.

If the fetus is not in the cephalic position at that point, the provider may try to turn it. If this doesn't work, some—but not all—practitioners will attempt to deliver vaginally, while others will recommend a Cesarean (C-section).

Getty Images

Why Is the Cephalic Position Best?

During labor, contractions dilate the cervix so the fetus has adequate room to come through the birth canal. The cephalic position is the easiest and safest way for the baby to pass through the birth canal.

If the fetus is in a noncephalic position, delivery becomes more challenging. Different fetal positions have a range of difficulties and varying risks.

A small percentage of babies present in noncephalic positions. This can pose risks both to the fetus and the mother, and make labor and delivery more challenging. It can also influence the way in which someone can deliver.

A fetus may actually find itself in any of these positions throughout pregnancy, as the move about the uterus. But as they grow, there will be less room to tumble around and they will settle into a final position.

It is at this point that noncephalic positions can pose significant risks.

Cephalic Posterior

A fetus may also present in an occiput or cephalic posterior position. This means they are positioned head down, but they are facing the abdomen instead of the back.

This position is also nicknamed "sunny-side up."

Presenting this way increases the chance of a painful and prolonged delivery.

There are three different types of breech fetal positioning:

• Frank breech: The legs are up with the feet near the head.
• Footling breech: One or both legs is lowered over the cervix.
• Complete breech: The fetus is bottom-first with knees bent.

A vaginal delivery is most times a safe way to deliver. But with breech positions, a vaginal delivery can be complicated.

When a baby is born in the breech position, the largest part—its head—is delivered last. This can result in them getting stuck in the birth canal (entrapped). This can cause injury or death.

The umbilical cord may also be damaged or slide down into the mouth of the womb, which can reduce or cut off the baby's oxygen supply.

Some providers are still comfortable performing a vaginal birth as long as the fetus is doing well. But breech is always a riskier delivery position compared with the cephalic position, and most cases require a C-section.

Likelihood of a Breech Baby

You are more likely to have a breech baby if you:

• Go into early labor before you're full term
• Have an abnormally shaped uterus, fibroids , or too much amniotic fluid
• Are pregnant with multiples
• Have placenta previa (when the placenta covers the cervix)

Transverse Lie

In transverse lie position, the fetus is presenting sideways across the uterus rather than vertically. They may be:

• Down, with the back facing the birth canal
• With one shoulder pointing toward the birth canal
• Up, with the hands and feet facing the birth canal

If a transverse lie is not corrected before labor, a C-section will be required. This is typically the case.

Determining Fetal Position

Your healthcare provider can determine if your baby is in cephalic presentation by performing a physical exam and ultrasound.

In the final weeks of pregnancy, your healthcare provider will feel your lower abdomen with their hands to assess the positioning of the baby. This includes where the head, back, and buttocks lie

If your healthcare provider senses that the fetus is in a breech position, they can use ultrasound to confirm their suspicion.

Turning a Fetus So They Are in Cephalic Position

External cephalic version (ECV) is a common, noninvasive procedure to turn a breech baby into cephalic position while it's still in the uterus.

This is only considered if a healthcare provider monitors presentation progress in the last trimester and notices that a fetus is maintaining a noncephalic position as your delivery date approaches.

External Cephalic Version (ECV)

ECV involves the healthcare provider applying pressure to your stomach to turn the fetus from the outside. They will attempt to rotate the head forward or backward and lift the buttocks in an upward position. Sometimes, they use ultrasound to help guide the process.

The best time to perform ECV is about 37 weeks of pregnancy. Afterward, the fetal heart rate will be monitored to make sure it’s within normal levels. You should be able to go home after having ECV done.

ECV has a 50% to 60% success rate. However, even if it does work, there is still a chance the fetus will return to the breech position before birth.

Natural Methods For Turning a Fetus

There are also natural methods that can help turn a fetus into cephalic position. There is no medical research that confirms their efficacy, however.

• Changing your position: Sometimes a fetus will move when you get into certain positions. Two specific movements that your provider may recommend include: Getting on your hands and knees and gently rocking back and forth. Another you could try is pushing your hips up in the air while laying on your back with your knees bent and feet flat on the floor (bridge pose).
• Playing stimulating sounds: Fetuses gravitate to sound. You may be successful at luring a fetus out of breech position by playing music or a recording of your voice near your lower abdomen.
• Chiropractic care: A chiropractor can try the Webster technique. This is a specific chiropractic analysis and adjustment which enables chiropractors to establish balance in the pregnant person's pelvis and reduce undue stress to the uterus and supporting ligaments.
• Acupuncture: This is a considerably safe way someone can try to turn a fetus. Some practitioners incorporate moxibustion—the burning of dried mugwort on certain areas of the body—because they believe it will enhance the chances of success.

A Word From Verywell

While most babies are born in cephalic position at delivery, this is not always the case. And while some fetuses can be turned, others may be more stubborn.

This may affect your labor and delivery wishes. Try to remember that having a healthy baby, and staying well yourself, are your ultimate priorities. That may mean diverting from your best laid plans.

Speaking to your healthcare provider about turning options and the safest route of delivery may help you adjust to this twist and feel better about how you will move ahead.

Glezerman M. Planned vaginal breech delivery: current status and the need to reconsider . Expert Rev Obstet Gynecol. 2012;7(2):159-166. doi:10.1586/eog.12.2

Cleveland Clinic. Fetal positions for birth .

MedlinePlus. Breech birth .

UT Southwestern Medical Center. Can you turn a breech baby around?

The American College of Obstetricians and Gynecologists. If your baby is breech .

Roecker CB. Breech repositioning unresponsive to Webster technique: coexistence of oligohydramnios .  Journal of Chiropractic Medicine . 2013;12(2):74-78. doi:10.1016/j.jcm.2013.06.003

By Cherie Berkley, MS Berkley is a journalist with a certification in global health from Johns Hopkins University and a master's degree in journalism.

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Why Is Cephalic Presentation Ideal For Childbirth?

5   Dec   2017 | 8 min Read

During labour, contractions stretch your birth canal so that your baby has adequate room to come through during birth. The cephalic presentation is the safest and easiest way for your baby to pass through the birth canal.

If your baby is in a non-cephalic position, delivery can become more challenging. Different fetal positions pose a range of difficulties and varying risks and may not be considered ideal birthing positions.

Two Kinds of Cephalic Positions

There are two kinds of cephalic positions:

• Cephalic occiput anterior , where your baby’s head is down and is facing toward your back.
• Cephalic occiput posterior , where your baby is positioned head down, but they are facing your abdomen instead of your back. This position is also nicknamed ‘sunny-side-up’ and can increase the chances of prolonged and painful delivery. 

How to Know if Your Baby is In a Cephalic Position?

You can feel your baby’s position by rubbing your hand on your belly. If you feel your little one’s stomach in the upper stomach, then your baby is in a cephalic position. But if you feel their kicks in the lower stomach, then it could mean that your baby is in a breech position.

You can also determine whether your baby is in the anterior or posterior cephalic position. If your baby is in the anterior position, you may feel their movement underneath your ribs and your belly button could also pop out. If your baby is in the posterior position, then you may feel their kicks in their abdomen, and your stomach may appear rounded up instead of flat. 

You can also determine your baby’s position through an ultrasound scan or a physical examination at your healthcare provider’s office. 

Benefits of Cephalic Presentation in Pregnancy

Cephalic presentation is one of the most ideal birth positions, and has the following benefits:

• It is the safest way to give birth as your baby’s position is head-down and prevents the risk of any injuries.
• It can help your baby move through the delivery canal as safely and easily as possible.
• It increases the chances of smooth labour and delivery.

Are There Any Risks Involved in Cephalic Position?

Conditions like a cephalic posterior position in addition to a narrow pelvis of the mother can increase the risk of pregnancy complications during delivery. Some babies in the head-first cephalic presentation might have their heads tilted backward. This may, in some rare cases, cause preterm delivery.

What are the Risks Associated with Other Birth Positions?

A small percentage of babies may settle into a non-cephalic position before their birth. This can pose risks to both your and your baby’s health, and also influence the way in which you deliver. 

In the next section, we have discussed a few positions that your baby can settle in throughout pregnancy, as they move around the uterus. But as they grow old, there will be less space for them to tumble around, and they will settle into their final position. This is when non-cephalic positions can pose a risk.  

Breech Position

There are three types of breech fetal positioning:

• Frank breech : Your baby’s legs stick straight up along with their feet near their head.
• Footling breech: One or both of your baby’s legs are lowered over your cervix.
• Complete breech: Your baby is positioned bottom-first with their knees bent.

If your baby is in a breech position , vaginal delivery is considered complicated. When a baby is born in breech position, the largest part of their body, that is, their head is delivered last. This can lead to injury or even fetal distress. Moreover, the umbilical cord may also get damaged or get wrapped around your baby’s neck, cutting off their oxygen supply.  

If your baby is in a breech position, your healthcare provider may recommend a c-section, or they may try ways to flip your baby’s position in a cephalic presentation.

Transverse Lie

In this position, your baby settles in sideways across the uterus rather than being in a vertical position. They may be:

• Head-down, with their back facing the birth canal
• One shoulder pointing toward the birth canal
• Up with their hands and feet facing the birth canal

If your baby settles in this position, then your healthcare provider may suggest a c-section to reduce the risk of distress in your baby and other pregnancy complications.

Turning Your Baby Into A Cephalic Position

External cephalic version (ECV) is a common, and non-invasive procedure that helps turn your baby into a cephalic position while they are in the womb. However, your healthcare provider may only consider this procedure if they consider you have a stable health condition in the last trimester, and if your baby hasn’t changed their position by the 36th week.

You can also try some natural remedies to change your baby’s position, such as:

• Lying in a bridge position: Movements like bridge position can sometimes help move your baby into a more suitable position. Lie on your back with your feet flat on the ground and your legs bent. Raise your pelvis and hips into a bridge position and hold for 5-10 minutes. Repeat several times daily.
• Chiropractic care: A chiropractor can help with the adjustment of your baby’s position and also reduce stress in them.
• Acupuncture: After your doctor’s go-ahead, you can also consider acupuncture to get your baby to settle into an ideal birthing position.

While most babies settle in a cephalic presentation by the 36th week of pregnancy, some may lie in a breech or transverse position before birth. Since the cephalic position is considered the safest, your doctor may recommend certain procedures to flip your baby’s position to make your labour and delivery smooth. You may also try the natural methods that we discussed above to get your baby into a safe birthing position and prevent risks or other pregnancy complications. 

When Should A Baby Be In A Cephalic Position?

Your baby would likely naturally drop into a cephalic position between weeks 37 to 40 of your pregnancy .

Is Cephalic Position Safe?

Research shows that 95% of babies take the cephalic position a few weeks or days before their due date. It is considered to be the safest position. It ensures a smooth birthing process.

While most of the babies are in cephalic position at delivery, this is not always the case. If you have a breech baby, you can discuss the available options for delivery with your doctor.

Does cephalic presentation mean labour is near?

Head-down is the ideal position for your baby within your uterus during birth. This is known as the cephalic position. This posture allows your baby to pass through the delivery canal more easily and safely.

Can babies change from cephalic to breech?

The external cephalic version (ECV) is the most frequent procedure used for turning a breech infant.

How can I keep my baby in a cephalic position?

While your baby naturally gets into this position, you can try some exercises to ensure that they settle in cephalic presentation. Exercises such as breech tilt, forward-leaning position (spinning babies program), cat and camel pose can help.

Stitches after a normal delivery : How many stitches do you need after a vaginal delivery? Tap this post to know.

Vaginal birth after caesarean delivery : Learn all about the precautions to consider before having a vaginal delivery after a c-section procedure. 

How many c-sections can you have : Tap this post to know the total number of c-sections that you can safely have.

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Chapter 15:  Abnormal Cephalic Presentations

Jessica Dy; Darine El-Chaar

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Malpresentations.

• TRANSVERSE POSITIONS OF THE OCCIPUT
• POSTERIOR POSITIONS OF THE OCCIPUT
• BROW PRESENTATIONS
• MEDIAN VERTEX PRESENTATIONS: MILITARY ATTITUDE
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The fetus enters the pelvis in a cephalic presentation approximately 95 percent to 96 percent of the time. In these cephalic presentations, the occiput may be in the persistent transverse or posterior positions. In about 3 percent to 4 percent of pregnancies, there is a breech-presenting fetus (see Chapter 25 ). In the remaining 1 percent, the fetus may be either in a transverse or oblique lie (see Chapter 26 ), or the head may be extended with the face or brow presenting.

Predisposing Factors

Maternal and uterine factors.

Contracted pelvis: This is the most common and important factor

Pendulous maternal abdomen: If the uterus and fetus are allowed to fall forward, there may be difficulty in engagement

Neoplasms: Uterine fibromyomas or ovarian cysts can block the entry to the pelvis

Uterine anomalies: In a bicornuate uterus, the nonpregnant horn may obstruct labor in the pregnant one

Abnormalities of placental size or location: Conditions such as placenta previa are associated with unfavorable positions of the fetus

High parity

Fetal Factors

Errors in fetal polarity, such as breech presentation and transverse lie

Abnormal internal rotation: The occiput rotates posteriorly or fails to rotate at all

Fetal attitude: Extension in place of normal flexion

Multiple pregnancy

Fetal anomalies, including hydrocephaly and anencephaly

Polyhydramnios: An excessive amount of amniotic fluid allows the baby freedom of activity, and he or she may assume abnormal positions

Prematurity

Placenta and Membranes

Placenta previa

Cornual implantation

Premature rupture of membranes

Effects of Malpresentations

Effects on labor.

The less symmetrical adaptation of the presenting part to the cervix and to the pelvis plays a part in reducing the efficiency of labor.

The incidence of fetopelvic disproportion is higher

Inefficient uterine action is common. The contractions tend to be weak and irregular

Prolonged labor is seen frequently

Pathologic retraction rings can develop, and rupture of the lower uterine segment may be the end result

The cervix often dilates slowly and incompletely

The presenting part stays high

Premature rupture of the membranes occurs often

The need for operative delivery is increased

Effects on the Mother

Because greater uterine and intraabdominal muscular effort is required and because labor is often prolonged, maternal exhaustion is common

There is more stretching of the perineum and soft parts, and there are more lacerations

Tears of the uterus, cervix, and vagina

Uterine atony from prolonged labor

Early rupture of the membranes

Excessive blood loss

Tissue damage

Frequent rectal and vaginal examinations

Prolonged labor

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• v.48(6); 2020 Jun

Clinical effectiveness of position management and manual rotation of the fetal position with a U-shaped birth stool for vaginal delivery of a fetus in a persistent occiput posterior position

1 Perinatal Center, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China

Tongying Yi

2 Delivery Room, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China

3 Ministry of Science and Technology Development, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China

Xiaoying Xu

4 Department of Anesthesia Surgery, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China

Qingmei Sun

5 Prenatal Diagnosis Center, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China

Xiaojuan Lin

6 Department of Obstetrics, Gansu Provincial Maternity and Child-care Hospital, Lanzhou, China

Zhaoyan Meng

To examine the effects of position management, manual rotation of the fetal position, and using a U-shaped birth stool in primiparous women with a fetus in a persistent occiput posterior position.

This was a prospective pilot study of women who delivered at Gansu Provincial Maternity and Child-care Hospital between January and June 2018. The women were divided into the position management ([PM] position management, manual rotation of fetal position, use of a U-shaped birth stool at different stages, and routine nursing) and control groups (position selected by women and routine nursing).

There were 196 women in the PM group and 188 in the control group. There were no significant differences in maternal age, gestational weeks, newborn weight, and the neonatal asphyxia rate between the PM and control groups. The duration of labor was shorter in the PM group than in the control group. Pain and blood loss 2 hours after delivery and the episiotomy rate were significantly lower in the PM group than in the control group.

Applying position management, manual rotation of the fetal position, and using a U-shaped birth stool should be considered for women with a fetus in a persistent occiput posterior position.

Introduction

Abnormal fetal position during delivery is a frequent cause of dystocia. 1 The most common fetal malposition is the occiput posterior position, accounting for 33.3% of malpositions occurring in labor, and the rate of dystocia is as high as 93.5%. 2 Entering the pelvis in the occiput anterior position is normal for the fetus. Entering the pelvis in the occiput posterior position should not necessarily be considered as abnormal because most fetuses spontaneously rotate to the occiput anterior position. 3 However, spontaneous rotation cannot occur in some cases, and a persistent occiput posterior position occurs in approximately 5% of births. 4

Early application of abdominal pressure can lead to cervical edema and fatigue of pregnant women, which in turn results in delayed or arrested labor. This situation increases the risks of caput succedaneum, scalp hematoma, and intrauterine distress of the fetus. 5 The result of increased difficulties with a fetus in the occiput posterior position is increased rates of assisted vaginal delivery and cesarean section. However, this can also lead to physical damage to the pregnant woman and poor neonatal outcomes. 4 Early discovery, diagnosis, and management of this position can reduce the risk of dystocia, decrease the rate of cesarean section, and increase the rate of spontaneous vaginal delivery. 6

Manual rotation of the fetal position is the most effective method for treating the occiput posterior position. 7 The position of pregnant woman is a critical factor affecting manual rotation of the fetal position. When pregnant women are standing upright, the angle between the plane of the pelvic outlet and the ground is approximately 60°, which favors descent of the fetus into the pelvis. Additionally, a sitting position increases the pelvic space, which helps accelerate descending fetal presentation and rotation of the fetal head in the birth canal. 8 The gravity of the fetus and buoyancy of the amniotic fluid promote the fetus to rotate around its long axis downward. 9

In our hospital, position management and manual rotation of the fetal position are applied in combination with use of a U-shaped birth stool for primiparous women with a fetus in a persistent occiput posterior position. We hypothesized that these procedures effectively shorten the birth process time, reduce pain, reduce rates of assisted delivery and cesarean section, and increase the rate of spontaneous delivery. Therefore, we performed a pilot comparison study to examine the effects of position management and manual rotation of the fetal position in the first stage of labor, combined with using a U-shaped birth stool in the second stage of labor, on delivery in primiparous women with a fetus in a persistent occiput posterior position.

Primiparous women with an occiput posterior fetal position who were awaiting childbirth in the delivery room of Gansu Provincial Maternity and Child-care Hospital between January 2018 and June 2018 were included in this pilot clinical trial. The inclusion criteria were as follows: 1) aged ≤35 years; 2) primiparous; 3) term pregnancy; 4) singleton; 5) persistent occiput posterior position, which was defined as a fetus that did not spontaneously rotate and was delivered in the occiput posterior position or would be delivered in the occiput posterior position when cervical dilatation was ≥3 cm; 4 , 10 and 6) the fetus was in good condition (no fetal malformation and class I traces on fetal heart rate monitoring). 11 The exclusion criteria were as follows: 1) pregnancy complications or obstetric complications; 2) intrauterine fetal distress; 3) uterine hyperkinesia; 4) evident edema or hematoma in the head of the fetus; 5) severe cervical edema; 6) severe perineal edema; and 7) low birth weight or large for gestational age.

This study was approved by the Ethics Committee of Gansu Provincial Maternity and Child-care Hospital. All pregnant women signed informed consent forms.

Strategy for therapy

As per routine practice at our center, the fetal position was tested by a midwife in the delivery room. Patients with the occiput posterior position of the fetus then received a bedside ultrasound scan by qualified obstetricians to eventually diagnose the position. Patients were allocated in a 1:1 ratio into the position management (PM) group and control group (see details below), using blocks of four women. Women in both groups were transferred to the delivery room to wait for delivery when cervical dilatation was 3 cm, with routine nursing and care. Epidural anesthesia was provided for women who volunteered to receive it. The self-made Scale of Assessing Risk Factors of Falling (Appendix 1) was applied to all women. All women were asked to empty their bladder to avoid influencing uterine contractions and descending fetal presentation. The midwife was asked to closely monitor the progression of labor and uterine contractions. Effective uterine contractions (3–5 within 10 minutes) were ensured throughout the labor process, and evaluated using an Avalon Fetal Monitor M2702A (Philips Medizin Systeme Boeblingen GmbH, Boeblingen, Germany). Regular fetal heart rate monitoring was also conducted using an Avalon Fetal Monitor M2702A (Philips Medizin Systeme Boeblingen GmbH). Regular fetal heart rate was defined as class I on fetal heart rate monitoring. 12

For women in the PM group, position management, manual rotation of the fetal position, and a U-shaped birth stool were used. Position management was applied when cervical dilatation was 4 to 6 cm. When the fetal position was the left occiput posterior position, the woman was asked to lie in a right prone position, with the left leg bent close to the abdomen, the right leg stretched backward, the left shoulder pressed downward, and the abdomen as close to the bed as possible. When the fetal position was the right occiput posterior position (ROP), the woman was asked to lie in a left prone position, with the right leg bent close to the abdomen, the left leg stretched backward, the right shoulder pressed downward, and the abdomen as close to the bed as possible. The women were asked to lie in such a position for at least 40 minutes.

For women with cervical dilatation of 6 to 8 cm, while the fetal position was still in the occiput posterior position after position management (s = 0 or s = +1), manual rotation of the fetal position was conducted. The external genital area was routinely disinfected and draped. The direction of the fetal head, size of the fetus, and dilation of the vagina were examined. The midwife placed her forefinger and middle finger into the vagina during intervals of uterine contractions to determine the position of the fetal head and avoid touching the fontanels. For a fetus in the left occiput posterior position, the fetal head was gently rotated in the counterclockwise direction. For a fetus in the right occiput posterior position, the fetal head was gently rotated in the clockwise direction. The angle of rotation was approximately 45° to 90°. After the fetal head was rotated to the occiput anterior position, the fetal position was fixed after two to three uterine contractions. The fetal head was induced to descend. During descent of the fetal head, the midwife ensured that there were no signs of prolapse of the umbilical cord, and her hand was only withdrawn after the conditions were normal. Moreover, the fetal heart rate was monitored closely during these processes, which were stopped immediately if there were any abnormalities. Sesarean section was conducted for cases of umbilical cord prolapse. After rotation of the fetal position succeeded and the fetal heart rate had been monitored for 5 to 10 minutes, the women were allowed to walk with the assistance of a delivery vehicle or to swing gently on a birth ball (monitoring of the women and fetus was conducted by the midwife). If the rotation failed, the women were still allowed to perform the same activities, or further position management was conducted.

For women with a cervix at full dilatation, but the fetus was still in the occiput posterior position, manual rotation of fetal position could still be conducted, as above. When rotation remained impossible, despite all of the above-mentioned measures, a U-shaped birth stool could be used. During uterine contractions, the women were guided to lean forward, with their legs stretched apart and both feet on the ground, and both hands were holding the handles of the birth stool. The women were asked to take a deep inhalation and then push downward, holding their breath for as long as possible. This process was repeated immediately after exhalation until the uterine contraction stopped. The women were asked to rest and relax in the intervals of uterine contractions. When using the U-shaped birth stool, the midwife provided one-to-one guidance and observation. Fetal heart rate, uterine contractions, cervical dilatations, and descent of fetal presentation were closely monitored. When 3 to 4 cm of the fetal head appeared at the vaginal orifice during uterine contractions, women were transferred to the obstetric table. The women were then placed in the supine lithotomy position for delivery. For women with a normal fetal position, the U-shaped birth stool was used directly, as above. For women with more than five contractions in 10 minutes, 13 abnormal signs in fetal heart rate monitoring, or severe perineal edema, the birth stool was not used.

Women in the control group were allowed to select their position in the first stage of labor and were provided with routine nursing. The labor process was monitored. After full cervical dilatation, the women felt anal expansion and pushed, while spontaneously holding their breath. The women were placed in the supine lithotomy position, with both hands holding both handles of the obstetric table tightly, and both feet against the footstools of the obstetric table. The women were asked to take a deep inhalation, and then hold their breath and push hard, with both hands pulling upward, and both feet stepping downward. The women were asked to rest and relax during intervals of uterine contractions. Food and water were provided for women to maintain their physical strength.

Clinical data collection

The delivery mode (spontaneous delivery, vacuum extraction, forceps delivery, and cesarean section), duration of the first and second stages of labor, pain score, volume of blood loss at 2 hours after delivery, perineal outcome, and the neonatal asphyxia rate in both groups were recorded. Neonatal asphyxia was defined as a 1-minute Apgar score ≤7 or 5-minute Apgar score ≤7, with an umbilical artery pH at birth of ≤7.20. Severe asphyxia was defined as a 1-minute Apgar score ≤3 or 5-minute Apgar score ≤5, with an umbilical artery pH at birth of ≤7.0. 14

The visual analog scale method was used for assessing pain. The stage of perineal laceration was assessed according to the Royal College of Obstetricians and Gynaecologists (RCOG) criteria. 6 The volume of blood loss at 2 hours after delivery was measured by the volumetric method and gravimetric method.

Statistical analysis

SPSS 13.0 software (SPSS, Inc., Chicago, IL, USA) was used for statistical analysis. Continuous variables with a normal distribution are shown using mean and standard deviation, and were compared by the independent t-test. Non-normally distributed continuous variables are shown as median (range) and were compared using the Kruskal–Wallis test. Categorical variables are shown as percentages and were compared by the chi-square test or Fisher’s exact test. P<0.05 was considered statistically significant.

General characteristics

A total of 400 primiparous women with a fetus in a persistent occiput posterior position were included in this study. The women were divided into the PM and control groups, with 200 women in each group. Four women in the PM group and 12 in the control group underwent cesarean section. Therefore, analysis was performed in 196 women in the PM group and 188 in the control group ( Figure 1 ). The characteristics of the study population are shown in Table 1 . There were no significant differences in maternal age, gestational weeks, and newborn weight between the two groups.

Inclusion process of the study participants. PM: position management.

Baseline characteristics of the general study population.

Values are mean ± standard deviation. PM: position management; BMI: body mass index.

Delivery mode and perineal outcome in the two groups

Table 2 shows the delivery modes in the two groups. A total of 185 (94.4%) women in the PM group and 169 (89.9%) in the control group had spontaneous delivery, with no significant difference in delivery mode between the two groups (P = 0.07). There was a significant difference in perineal outcome between the two groups (χ 2 test, P = 0.04) as follows. Women in the PM group had a higher frequency of first-degree laceration and a lower frequency of episiotomy compared with the control group.

Comparison of labor and outcomes between the two groups.

PM: position management; SD, standard deviation.

Duration of labor, pain score, and volume of blood loss at 2 hours after delivery in the two groups

The first and second stages of labor were significantly shorter in the PM group than in the control group (both P<0.05), while the pain score was significantly lower in the PM group than in the control group (P = 0.003). The volume of blood loss at 2 hours after delivery was also significantly lower in the PM group than in the control group (P<0.05) ( Table 2 ), but there was no significant difference in the frequency of women with blood loss >250 mL.

Neonatal asphyxia rate in the two groups

The rate of neonatal asphyxia was not significantly different between the two groups. No maternal or neonatal death occurred in both groups.

This study investigated whether position management, manual rotation of the fetal position, and using a U-shaped birth stool improved delivery in primiparous women with a fetus in a persistent occiput posterior position compared with standard methods. There was no significant difference in delivery mode between the two groups, but the duration of labor was shorter in the PM group than in the control group.

Confirming the position of the fetal head using ultrasound is important for correct management of the delivery process. Indeed, Akmal et al. 15 reported a high failure rate of determining the fetal head position by a clinical examination. Dupuis et al. 16 reported that the difference in fetal head position between a clinical examination and ultrasound could differ by >45° in 20% of the cases. Ultrasound is a simple, fast, inexpensive, and bedside method for determining the fetal head position. Inappropriate estimation of the fetal head position is associated with poor progress of labor, a higher rate of instrumental delivery and cesarean section, and a higher rate of morbidity for the mother and the newborn. 12 , 17 , 18

Various methods have been used to improve the birth process in women who present with a fetus in a persistent occiput posterior position. At the beginning of labor, a popular approach is to use maternal postures that might facilitate flexion of the fetal head and favor its rotation into the occiput anterior position, but there is no consensus on the best position. 5 , 12 , 19 , 20 In this study, women with the left occiput posterior position were asked to lie in a right prone position, while women with the right occiput posterior position were asked to lie in a left prone position. Previous studies have suggested that manual rotation reduces the rate of operative delivery, but it might not be used often. 21 , 22 The fetal head should not be pushed too far upward during manual rotation of the fetal position to avoid inducing umbilical cord prolapse. The third intervention performed in the PM group was provision of a birthing stool during the second stage of labor. The supine lithotomy position is generally used for parturition in China. In this position, labor and fetal heart rate are easily monitored, and delivery is easy to conduct. However, this position is not in agreement with the physiological position of regular parturition because expansion of the sacrococcygeal joint is difficult and the pelvic outlet is narrow. Furthermore, a supine position could allow the uterus to press the abdominal aorta and inferior vena cava, and, therefore, increase the risk of fetal hypoxia. 23 In contrast, delivery in the sitting position is better in agreement with physiological features of the birth canal. 24 Previous studies have shown that when women are in the sitting position, more endorphin is secreted. 25 In this study, the second stage of labor was shorter in the PM group than in the control group, and this may have been due to the option of using a sitting position and a birthing stool for these women. Women who give birth in a supine position are also more likely to have an episiotomy than those who give birth in a sitting position. 26

This study has some limitations. The study was undertaken in one maternity unit. Therefore, the sample size was relatively small in both groups. Consequently, the women were not representative of the general or Chinese population. Therefore, our findings need to be generalized with caution, and our study was considered a pilot study. A larger study would provide more evidence for these results. Women who finally underwent cesarean section were excluded from the analysis. Indeed, this study aimed to examine the effects of position management, manual rotation of the fetal position, and use of a U-shaped birth stool in primiparous women with a fetus in a persistent occiput posterior position. Finally, the PM group was managed using a combination of methods, and we cannot determine which method contributed the most to the outcomes. Nevertheless, the strength of this study was its randomized design.

In conclusion, adjusting an abnormal fetal position is critical for reducing dystocia of cephalic presentation and increasing the quality of vaginal delivery. 27 Applying position management in the first stage of labor, rotation of the fetal position, and use of a U-shaped birth stool in the second stage of labor to change the occiput posterior position to the occiput anterior position effectively shorten labor, and decrease pain and blood loss in women. Therefore, these methods are worth considering for women with a fetus in a persistent occiput posterior position.

Appendix 1.

Scale of assessing risk factors of falling.

Application of the scale: After the pregnant woman enters the delivery room, the scale can be applied (excluding those with absolute indications to be in bed) throughout the entire delivery process. Please check the boxes after the corresponding descriptions.

The scale has a total score of 34 and each check represents 1 point

1. If the score falls between 0 and 5, the risk of falling is low and the nurse in charge should provide general care.

2. If the score falls between 6 and 10, the risk of falling increases and the nurse in charge should provide one-on-one care.

3. If the score falls between 10 and 15, the risk of falling is relatively high and the nurse in charge should report to the doctor in charge for further evaluation. If getting out of bed is essential to promote delivery, the nurse in charge should provide sufficient notification and education in addition to one-on-one care. Proper activity tools should be selected.

4. If the score is >15, the risk of falling is high and the patient is not suggested to be out of bed. The nurse in charge should provide explanations and corresponding care with high quality.

Declaration of conflicting interest

The authors declare that there is no conflict of interest.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Zhaoyan Meng https://orcid.org/0000-0002-3567-5433

Cephalic Presentation Meaning In English

Cephalic Presentation translation, meaning, definition, explanation and examples of relevant words and pictures - you can read here.

Other Languages:

Cephalic Presentation is the position in which the head, of a fetus is bowed as it prepares to enter the birth canal.

Explanation

A term used to describe the position where the babys head is bent and facing the mothers spine. This means that if the babys head is turned in this position, you have a 97% chance of having a healthy delivery, which is considered the best way to deliver.

At around 32 weeks, the baby is usually lying head down, ready to be born, its called a cephalic presentation.

Random Words

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• Published: 30 January 2024

Effects of the WHO Labour Care Guide on cesarean section in India: a pragmatic, stepped-wedge, cluster-randomized pilot trial

• Joshua P. Vogel   ORCID: orcid.org/0000-0002-3214-7096 1 ,
• Yeshita Pujar 2 ,
• Sunil S. Vernekar   ORCID: orcid.org/0000-0002-0635-8041 2 ,
• Elizabeth Armari 1 ,
• Veronica Pingray 3 ,
• Fernando Althabe 3 ,
• Luz Gibbons   ORCID: orcid.org/0000-0002-0235-1635 3 ,
• Mabel Berrueta 3 ,
• Manjunath Somannavar   ORCID: orcid.org/0000-0002-8871-5072 2 ,
• Alvaro Ciganda 3 ,
• Rocio Rodriguez 3 ,
• Savitri Bendigeri 2 ,
• Jayashree Ashok Kumar 4 ,
• Shruti Bhavi Patil 4 ,
• Aravind Karinagannanavar 4 ,
• Raveendra R. Anteen 5 ,
• Pavithra Mallappa Ramachandrappa 5 ,
• Shukla Shetty 6 ,
• Latha Bommanal 6 ,
• Megha Haralahalli Mallesh 6 ,
• Suman S. Gaddi 7 ,
• Shaila Chikkagowdra 7 ,
• Bellara Raghavendra 7 ,
• Caroline S. E. Homer   ORCID: orcid.org/0000-0002-7454-3011 1 ,
• Tina Lavender 8 ,
• Pralhad Kushtagi 9 ,
• G. Justus Hofmeyr   ORCID: orcid.org/0000-0002-3080-1007 10 , 11 ,
• Richard Derman 12 &
• Shivaprasad Goudar   ORCID: orcid.org/0000-0002-8680-7053 2  

Nature Medicine volume  30 ,  pages 463–469 ( 2024 ) Cite this article

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Cesarean section rates worldwide are rising, driven by medically unnecessary cesarean use. The new World Health Organization Labour Care Guide (LCG) aims to improve the quality of care for women during labor and childbirth. Using the LCG might reduce overuse of cesarean; however, its effects have not been evaluated in randomized trials. We conducted a stepped-wedge, cluster-randomized pilot trial in four hospitals in India to evaluate the implementation of an LCG strategy intervention, compared with routine care. We performed this trial to pilot the intervention and obtain preliminary effectiveness data, informing future research. Eligible clusters were four hospitals with >4,000 births annually and cesarean rates ≥30%. Eligible women were those giving birth at ≥20 weeks’ gestation. One hospital transitioned to intervention every 2 months, according to a random sequence. The primary outcome was the cesarean rate among women in Robson Group 1 (that is, those who were nulliparous and gave birth to a singleton, term pregnancy in cephalic presentation and in spontaneous labor). A total of 26,331 participants gave birth. A 5.5% crude absolute reduction in the primary outcome was observed (45.2% versus 39.7%; relative risk 0.85, 95% confidence interval 0.54–1.33). Maternal process-of-care outcomes were not significantly different, though labor augmentation with oxytocin was 18.0% lower with the LCG strategy. No differences were observed for other health outcomes or women’s birth experiences. These findings can guide future definitive effectiveness trials, particularly in settings where urgent reversal of rising cesarean section rates is needed. Clinical Trials Registry India number: CTRI/2021/01/030695 .

An estimated 287,000 maternal deaths, 2.4 million neonatal deaths and 1.9 million stillbirths occur each year, the vast majority of which take place in low- and middle-income countries 1 , 2 , 3 . As many as 45% of these maternal deaths, stillbirths and neonatal deaths occur during labor, birth and the first 24 hours postpartum 4 . Ensuring good-quality care is available to all women during labor and birth (that is, the intrapartum period) is thus critical to any efforts to reduce global maternal and newborn morbidity and mortality 5 .

By 2030, an estimated 38 million women annually (28.5% of births worldwide) will undergo a cesarean section 6 . A cesarean section is an essential component of good-quality intrapartum care, yet it carries inherent risks for women and newborns 7 , 8 . When it is performed for a medical indication, these risks are outweighed by the benefits of intervening; it is lifesaving in some clinical situations 6 , 9 . However, the global cesarean rate increased by 19 percentage points between 1990 to 2018, driven in large part by cesareans performed without a clear medical indication (that is, an unnecessary cesarean section) 6 . These women and babies are exposed to the risks of cesarean sections, for no health benefit.

The World Health Organization (WHO) has long recommended that a woman in labor should be monitored by a skilled healthcare provider using a partograph, a paper clinical tool for documenting observations and helping make clinical decisions 10 . When completed prospectively, the partograph can determine whether and when an intervention—such as labor augmentation or cesarean section—is warranted. A WHO-led 1994 trial showed that prospective partograph use combined with intensive provider training optimized the use of intrapartum interventions and improved maternal and newborn outcomes 11 . Consequently, the WHO simplified partograph was widely adopted as a key component of routine intrapartum care internationally 12 . However, while more women than ever are giving birth in health facilities 13 , partographs are often used poorly, or not at all. Inadequate provider training and skills, heavy staff workloads, a lack of clinical equipment and supplies, and restrictive hospital policies are known barriers to partograph use 14 , 15 , 16 .

In 2018, the WHO published 56 recommendations to improve the quality of intrapartum care and enhance women’s childbirth experiences 17 . Key recommendations included changing the definition of active first stage of labor from the widely used 3 cm or 4 cm to starting from 5 cm of cervical dilation, and removal of the ‘alert’ and ‘action’ lines. These changes reflected a growing body of evidence that the historical ‘1 cm per hour’ rule for active labor progress is unrealistic for most women, and that slower dilation rates are not associated with adverse birth outcomes. In response to these recommendations, a ‘next generation’ partograph known as the WHO Labour Care Guide (LCG) was developed in 2020 through expert consultations, primary research with maternity healthcare providers and a multicountry usability study 18 , 19 , 20 .

The LCG aims to promote the use of evidence-based, respectful and woman-centered care during labor and childbirth 21 . The healthcare provider regularly records clinical parameters related to labor progress and maternal and fetal wellbeing; deviations from normal are highlighted to ensure the required actions are taken. The LCG has specific, evidence-based time limits for each centimeter of cervical dilatation. The provider also documents the provision of important, yet often overlooked, supportive care practices—labor companionship, oral hydration, mobility during first stage, birth position of choice and pain management. It is also used for monitoring the second stage of labor.

The WHO states that the LCG should be implemented into routine care globally 22 . However, introducing the LCG requires an active strategy that ensures a healthcare provider’s clinical practice improves, thereby enhancing the quality of intrapartum care, reducing the use of unnecessary interventions and improving support to women during labor. However, as the LCG is a novel tool, no such strategy has been developed or tested in a randomized trial. This knowledge gap was highlighted in the WHO’s recent global LCG research prioritization exercise, in which identifying optimal implementation strategies, as well as understanding the LCG’s effects on maternal and perinatal outcomes, were top research priorities 23 .

To address this gap, we conducted formative research and developed a complex ‘LCG strategy’ intervention. The intervention included a co-designed LCG training program for providers working in labor wards, comprising initial and refresher training workshops and 8 weeks of case-based teaching sessions using the LCG. The LCG strategy also included implementing monthly audit and feedback meetings for the hospital’s birth and cesarean data. These data were reported using the ten group Robson classification system, which is recommended by the WHO for evaluating cesarean section use 9 . It classifies women into one of ten groups on the basis of their parity, whether previous cesarean was used or not, onset of labor, fetal presentation and lie, number of neonates and gestational age (term or preterm) 24 . For example, women in Robson Group 1 are those who are nulliparous, gave birth to a singleton, term pregnancy in cephalic presentation, and were in spontaneous labor. Robson Group 1 usually accounts for 30% of the obstetric population, and overuse of cesarean section is often observed in this group.

In this pilot trial, we aimed to evaluate the effects of implementing the LCG strategy, as compared to routine intrapartum care; the latter included use of the simplified partograph. We performed this pilot trial to demonstrate whether the LCG strategy was practicable, as well as to generate preliminary effectiveness evidence to inform future research.

Characteristics of study population

Between 1 July 2021 and 15 July 2022, 26,331 women gave birth to 26,595 babies in the four hospitals during the control and intervention periods and were included for analysis (Fig. 1 ). The total number of women giving birth differed between hospitals, ranging from 5,295 to 8,772 women per hospital. The analysis population comprised 11,517 women (11,624 babies) who gave birth in the control period and 14,814 women (14,971 babies) who gave birth in the intervention period. The main analysis did not include the 1,080 women (1,089 babies) who gave birth in the transition period. Clusters implemented the intervention at the scheduled time, with no substantive adaptations.

The four clusters (hospitals) were randomly allocated to four different sequences. Each sequence had a different schedule of control condition (gray), transition condition (light blue) and intervention condition (dark blue). Each cell shows the number of women and babies at each time point.

While there were more women in the intervention than the control, the characteristics of women were similar (Table 1 ). Nearly half of included women were nulliparous (46.7% of the control group and 47.5% of the intervention group), while more than half of multiparous women had no prior cesarean section (56.7% versus 55.0%). The distribution of women across the ten Robson classification groups was also similar (Supplementary Table 1 ). Robson Group 1 accounted for 30.8% (3,543 of 11,517) of women in the control group and 29.0% (4,302 of 14,814) of women in the intervention group. The intervention group had a slightly higher proportion of women in Group 2 and a slightly lower proportion of women in Group 3.

Primary and secondary outcomes

Table 2 reports the intervention effect sizes for the primary outcome and secondary maternal process-of-care outcomes. For the primary outcome, the cesarean section rate in Robson Group 1 for the control group was 45.2%, while in the intervention group it was 39.7%, with a crude absolute difference of −5.5% (relative risk (RR) 0.85, 95% confidence interval (CI) 0.54–1.33, P value 0.1088). The estimated intraclass correlation coefficient (ICC) for the primary outcome during the control period was 0.015 (95% CI 0; 0.043). For secondary outcomes, the cesarean section rate in Robson Groups 1 and 3 was 30.9% for the control group, and 26.9% for the intervention group—a crude absolute difference of −4.0% (RR 0.81, 95% CI 0.59–1.11). The overall cesarean section rate was 50.5% for the control group and 50.7% for the intervention group (RR 0.91, 95% CI 0.71–1.15) For the secondary outcome augmentation with oxytocin during spontaneous labor, the prevalence in the control group was 27.3% and in the intervention group it was 9.3% (crude absolute difference −18.0%). However, the estimate of effect was not significant (RR 0.34, 95% CI 0.01–15.04)—the wide CI was attributable to the high variability in outcome prevalence between hospitals and time periods.

Table 3 reports the intervention effects on other secondary maternal, fetal and newborn health outcomes. For maternal secondary outcomes—third- or fourth-degree tears, postpartum hemorrhage requiring uterine balloon tamponade or surgical intervention, and maternal infection requiring therapeutic antibiotics—the prevalence was less than 1% in both groups, and there were no clear differences. For the baby, there were no clear differences in stillbirth (RR 0.97, 95% CI 0.43–2.19), neonatal death before discharge/day 7 (RR 1.31, 95% CI 0.37–4.71) or perinatal death before discharge/day 7 (RR 1.06, 95% 0.41–2.73). We measured several newborn morbidity outcomes before discharge/day 7 (Apgar score <7 at 5 minutes; use of bag and mask ventilation; use of mechanical ventilation; >48 hour admission in neonatal intensive care unit (NICU); and newborn requiring NICU admission for hypoxic ischemic encephalopathy) and found no clear differences for any of these.

A total of 1,438 women in the control group and 1,277 women in the intervention group consented (100% and 99.9% consent rate, respectively) and completed postpartum surveys. Table 4 reports the effects on women’s experiences at birth, for which there were no differences between groups. In terms of adverse events, there were five maternal deaths, 196 neonatal deaths and 367 stillbirths in the control period, and 13 maternal deaths, 200 neonatal deaths and 449 stillbirths in the intervention period (Supplementary Tables 3 and 4 ). None of these deaths were assessed as being related to the intervention.

In this stepped-wedge, cluster-randomized pilot trial in India, we implemented a strategy to introduce the LCG into routine care for women giving birth, as well as initiating monthly audit and feedback meetings on cesarean section data using Robson classification. We observed a 5.5% crude absolute reduction in cesarean rates among women in Robson Group 1 following introduction of the intervention; however, this difference was not statistically significant. Maternal process-of-care measures were not significantly different, though the crude absolute difference for labor augmentation using oxytocin was −18.0%. We did not observe any clear differences in maternal, fetal or newborn health outcomes, or women’s experiences at birth. The findings do not preclude the possibility that the LCG strategy may reduce cesarean section and augmentation of labor in larger, definitive trials.

Reversing the worldwide trend in rising cesarean section rates, driven in large part by medically unnecessary cesarean use, has proven to be a challenging problem—a 2018 WHO guideline identified few effective interventions to address this 25 , 26 . The LCG promotes several supportive care measures that have been shown in trials to prevent cesarean section, such as labor companionship, mobilization during labor and adequate pain relief 27 , 28 , 29 . Also, the use of 5-cm dilatation to define the active first stage, as well as removal of the ‘1-cm-per-hour rule’, would, assumedly, lead to fewer intrapartum interventions. As the LCG is a novel clinical tool, there are few effectiveness studies available for comparison, though more trials using the LCG are planned 30 , 31 . In 2022, Pandey et al. published findings of an individually randomized trial of 271 low-risk women in a single hospital in India, comparing the effects of using the LCG versus modified partograph 32 . They reported a dramatic reduction in cesarean section—1.5% in the LCG group compared with 17.8% in the control group ( P value 0.0001)—as well as significantly lower oxytocin use and shorter duration of the active phase of labor with the LCG.

In planning this trial, the sample size calculation was based on an estimated 25% RR reduction for cesarean section rate in Robson Group 1. The intervention was implemented as planned with good uptake, and the target sample size was met. As this was a pilot trial, we cannot draw definitive conclusions on the magnitude of the LCG strategy’s effect on the primary or secondary outcomes. However, we consider these pilot trial findings to be promising, and that further definitive trials are warranted. The trial cannot test a superiority hypothesis for rarer adverse outcomes (such as mortality and severe morbidity of women and babies), although, reassuringly, there was no evidence of short-term harms associated with the LCG strategy. Data on these outcomes should be monitored in future, larger-scale research.

We did not detect any differences for outcomes on women’s experiences. However, these data showed women had high levels of satisfaction with the amount of time health workers spent with them, with the way they were communicated with and with their overall birth experience. It also showed that some supportive care practices, such as being offered a labor companion, were reasonably common, though other women-centered interventions were not well implemented. For example, being offered pain relief (5.2% and 15.3%) and being asked which birth position they preferred (0.7% and 2.1%) were poorly used. This highlights that substantive gaps persist in the provision of supportive care around the time of birth. Additional strategies are needed to address these gaps.

This trial was conducted in large, busy, public tertiary hospitals with high cesarean use, within one state of India. In three hospitals, partograph completion was the responsibility of postgraduate residents only. In India, the national Labour Room Quality Initiative (‘LaQshya’) and hospital accreditation process 33 has a strong emphasis on respectful maternity care, which is well aligned with the WHO’s recommendations and the LCG’s foundational principles. These factors mean the trial findings may not necessarily generalize to other settings that are naïve to respectful maternity care principles and policies. For example, it may be more challenging to generate provider behavior change in settings without a national policy framework. Contextual differences around how frequently obstetric interventions are used, as well as differences in the risk profile of obstetric populations, may mean the LCG strategy has variable effects.

We describe this study as a pilot trial as it was exploratory—we tested a complex intervention for which the effect size was initially unknown. We also demonstrated viability of the LCG strategy and the stepped-wedge study design, and generated evidence for a future definitive trial (particularly sample size). Such a trial should use a stepped-wedge, cluster-randomized design and should involve more hospitals (clusters) that have high rates of cesarean section. Such a trial would also be able to assess other, rarer adverse outcomes. Strengths include the use of a theory-based, evidence-informed, co-design approach to developing the LCG strategy, which aimed to address factors known to impair partograph use 16 . We also used a robust, cluster-randomized design and recruited a large number of participants in a real-world clinical setting. The stepped-wedge design means that all hospitals were implementing the LCG strategy at trial conclusion.

This trial nonetheless has some limitations. CIs for several outcomes were quite wide. This was driven by variability in outcome rates between time periods and between clusters, as well as the small number of clusters. Also, as this is a pilot trial, wider CIs are not unexpected. The use of a generalized estimating equation (GEE) and the corresponding adjustment is appropriate in situations where there are few clusters, though results are approximate and thus should be interpreted cautiously. This issue could be mitigated in larger trials with more clusters. The intervention did not have a specific component aimed at the antenatal period, though in retrospect it would be helpful to better prepare women for the introduction of new supportive care options. The use of the same clusters over a 54-week period means we cannot exclude the possibility that some women may have given birth twice during the study. We measured women’s experiences using a survey instrument in their language of choice; however, their responses may have been affected by social or courtesy biases.

Findings from this multicentered, stepped-wedge, cluster-randomized pilot trial suggest that the LCG strategy is a promising intervention that can improve quality of labor and childbirth care, reducing overuse of intrapartum interventions. This study provides important evidence on the debate around the introduction of the LCG into routine clinical practice internationally. Further evaluation in larger-scale, definitive trials are warranted.

Overview of study design

We designed and conducted a pragmatic, stepped-wedge, cluster-randomized pilot trial that was conducted between 1 July 2021 and 15 July 2022. We used an evidence-based, theory-informed approach to develop the intervention, and conducted the trial to determine whether it might have an effect on overuse of cesarean section or other important maternal and newborn outcomes. The trial was preceded by a 6-month formative phase, which was guided by the COM-B model of behavior change, which recognizes that individuals must have capability (C), physical and social opportunity (O) and motivation (M) to perform a behavior (B) 34 . We used co-design principles and primary data collection to develop and refine the ‘LCG strategy’ intervention, which included provider training and audit and feedback activities, and developed a theory of change (Supplementary Fig. 1 ). The intervention was then introduced in a stepwise manner in four public hospitals in the state of Karnataka, India, in accordance with a randomization schedule. Given the risk of cross contamination, individual randomization was not possible. We used a stepped-wedge approach as the LCG reflects the WHO’s current advice regarding standard of care 17 , and it was thus not ethically feasible to use a parallel-group design.

Trial approvals and oversight

This trial was designed and conducted in accordance with the ethical principles of the World Medical Association’s Declaration of Helsinki, the Ottawa Statement for the Ethical Design and Conduct of Cluster Randomized Trials, and Good Clinical Practice standards 35 , 36 , 37 . We developed the trial protocol and reported findings in accordance with Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidance for randomized trials, and the Consolidated Standards of Reporting Trials (CONSORT) statement for stepped-wedge cluster-randomized trials (CONSORT checklist in Supplementary File 1 ) 38 , 39 . The trial protocol was preregistered (CTRI/2021/01/030695), with the protocol and statistical analysis plan published before trial closure; there were no major deviations or changes 40 .

We sought permission from the head of study hospitals (gatekeepers) and individual providers before commencing the trial. The study protocol specified a waiver of individual consent for data collected on women giving birth; these data were nonidentifiable, routinely collected clinical variables in medical records and labor ward registries. Routine medical records in participating hospitals, from which study data were captured, use the variable ‘sex’. For study participants invited to complete a postpartum survey, an informed consent was conducted. The trial was approved by the Alfred Hospital Human Ethics Committee (737/20), and the institutional ethics committees of the KLE Academy of Higher Education and Research (D-281120003), JJM Medical College, Davanagere (IEC-136/2020), Vijayanagar Institute of Medical Sciences (SVN IEC/20/2020-2021) and the Gadag Institute of Medical Sciences (IEC/01/2020-21), as well as the State Ethics Committee, Department of Health and Family Welfare, Government of Karnataka (DD(MH)/71/2020-21) and the Health Ministry’s Screening Committee, Indian Council of Medical Research (2020-10127). An independent, three-member Data and Safety Monitoring Committee oversaw the trial.

Setting and participating healthcare providers

We purposively selected four public maternity hospitals in the state of Karnataka to participate. Eligibility criteria for these facilities were their capacity to provide comprehensive emergency obstetric care (including access to cesarean section), attending to more than 4,000 women giving birth each year, and having an overall cesarean section rate of 30% or more. In three hospitals, labor monitoring and partograph completion is primarily performed by postgraduate resident doctors, while in the remaining hospital it was performed by nurses. All hospitals had either completed or were undergoing accreditation under the Government of India’s national Labour Room Quality Initiative (‘LaQshya’), which is closely aligned with WHO intrapartum care recommendations 33 .

Each hospital was treated as a cluster. Two senior obstetricians working at each hospital were appointed as facility investigators and were responsible for trial activities at their hospital. The targets of the intervention were labor ward staff, including obstetricians, postgraduate doctors and nurses. These staff usually use a WHO simplified partograph to make decisions about labor interventions. We hypothesized that the intervention would promote correct LCG use by these providers, changing their labor monitoring and management practices to align with the WHO’s intrapartum recommendations. In turn, this could reduce overuse of cesarean section, improve maternal and newborn outcomes, and enhance women’s care experiences.

Inclusion and exclusion criteria

The eligibility criteria for women to be in the study population were those giving birth at ≥20 weeks’ gestation in participating hospitals, during the study period. Pregnant women who were admitted but did not give birth at these hospitals were not included, nor were women who gave birth at another facility or in the community and arrived at a study hospital postpartum. The period of interest for study data collection was the time of a woman’s admission for childbirth until the time of discharge, transfer, death or until 7 days after admission (whichever came first).

Randomization and blinding

Before trial commencement, the four clusters (hospitals) were randomly assigned to one of four sequences (H1, H2, H3 or H4; Fig. 1 ) using a computer-generated list of random numbers that was managed by the study statistician. The allocation sequence was concealed from the investigators and study teams and only revealed by the statistician 1 month before crossover to allow time for planning LCG strategy implementation activities. Once the hospital had commenced the intervention, blinding of hospital staff, research staff and individual women was not possible. The intervention was commenced in hospitals according to the randomly assigned sequence, with one hospital transitioning to intervention at 2-month intervals (that is, a step occurred every 2 months). A 2-week transition period was used to allow for the intervention to be fully adopted.

Control and intervention

The control condition for the trial was current labor monitoring and management practices (‘usual clinical care’). While the WHO simplified partograph is widely used in India, the formative phase showed that its use was inconsistent and oftentimes retrospective. Training seminars were conducted at all hospitals on using the WHO simplified partograph to standardize the control condition. The WHO intrapartum care recommendations were also disseminated at all hospitals at the start of the trial.

The LCG strategy intervention was applied at cluster (hospital) level, and thus might affect all women giving birth in participating hospitals. The intervention included a co-designed LCG training program for doctors and nurses working on labor wards, and a monthly audit and feedback process using hospital cesarean section data (Supplementary File 2 ). For training, we developed and ran 2-day workshops for all labor ward staff, coordinated by facility investigators who had undergone a ‘training of trainers’ workshop. These workshops were based on WHO recommendations and the LCG manual 17 , 22 and included practice clinical cases. After this, all providers working on labor wards underwent an 8-week ‘low-dose, high-frequency’ training program 41 , comprising clinical cases and bedside teaching using the LCG with senior clinical staff. The 8-week training was delivered in cycles to accommodate postgraduate resident rotations every 3 months. Refresher training was used if new staff arrived during the intervention period. All training activities encouraged providers to implement all aspects of the LCG, including offering or encouraging women on supportive care measures (labor companionship, pain relief options, oral intake, mobility, birth position of choice). At the time of randomization, all simplified WHO partographs in the labor ward were replaced with the LCG. Senior labor ward staff were encouraged to monitor and promote consistent, accurate LCG use through supportive supervision.

The intervention also included monthly audit and feedback meetings on cesarean rates using the Robson classification. Audit and feedback is widely used to promote evidence-based clinical practice, and is recommended by the WHO for avoiding unnecessary cesarean sections 26 , 42 . The WHO also recommends that countries use the Robson classification for assessing, monitoring and comparing their cesarean rates over time 9 . The Robson classification organizes all births in a facility into one of ten mutually exclusive, all-inclusive groups, on the basis of parity, previous cesarean, onset of labor, fetal presentation and lie, number of neonates and gestational age (term or preterm) 24 . Providers at randomized hospitals underwent a brief training based on the WHO implementation manual on how to interpret Robson classification data and how audit and feedback can help optimize cesarean section use. Robson classification tables were prepared using trial data and were shared directly with the study hospital on a monthly basis. These data were presented by senior clinical staff at monthly meetings, with structured discussions among the attendees on how to improve hospital performance. Hospitals and staff were instructed that all other aspects of clinical care during the trial should be in accordance with relevant local guidelines and protocols. In addition, facility leads were encouraged to identify and address anticipated barriers to the LCG strategy in their hospital. This included revision of hospital policies, standardization of clinical protocols, rearrangements to the physical labor ward environment and addressing some supply and equipment constraints. We used logbooks, tracking sheets and site visits to confirm that all eligible staff underwent LCG training activities, were using the LCG routinely and attended monthly cesarean audit meetings as planned.

Trained research staff collected nonidentifiable, individual-level data on all eligible women (that is, those giving birth from 20 weeks’ gestation onwards) and their babies. Data were collected from the time of admission for childbirth until the time of discharge, transfer, death or until 7 days after admission (whichever came first).

The primary trial outcome was the use of cesarean section among women in Robson Group 1. Robson Group 1 is comprised of women who were nulliparous, gave birth to a singleton, term pregnancy in cephalic presentation and were in spontaneous labor. It is a subset of the obstetric population (usually around 30%) and includes largely low-risk women. The WHO advises that cesarean rates at or below 10% are achievable for Robson Group 1, while maintaining good outcomes 24 . However, in some low- and middle-income countries, the cesarean rate in Robson Group 1 exceeds 20% to 25%, indicative of overuse 43 . We anticipated that effects of the LCG strategy would be most easily detected in Robson Group 1. Conversely, the LCG strategy is unlikely to reduce cesarean use in higher-risk women, such as those with multiple pregnancies (Group 8) or with an oblique lie (Group 9), for whom the cesarean section rate is necessarily high. We did not anticipate any effects on antepartum cesarean use, as these women do not experience labor and thus do not require an LCG or partograph.

Secondary outcomes included use of intrapartum interventions (cesarean section, augmentation, artificial rupture of membranes, episiotomy, operative vaginal birth), maternal, fetal and neonatal mortality and severe morbidity outcomes, hospital admission and use of advanced newborn care interventions. The denominator varied depending on the outcome of interest (see Supplementary Table 1 for outcome definitions). We also measured women’s experiences of care using a pretested, interviewer-administered survey, conducted in a local language (Kannada, Hindi or Marathi), which was completed by postnatal day 7 or discharge (whichever came first) in a sample of postpartum women. This sample comprised women in Robson Group 1 or 3 who gave birth in the last 15 days of each 2-month period, had a liveborn baby, were 18 years or older and provided informed consent. In each hospital, trained interviewers approached and invited all eligible women to complete the survey.

All data were collected into predesigned study forms and managed using REDCap electronic data capture via tablets. Each hospital team had access to their own hospital data only, and facility investigators were responsible for checking completeness and accuracy of all collected data. To minimize errors, data validation processes were implemented in the data collection system. Statistical methods and data cleaning algorithms were utilized to identify potential errors and outliers for further investigation and correction. Regular data and trial progress review meetings and audits were conducted to identify and rectify any inconsistencies or outliers. Data monitors periodically visit the study sites to verify the accuracy and completeness of the collected data. They also provided training and guidance to study personnel, addressing any issues or concerns that might arise during the study. The trial concluded when 15 July 2022 was reached, as planned.

Sample size

At the time of writing the trial protocol, no previous trial using the LCG had been conducted, meaning the effect size of our strategy was difficult to estimate. For the year 2020 (before the trial), these four hospitals collectively averaged 24,000 births per year, and their overall cesarean rate was 44%. The cesarean rate in women in Robson Group 1 (that is, the primary outcome) for all four hospitals was at least 40%. The trial was designed to provide 92% power to detect a 25% reduction in the Robson Group 1 cesarean rate from 40% to 30%, assuming an ICC equal to 0.02, a cluster auto correlation equal to 0.90 and an average of 300 women per cluster per time period with a coefficient of variation of cluster size equal to 0.60 (ref. 44 ).

Statistical methods and analysis

Analyses were performed according to the intention-to-treat principle (according to planned exposure). Maternal baseline characteristics were summarized by trial arm as means and standard deviations or numbers and percentages, as appropriate. For the primary and secondary outcomes, a GEE to estimate the effect of the intervention with respect to the population average was used. A bias correction method and degree of freedom approximation due to the small number of clusters was applied in the GEE models to maintain the validity of the estimations. A Manck and DeRouen correction method with N-2 degrees of freedom was selected due to being the most conservative option 45 . An exchangeable correlation structure was assumed and the modified Poisson distribution with a log link function was considered. The model was constructed considering two variables: a binary indicator for treatment—indicating whether the observation was made during the control or the intervention period—and a categorical variable indicating the time period. The RR and the 95% CI were reported as the size effect. For the secondary outcomes, in which duration was measured in days, the effect size was calculated as the difference between the mean of days in the intervention group and the mean of days in the control group. The ICC was estimated under the control period using the GEE model. As no adjustment for multiplicity testing of secondary outcomes was considered, their results are reported as point estimates with 95% CIs and P values.

Ethics and inclusion statement

Our study team support the principles of the Cape Town Statement, in particular the commitment to equitable international collaborations. The study was designed in partnership between three research groups (India, Argentina, Australia), building on multiple years of research collaborations and coauthored publications between several coauthors. This study was funded by a Global Grand Challenges grant—the submission was jointly prepared by J.P.V., S.G., Y.P., S.S.V., V.P., F.A. and L.G. This grant funding went to all three of our research organizations, with the largest amount of this funding received by the JNMC-India research team. The study protocol had 14 named investigators—12 from India, one from Argentina and one from Australia. J.P.V. and S.G. were named as co-Principal Investigators. During the study, decisions were taken by consensus among the steering group during fortnightly teleconferences. The authorship group (29 individuals) comprised 17 women and 12 men, and included late-, mid- and early-career individuals. Members of the authorship group include researchers in India (Y.P., S.S.V., M.S., S.B., J.A.K., S.B.P., A.K., R.R.A., P.M.R., S.S., L.B., M.H.M., S.S.G., S.C., B.R.), Argentina (V.P., F.A., L.G., M.B., A.C., R.R.) and Australia (J.P.V., E.A., C.S.E.H.). The lead author (J.P.V.) is in Australia and the senior author (S.G.) is in India. Our Technical Advisory Group (T.L., P.K., G.J.H., R.D.) included senior researchers from India, the United Kingdom, South Africa and the United States, and our Data and Safety Monitoring Committee included individuals from India, Switzerland and the United States.

Reporting summary

Further information on the research design is available in the Nature Portfolio Reporting Summary linked to this article.

Data availability

In keeping with the Bill & Melinda Gates Foundation Open Access Policy, the de-identified individual-level data and the data dictionary are hosted publicly at the Gates Open Research-approved repository Zenodo. They can be accessed under https://doi.org/10.5281/zenodo.8140454 . No restrictions on the availability of the data have been set.

Code availability

R code used for data analysis along with detailed instructions on its usage is publicly available at https://doi.org/10.5281/zenodo.8140454 . No restrictions on the availability of the code have been set.

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Acknowledgements

We gratefully acknowledge A. P. Betran (Chair), D. Wallace and S. Mundle for their role as Data and Safety Monitoring Board members, and O. T. Oladapo and M. Bonet for their role as observers to the study. We also acknowledge K. Hemming for statistical advice. This study was financially supported by a Global Grand Challenges grant from the Bill & Melinda Gates Foundation (grant no. INV-023273). We also received funding from the Burnet Institute—the Alistair Lucas Award and a FREDA (Funding Research Enhancing Data to Accelerate) grant. J.P.V. is supported by Australian National Health and Medical Research Council (NHMRC) Emerging Leadership Investigator Grant (GNT1194248), C.S.E.H. is supported by an Australian NHMRC Leadership Investigator Grant (GNT2016379) and E.A. is supported by an Australian NHMRC Postgraduate Scholarship (GNT2013981).

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Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia

Joshua P. Vogel, Elizabeth Armari & Caroline S. E. Homer

Women’s and Children’s Health Research Unit, Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research, Belgaum, India

Yeshita Pujar, Sunil S. Vernekar, Manjunath Somannavar, Savitri Bendigeri & Shivaprasad Goudar

Instituto de Efectividad Clínica y Sanitaria (IECS-CONICET), Buenos Aires, Argentina

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The analysis results were prepared by L.G. (trial statistician), which were presented and discussed at multiple meetings attended by named authors. The first draft of the paper was written by J.P.V., with multiple rounds of revisions from E.A., V.P., F.A., L.G., M.B., M.S., A.C., R.R., S.B., J.A.K., S.B.P., A.K., R.R.A., P.M.R., S.S., L.B., M.H.M., S.S.G., S.C., B.R., C.S.E.H., T.L., P.K., G.J.H., R.D. and S.G. All named authors reviewed and commented on the paper before submission for publication.

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Correspondence to Joshua P. Vogel .

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Competing interests.

J.P.V., Y.P., V.P., F.A., C.S.E.H., T.L. and G.J.H. participated in technical consultations coordinated by the World Health Organization, within which the Labour Care Guide was developed. J.P.V., Y.P., V.P., F.A., C.S.E.H. and T.L. have participated in primary research that contributed to development of the Labour Care Guide, which was financially supported by the World Health Organization. The other authors declare no competing interests.

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Supplementary Files 1 and 2, Tables 1–4 and Fig. 1.

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Vogel, J.P., Pujar, Y., Vernekar, S.S. et al. Effects of the WHO Labour Care Guide on cesarean section in India: a pragmatic, stepped-wedge, cluster-randomized pilot trial. Nat Med 30 , 463–469 (2024). https://doi.org/10.1038/s41591-023-02751-4

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Received : 16 July 2023

Accepted : 02 December 2023

Published : 30 January 2024

Issue Date : February 2024

DOI : https://doi.org/10.1038/s41591-023-02751-4

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