Undisturbed Labour and Birth Index

The Undisturbed Labour and Birth (ULaB) index is a facility level quality measure comprised of indicators that either support or detract from the physiology of labour and birth; birth that begins, progresses and concludes spontaneously. Following an environmental scan for evidence-based indicators, we convened a multi-disciplinary Delphi panel of experts to develop this index. This process illuminated 18 domains across environmental, experiential, and structural conditions that are crucial to supporting physiologic labour and birth. These domains were operationalized into a set of measurable indicators within a composite index, including a weighted scoring system. This index is intended to aid facilities to identify focused quality improvement initiatives and provision of cost-effective services. The ULaB provides facilities and their employees a road map to measure and demonstrate success.

The ULaB Index is a tool that can aid facilities in lowering intervention rates and costs, while increasing quality and safety for all. The domains that the index measure are informed by current evidence-based practices endorsed by the World Health Organization (WHO), Society of Obstetricians and Gynaecologists of Canada (SOGC), American College of Obstetricians and Gynaecologists (ACOG), the American College of Nurse Midwives (ACNM), the National Association of Certified Nurse Midwives (NACPM), The Royal College of Midwives, the National Institute for Health and Care Excellence (NICE), the Canadian Association of Perinatal and Women’s Health Nurses (CAPWHN), the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN), and the International Childbirth Initiative of the International Federation of Gynecology and Obstetrics (ICI-FIGO).

  1. Supportive physical environment1,2
  2. Respectful Maternity Care and Freedom from Mistreatment1–7
  3. Culturally Safe Care2,3,6,8,9
  4. Access to Midwifery Care1,3,4,6–8,10–13
  5. Integration of Care Across Birth Settings1,4,8,9,12,13
  6. Admission to Hospital in Active Labour4,6–10,14
  7. Informed Choice and Person-Centred Decision Making1,3–11,13,14
  8. Continuous Emotional Support2,4–10,15
  9. Non-pharmacological Pain Management1–4,6–13,15
  10. Induction and Augmentation of Labour2,3,6–9,11,15
  11. Freedom to Eat and Drink During Labour1–4,6
  12. Freedom of Movement and Choice of Birth Position1–4,6,7,10–13,15
  13. Fetal Monitoring3,4,6,9–11,15
  14. Self-directed/spontaneous Pushing During Second Stage of Labour1,3,4,6,7,10,11,15
  15. Cord Clamping3–5
  16. Immediate Postpartum Togetherness2,6–8,10
  17. Undisturbed Birth Rate
  18. Breastfeeding Support3–5,11


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  2.     International Federation of Gynecology and Obstetrics, International Confederation of Midwives, White Ribbon Alliance, International Pediatric Association, World Health Organization. Mother-baby friendly birthing facilities. Int J Gynaecol Obstet. 2015;128(2):95-99. doi:10.1016/j.ijgo.2014.10.013
  3.     Supporting Healthy and Normal Physiologic Childbirth : A Consensus Statement by ACNM, MANA, and NACPM. J Perinat Educ. 2013;22(1):14-18. doi:10.1111/j.1542-2011
  4.     National Institute for Health and Clinical Excellence. Intrapartum Care for Healthy Women and Babies.; 2014. https://www.nice.org.uk/guidance/cg55.
  5.     World Health Organization. Standards for Improving Quality of Maternal and Newborn Care in Health Facilities.; 2016. doi:978 92 4 151121 6
  6.     World Health Organization. Intrapartum Care for a Positive Childbirth Experience.; 2018. http://apps.who.int/iris/bitstream/10665/260178/1/9789241550215-eng.pdf?ua=1%0Ahttp://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/.
  7.     Clinical Practice Guideline on Care in Normal Childbirth. Quality Plan for the Spanish National Healthcare System of the Spanish Ministry for Health and Social Policy.; 2011. http//publicaciones.administraciones.es.
  8.     Avery MD, Bell AD, Bingham D, et al. Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing.; 2018.
  9.     Smith H, Peterson N, Lagrew D, Main E. Toolkit to Support Vaginal Birth and Reduce Primary Cesareans Birth and Reduce Primary Cesareans.; 2016. https://www.cmqcc.org/resources-tool-kits/toolkits.
  10.   Adams ED, Stark MA, Low LK. A Nurse’s Guide to Supporting Physiologic Birth. Nurs Womens Health. 2016;20(1):76-86. doi:10.1016/j.nwh.2015.12.009
  11.   Halpern S. SOGC Joint Policy Statement on Normal Childbirth. J Obstet Gynaecol Canada. 2009;31(7):602. doi:10.1016/S1701-2163(16)34236-0
  12.   Dodwell M, Newburn M. Normal Birth as a Measure of the Quality of Care: Evidence on Safety, Effectiveness and Women’s Experiences.; 2010. www.nct.org.uk.
  13.   Beech BL. Making Normal Birth a Reality. AIMS J. 2008;20(4):9.
  14.   The Bree Collaborative. Obstetrics Care Topic.; 2012.
  15.   American College of Obstetricians and Gynecologists. Approaches to Limit Intervention During Labor and Birth. Committee Opinion No. 687. Obstet Gynecol. 2017;129(2):403-404. doi:10.1097/AOG.0000000000001904