Accouchement normal: accompagnement de la physiologie et interventions médicales. Recommandations de la Haute Autorité de Santé (HAS) avec la collaboration du Collège National des Gynécologues Obstétriciens Français (CNGOF) et du Collège National des Sages-Femmes de France (CNSF) – Quand et comment intervenir médicalement au cours du travail?

OBJECTIVE The aim of this chapter is to provide recommendations for good practice regarding drug and technical interventions that may be considered during normal delivery. METHODS These recommendations were established by an expert consensus based on an analysis of the scientific literature and the French and international recommendations available on the subject. RESULTS Interventions during latent phase of the first stage of labor (up to 5-6 cm) must be performed according to the fetal and maternal contraction tolerance (consensus agreement). In the active phase (from 5 - 6 cm to full dilatation), dilation speed under 1 cm / 4h between 5 and 7 cm or under 1 cm / 2h beyond 7 cm is considered abnormal, it is then recommended to propose: an amniotomy if the membranes are intact and administration of oxytocin if membranes are already ruptured and uterine contractions are considered insufficient (consensus agreement). Intravenous (IV) antibiotic prophylaxis (at least four hours before birth) is recommended during labor in women at risk for group B streptococcal (GBS) maternofetal infection (GBS vaginal portage or GBS bacteriuria during pregnancy or history of maternofetal GBS infection) (grade B). In case of rupture of membranes after 37 weeks of gestation without spontaneous labor, it is recommended: if the patient has GBS, to begin antibiotic prophylaxis immediately (consensus agreement); if delivery did not occur after 12 hours, to start antibiotic prophylaxis (grade A), to set up dedicated patient monitoring (consensus agreement), to screen for an infection (at least a full blood count, a vaginal sample and a dipstick test) (consensus agreement). It is recommended not to start expulsive efforts as soon as a complete dilation is identified but to let the fetal presentation go down (grade A). The administration of oxytocin is recommended if the patient does not feel inclined to push and the presentation has not reached low-pelvic station after two hours of complete dilation in case of insufficient uterine activity (AE). There is no argument for recommending a push technique over another (grade B). It is recommended to inform the gynecologist-obstetrician in case of non-progression of the fetus after two hours of complete dilation with sufficient uterine activity (AE). Prophylactic administration of oxytocin at 5 or 10 IU is recommended to prevent postpartum hemorrhage after vaginal delivery (grade A). Administration could be performed intravenously (slow injection over about a minute) or intramuscularly (AE). In case of placental retention, manual removal of the placenta is recommended (grade A). In absence of bleeding, it must be performed after 30 minutes after birth, without exceeding 60 minutes (AE). CONCLUSION These recommendations define indications and methods for drug and technical interventions during a normal delivery to prevent poor obstetrical outcomes.