• Fetal assessment tests upon admission: FHR tracing FHR tracing for 20 min upon admission for 20min. followed by auscultation is not associated with any benefits compared to intermittent auscultation, including similar neonatal morbidity and mortality., AFI Obtaining an AFI in early labor is associated with an higher incidence of CD, and similar neonatal outcomes, compared to no AFI. Neither a 2x1 pocket (abnormal in 8%) nor a AFI (abnormal in 25%) upon admission for labor identifies a pregnancy at risk for adverse outcome such as NRFHT or CD for NRFHT. Other tests There is insufficient evidence (no RCTs) to support the use of vibroacustic stimulation, or Doppler ultrasound as fetal admission tests. • Enemas There is not enough evidence to recommend the routine use of enemas during the first stage of labor. Compared to not receiving enemas, receiving enemas in the first stage of labor is associated with no significant differences for infection rates in women (2 RCTs; 594 women; RR 0.66, 95% CI 0.42 to 1.04) or newborn children (1 RCT; 370 newborns; RR 1.12, 95% CI 0.76 to 1.67) after one month of follow up. No significant differences were found in the incidence of lower or upper respiratory tract infections. Length of labor and other maternal and neonatal outcomes are not different overall. The RCTs were not blinded. This intervention (enema) generates discomfort in women and increases the costs of delivery. As they do not have a significant effect on infection rates such as perineal wound infection or other neonatal infections and women's satisfaction, the routine use of enemas during labor should be discouraged. • Perineal shaving Routine perineal shaving for women prior or at the beginning of labor is not associated with benefits. Maternal febrile morbidity (OR 1.16, 95% CI 0.70 to 1.90), perineal wound infection (OR 1.52, 95% CI 0.79 to 2.90) and perineal wound dehiscence (OR 0.13, 95% CI 0.00 to 6.70) are similar compared to just selective clipping of hair or no shaving. The potential for complications (redness, multiple superficial scratches and burning and itching of the vulva, embarrassment and discomfort afterwards when the hair grows back) suggests that shaving should not be part of routine clinical practice. • Chlorhexidine Compared to placebo sterile water irrigation, vaginal chlorhexidine irrigation during labor is associated with similar incidences of maternal and neonatal infections, including similar chorioamnionitis, postpartum endometritis, neonatal sepsis and perinatal mortality. The effectiveness of vaginal chlorhexidine might depend on the concentration and volume of the solution used. Chlorhexidine solution is safe, not expensive and vaginal irrigation is easy to perform, but apparently not beneficial. • GBS prophylaxis Universal prenatal maternal screening with ano-vaginal specimen at 35-37weeks and intrapartum (penicillin first line) antibiotic treatment is the most efficacious of the current strategies for prevention of early-onset GBS disease. It is >50% more effective than a risk-factor based strategy. There is no prevention of late-onset GBS sepsis. Women with GBS bacteriuria in the current pregnancy or who had a prior infant with GBS sepsis are candidates for intrapartum antibiotics prophylaxis, and should be the only two groups not screened. Intrapartum treatment for chorioamnionitis is recommended regardless of GBS maternal status. Vaginal disinfection with chlorhexidine in labour for preventing early-onset GBS sepsis is not associated with significant benefits for the neonate. See GBS guideline for details. • Continuous support in labor (eg doula) Definition: For support, it is generally intended emotional support (continuous presence, reassurance, and praise), information about labor progress and advice regarding coping techniques, comfort measures (comforting touch, massage, warm baths/showers, promoting adequate fluid intake and output), and advocacy (helping the woman articulate her wishes to others). Mechanism of action: Anxiety during labor is associated with high levels of the stress hormone epinephrine in the blood, which may in turn lead to abnormal fetal heart rate patterns in labor, decreased uterine contractility, a longer active labor phase with regular well-established contractions, and low Apgar scores. One example of possible mechanisms of action for support to reduce complications of labor and delivery is decreased anxiety. This in turn can lead to a beneficial ‘chain-reaction’: for example, if continuous support leads to reduced use of epidural analgesia, then several complications associated with regional anesthesia (see anesthesia guideline) can be prevented. Types of support: family member or friend (not part of hospital staff), or hospital-based (part of hospital staff). Doula (a Greek word for 'handmaiden') is a support person with the sole job of providing support to the laboring woman. They are usually not part of the hospital staff. This member of the caregiver team may also be called a labor companion, birth companion, labor support specialist, labor assistant, or birth assistant. Effectiveness: All women should have support throughout labor and birth. Women who have continuous intrapartum support are more likely to have a slightly shorter labour, a spontaneous vaginal birth and less likely to have intrapartum analgesia or to report dissatisfaction with their childbirth experiences. Continuous support is not associated with significant changes in incidences of artificial oxytocin during labor; low 5-minute Apgar scores; admission of the newborn to a special care nursery; postpartum reports of severe labor pain or a significant change in labor length. In general, continuous intrapartum support was associated with greater benefits when the provider was not a member of the hospital staff, when it began early in labour and in settings in which epidural analgesia was not routinely available. It may be possible to increase access to one-to-one continuous labor support worldwide by encouraging women to invite a family member or friend to commit to being present at the birth and assuming this role. The mother selects her doula during pregnancy; they establish a relationship (which is likely to involve the woman's partner, if any) and discuss the mother's and partner's preferences and concerns before labor. The doula brings her experience and training (often to the level of certification) to the labor support role during childbirth, and the mother and doula frequently have telephone and/or face-to-face contact in the early postpartum period. Other models of support, for which there are little or no data, include support by a female family member and support by the husband/partner. • Nutrition in labor There is insufficient evidence for providing nutritional recommendations for women in labor. There are no trials evaluating solid foods. Ice chips to moisten the mouth and sips of clear liquids are the only oral intake recommended by USA authorities. Some experts and common usage in many other countries allow also sport drinks, yogurt or sherbet. In the Netherlands women in labor are allowed to eat and drink. The reason for avoiding solid food is risk of aspiration, which is rare. When there is increased gastric volume, there is increased risk of vomiting and therefore aspiration. Airway precautions in labor and delivery are paramount to avoid aspiration. A carbohydrate (mean intake 44g in 350ml) drink in early labor is associated with an increased risk of CD compared to placebo in women allowed to drink ‘at-will’, but a carbohydrate (25g) drink in late (8-10cm) labor is associated with similar rates of CD compared to placebo. Umbilical cord studies revealed lactate transport to the fetal circulation with potential (but not observed) fetal acidemia., Maternal glucose administration in labor has been associated in some studies, but not others, with increased neonatal lactic acidosis. There is no good evidence to support the routine administration of acid prophylaxis drugs in normal labour to prevent gastric aspiration and its consequences. There is limited evidence that vomiting may be reduced by antacids (RR 0.46, 95% CI 0.27-0.77, n = 578, one trial) or by dopamine antagonists given alongside pethidine (RR 0.40, 95% CI 0.23-0.68, n = 584, one trial). Comparisons between different drugs showed no significant differences, though the number of participants was small. There was no evidence that H2 receptor antagonists improved outcomes compared with antacids, though only one trial addressed this issue. There are no RCTs on proton-pump inhibitors. • IV fluids, and infusion rate There are no trials comparing the use of IV fluids to no IV fluids in labor. The data on IV fluids type and infusion rate is insufficient for a strong recommendation. Compared to 125ml/hr, an infusion rate of intravenous fluids (lactated ringers or normal saline) of 250ml/hr in early labor (2-5cm) of term nulliparous women with vertex presentation is associated with less labors lasting >12 hours. Other outcomes (length of labor for vaginal deliveries, use of oxytocin, successful vaginal delivery) are not significant, but trended for benefit of 250ml/hr, for example in a 71 minutes shorter labor, in particular first stage. While the data in pregnancy is limited to one trial, the benefits are supported by the fact that several trials in non-pregnant adults demonstrate that increased fluid intake improves exercise performance. In one RCT, IV destrose shortned the duration of active labor compared to normal saline in nulliparous women who delivered vaginally. In one small RCT, IV fluids (at 120cc/hr) containing 5% glucose were associated with reduced umbilical cord acidemia and hypercarbia compared to a lactated ringers solution. • Maternal position There is evidence that upright position in the first stage of labor reduces the length of labor and is not associated with increased intervention or negative effects on mothers' and babies' wellbeing. The first stage of labor is approximately 1 hour shorter for women randomised to upright as opposed to recumbent positions. Women randomised to upright positions are less likely to have epidural analgesia (RR 0.83 95% CI 0.72-0.96). There are no differences between groups for other outcomes including length of the second stage of labor, mode of delivery, or other outcomes related to the wellbeing of mothers and babies. For women who have epidural analgesia there are no differences between those randomised to upright versus recumbent positions for any of the outcomes examined . Little information on maternal satisfaction was collected, and none of the studies compared different upright or recumbent positions. It's important that women take up a comfortable upright position in the first stage of labor. • Ambulation Compared to remaining in bed, walking in labor is associated with similar length of first stage of labor, use of oxytocin, use of analgesia, need for forceps vaginal delivery, or cesarean delivery, and also similar neonatal outcomes in women at term with cephalic presentation starting at 3-5cm of dilatation or in other groups of women.,,,, Since walking does not seem to have a beneficial or detrimental effect on labor and delivery, women can choose freely to ambulate or not during labor, whichever is more comfortable for them. • Immersion in water In the first stage of labor, water immersion is associated with a significant reduction in the epidural/spinal analgesia rate compared to controls (478/1254 vs 529/1245; OR 0.82, 95% CI 0.70-0.98, six trials). There was no difference in assisted vaginal deliveries (OR 0.84, 95% CI 0.66-1.06, seven trials), cesarean sections (OR 1.23, 95% CI 0.86-1.75, eight trials), perineal trauma or maternal infection. There are no differences for Apgar score less than seven at five minutes, neonatal unit admissions, or neonatal infection rate. There is limited information for other outcomes related to water use during the first and second stages of labor, due to intervention and outcome variability. One trial explores birth (second stage) in water, but is too small to determine significant differences in outcomes for women or neonates. Water aspiration by the neonate has been reported for waterbirths. Blinding is not possible in these waterbirth studies. The effects of immersion in water during pregnancy (no trials), or in the third stage (no trials) are also unclear. • Aromatherapy There is insufficient evidence to make any recommendation ragrding aromatherapy in labor. One pilot RCT did not show any significant benefit or harm from this intervention. • Early artificial rupture of membranes (AROM) (aka amniotomy) There is no clear statistically significant difference between early amniotomy in length of the first stage of labor (mean difference -20 minutes), cesarean section (RR 1.26, 95% CI 0.98-1.62), maternal satisfaction with childbirth experience, or low Apgar score < 7 at 5 minutes (RR 0.55, 95% CI 0.29-1.05). There is no consistency between RCTs regarding the timing of amniotomy during labor in terms of cervical dilatation. So routine early amniotomy is associated with both benefits and risks. The 20min. reduction in labor is offset by the trend toward a 26% increase in the risk of CD. An association between early amniotomy and cesarean delivery for NRFHT is noted in one large trial. Indicators of neonatal status such as arterial cord pH, NICU admissions do not differ. There is no evidence of an effect of a policy of amniotomy on the mother's satisfaction with labor. This evidence suggests that routine early amniotomy should not be routinely used in women in normal labor, and possibly be considered only for women with slow labor progress. • Stripping in labor There are no trials to evaluate stripping during spontaneous labor. • Use of partogram The general intervention with the partogram is early use of oxytocin as soon as the cervical dilatation falls to the right of the partogram (action line) on the every 2 to 4 hour exams. The use of the partogram as part of standard labor management and care is not supported by the evidence. This is because there is no evidence of any difference between partogram and no partogram in cesarean section (RR 0.64, 95% CI 0.24-1.70); instrumental vaginal delivery (RR 1.00, 95% CI 0.85-1.17) or Apgar score < 7 at 5 minutes (RR 0.77, 95% CI 0.29-2.06) between the groups in 2 RCTs. Therefore studies that compare use of different action lines are of limited clinical validity. When compared to a 4-hour action line, women in the 2-hour action line group were more likely to require oxytocin augmentation (RR 1.14, 95% CI 1.05-1.22). When the 3- and 4-hour action line were compared, cesarean section rate was lowest in the 4-hour action line group and this difference was statistically significant (RR 1.70, 95% CI 1.07-2.70, n = 613, one trial).,, Patience seems to pay in obstetrics (etimology: 'ob', and 'stare', meaning 'stand by') • Frequency of cervical exams There are no trials to evaluate the frequency of cervical exams in labor per se. Most studies, including those with active management, perform cervical exams every 2 hours in labor. The risk of chorioamnionitis though increases with increasing number of exams. • Timing and dosing of oxytocin There are no trials to evaluate the timing and dosing of oxytocin in labor per se. When analysis of labor management RCTs is focused on early intervention with both amniotomy and oxytocin, these two interventions together are associated with a non-significant modest reduction in the risk of cesarean section (RR 0.89; 95% CI 0.79-1.01). In Prevention trials, early oxytocin augmentation was associated with a modest reduction in the number of cesarean births (RR 0.88; 95% CI 0.77 to 0.99). A policy of early amniotomy and early oxytocin was associated with a shortened duration of labour (mean difference - 1.11 hour). Sensitivity analyses excluding three trials with a full package of Active Management did not substantially affect the point estimate of the effect (RR 0.87; 95% CI 0.73-1.04). No other significant effects were for the other indicators of maternal or neonatal morbidity. • Active management of labor Active management of labor was originally devised to prevent prolonged labor.[O'Driscoll K, jackson RJA, gallagher JT. prevention of prolonged labor.BMJ1969;2:47780.[prospective observational study, n=1,000] Its components have varied somewhat in the literature, but generally include antenatal classes, admission not before PROM or 2cm dilatation and full effacement (active labor), early amniotomy, support by doula, use of partogram, vaginal exams every 2 hours, with oxytocin started for rate of progress off the partogram or <1cm/hr. Oxytocin rate is stated at 4-6mu/min, increased by 4-6mu every 15min to reach contractions every 2-3minutes (but not more than 7/15min) or 40mu/min. Early amniotomy, and early use of high dose oxytocin are the two most characteristic interventions of active management of labor. More women in the active management group have labors lasting less than 12 hours in the RCTs evaluating active management of labor, but there is wide variation in length of labor within and between trials. The cesarean delivery rate is slightly lower in the active management group compared to the group that received routine care, but this difference does not reach statistical significance (RR 0.88, 95% CI 0.77 to 1.01). There were no differences between groups in use of analgesia, rates of assisted vaginal deliveries or maternal or neonatal complications. Only one trial examined maternal satisfaction; the majority of women (over 75%) in both groups were very satisfied with care.,,, The shorter labor may be due to the early amniotomy (see Early amniotomy above). The similar incidence of CD may be due to the fact that some aspects of active management, ie support by doula, decrease CD rate, but some others (ie early amniotomy) increase it. It is recommended that the individual interventions which are part of active management of labor be studied separately, and only those which are beneficial (eg continuous support by doula) implemented. • Continuous vs intermittent monitoring, amnioinfusion for variables, scalp sampling, etc. See Intrapartum FHR guideline. • Bladder catheterization There are no trials to evaluate the necessity, timing and frequency of bladder catheterization in labor. • Epidural or other anesthesia See Anesthesia guideline. • Criteria for diagnosis of dystocia/failure to progress in first stage/ use of intrauterine pressure catheter (IUPC) Abnormal progression of labor, including terms such as dystocia, dysfunctional labor, failure to progress, cephalopelvic disproportion and others, is the most common problem in labor, and the reason for the majority of CDs. Risk factors for dystocia include, among others: obesity, induction, Bishop <5 at start of labor, station higher than -2, persistent occiput posterior, macrosomia, epidural anesthesia, etc. While these variables are predictive of a higher chance for operative/cesarean delivery, no intervention has been tested by a trial. IUPC can measure more objectively than external tocomonitor the intensity of uterine contractions. It necessitate rupture of membranes (ROM). Intensity is usually calculated by Montevideo units, ie sum of peak pressures above baseline of all contractions in 10 minutes. In term women in spontaneous active labor not on oxytocin and with no epidural, the 5th percentile rates of dilatation for nulliparous and parous women are 1.2cm/hr and 1.5cm/hr., In term women in labor necessitating oxytocin and with epidural, the 5th percentile rate for dilatation is about 0.5cm/hr for both nulliparous and parous women. Dystocia cannot be diagnosed unless ROM has occurred, and adequate oxytocin to achieve at least 3-5 adequate contractions per hour has been instituted. The majority (>60%) of women who experience 2 hours of labor arrest despite a sustained uterine contraction pattern of at least 200 Montevideo units in the first stage of labor will achieve a vaginal delivery if oxytocin is continued. Before performing a CD for active phase labor arrest, labor should be arrested for a minimum of 4 hours (if uterine activity is greater than 200 Montevideo units) or 6 hours (if greater than 200 Montevideo units could not be sustained). There was a significant higher risk of shoulder dystocia among parturient who had arrest for 4 hours or more. These management suggestions are not based on a RCT. VBAC and diabetics were not included in this study. There are no trials to evaluate use of IUPC in labor per se. In women at term with singleton gestations and requiring oxytocin by obstetrician because of ‘dystocia’ at 4-6cm, meperidine 100mg IV does not affect operative delivery rates and worsens neonatal outcomes compared to placebo.
