• Education and classes regarding natural childbirth are not associated with significant effects on incidence of epidural anesthesia, improvement in birth experience, or less stress.
• If non-vertex presentation detected, cesarean delivery is recommended (see Malpresentation guideline)
• Induction advised at ≥41 week (see Postterm guideline)
• Self-diagnosis of active labor
There is not enough evidence to evaluate the use of a specific set of criteria for self-diagnosis of active labor. A specific antenatal education program is associated with a reduction in the mean number of visits to the labor suite before the onset of labor. It is unclear whether this results in fewer women being sent home because they are not in labor.
• Pelvimetry
There is not enough evidence to support the use of x-ray pelvimetry in women whose fetuses have a cephalic or non-cephalic presentation. Women undergoing x-ray pelvimetry are more likely to be delivered by caesarean section. No significant impact is detected on perinatal outcome, but numbers are small, insufficient for meaningful evaluation (eg. perinatal mortality 1 vs 2%). The results are similar for women with or without a prior CD.
Site of Labor and delivery
• Home vs hospital
There is insufficient evidence to favor either planned hospital birth or planned home birth for low risk pregnant women. There are no randomized controlled trials (RCTs) comparing home to any other kind of place (eg hospital, or 'birth center'). Intrapartum perinatal mortality has been reported to be higher (about 3/1,000) for home births in large retrospective studies There are diverging opinions even in western countries, with about 30% of Dutch births occurring at home, versus <1% of USA births. The rate of perinatal deaths in the Netherlands is the 2nd highest in Europe Women with risk factors for abnormal outcome should deliver in a hospital setting. A home birth service ought to be backed up by a modern hospital system. All women should be aware of possible maternal and fetal risks, including severe morbidity and mortality, associated with labor and delivery even in low-risk women, and should be aware of the absence of intensive care and operative capabilities in the home setting. Inference from results of randomized trials of ‘home-like’ vs conventional ward setting (see below) should warn against home birth.
• ‘Home-like’ (birth center) vs hospital
When compared to conventional institutional settings, home-like settings for childbirth are associated with modest benefits, including reduced medical interventions and increased maternal satisfaction, at the expense of increased perinatal mortality, and therefore ‘home-like’ settings for birth cannot be recommended. About 50% of women allocated to home-like settings are transferred to standard care before or during labor. Home-like setting significantly increase the likelihood of: no intrapartum analgesia/anesthesia, spontaneous vaginal birth, vaginal/perineal tears, preference for the same setting the next time, satisfaction with intrapartum care, and breastfeeding initiation and continuation to six to eight weeks. Allocation to a home-like setting decreased the likelihood of episiotomy. There was a strong trend towards a 87% higher perinatal mortality in the home-like setting. The 1% increase in SVD may be secondary to less epidural anesthesia, which may in turn be secondary to lack of availability in home-like settings, and/or to less intra-partum monitoring. The increase in perinatal mortality may be secondary to lack of appropriate interventions in home-like settings, less communication or monitoring. No firm conclusions could be drawn regarding the effects of staffing or organizational models, which can certainly influence the outcome above (eg midwives vs doctors, continuity of care, etc).
• Midwifery care vs physicians
Women who had midwife-led models of care are less likely to experience antenatal hospitalization (RR 0.90, 95% CI 0.81-0.99), regional analgesia (RR 0.81, 95% CI 0.73-0.91), episiotomy (RR 0.82, 95% CI 0.77-0.88), and instrumental delivery (RR 0.86, 95% CI 0.78-0.96), and are more likely to experience no intrapartum analgesia/anesthesia (RR 1.16, 95% CI 1.05-1.29), spontaneous vaginal birth (RR 1.04, 95% CI 1.02-1.06), feeling in control during childbirth (RR 1.74, 95% CI 1.32-2.30), attendance at birth by a known midwife (RR 7.84, 95% CI 4.15-14.81) and initiate breastfeeding (RR 1.35, 95% CI 1.03-1.76), although there were no statistically significant differences between groups for cesarean births (RR 0.96, 95% CI 0.87-1.06). Women who were randomized to receive midwife-led care were less likely to experience fetal loss before 24 weeks (RR 0.79, 95% CI 0.65-0.97), although there were no statistically significant differences in fetal loss/neonatal death of at least 24 weeks (RR 1.01, 95% CI 0.67-1.53) or in fetal/neonatal death overall (RR 0.83, 95% CI 0.70-1.00). In addition, their babies were more likely to have a shorter length of hospital stay (mean difference -2.00, 95% CI -2.15 to -1.85).
• Teamwork training with crew resource management has not been shown to affect adverse outcomes in L&D in the only RCT published so far.
• Traditional birth assistants (TBA)
In developing countries, care by TBA is associated with significantly lower rates of fetal deaths (adjusted OR 0.69, 95% CI 0.57 to 0.83), perinatal deaths (adjusted OR 0.70, 95% CI 0.59 to 0.83) and neonatal deaths (adjusted OR 0.71, 95% CI 0.61 to 0.82). Maternal death rate was lower but not significant (adjusted OR 0.74, 95% CI 0.45 to 1.22) while referral rates were significantly higher (adjusted OR 1.50, 95% CI 1.18 to 1.90).
• Admission:
Delayed vs early hospital admission
Labor assessment programs, which aim to delay hospital admission until active labor, may benefit women with term pregnancies. Active labor was defined as regular painful contractions and cervical dilatation >3cm. Compared to direct admission to hospital, delayed admission until active labor is associated with less time in the labor ward, less intrapartum oxytocics, and less analgesia. Women in the labor assessment and delayed admission group report higher levels of control during labor. Cesarean delivery (CD) rates are similar, with a non-significant 30% decrease. A 30-40% decrease in CD has been reported in retrospective studies with delayed versus direct admission. There is insufficient evidence (a larger trial needed) to assess true effects on rate of CD and other important measures of maternal and neonatal outcome. Potential risks of delayed admission include unplanned out-of-hospital births and the potentially harmful effects of withholding caregiver support and attention to women in early or latent phase labor.
An algorithm form diagnosis of active labor (painful, regular, moderate or strong contractions, plus one of these 3: cervix effacing or at least 3cm dilated, spontaneous rupture of membranes, or 'show') did not affect outocomes compared to standard admission requirements in one cluster RCT.
Suggested criteria for admission based on these studies are a cervix of at least 3-4cm dilatation and regular painful contractions. Pregnant women should be informed of these data during prenatal care.
