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Evidence-based labor and delivery management


Vincenzo Berghella, MD; Jason K. Baxter, MD, MSCP; Suneet P. Chauhan, MD

T he word obstetrics is derived from


the Latin “ob” and “stare,” which
mean “to stand by.” Standing by, or in
Our objective was to provide evidence-based guidance for managment decisions during
labor and delivery. We performed MEDLINE, PubMed, and COCHRANE searches with the
front of, the laboring woman is intended terms labor, delivery, pregnancy, randomized trials, plus each management aspect of
to be the assistance to the pregnant labor and delivery (eg, early admission). Each management step of labor and delivery was
woman during labor and delivery. Man- reviewed separately. Evidence-based good quality data favor hospital births, delayed
agement of labor and delivery is at the admission, support by doula, training birth assistants in developing countries, and
heart of the obstetric profession, is the upright position in the second stage. Home-like births, enema, shaving, routine vaginal
most important aspect of the support to irrigation, early amniotomy, “hands-on” method, fundal pressure, and episiotomy can be
the pregnancy, and often is the aspect associated with complications without sufficient benefits and should probably be avoided.
that made us go into 1 of the most re- We conclude that labor and delivery interventions supported by good quality data as just
warding and satisfying professions one described should be routinely performed. All aspects with lower data quality should be
could ever choose. researched with adequately powered and designed trials.
There are more than 130 million an-
nual births in the world, of which more Key words: delivery, evidence-based, labor
than 4 million occur in the United States.
Management of labor and delivery is cer-
tainly 1 of the most common medical is- membranes). The search was between
sues to face health personnel. Prevention 1966 and 2008, and was not restricted by
of complications has priority over man- mortality, that can be associated with la- language.
agement of complications. Obstetric bor and delivery for both the mother and
care has been blessed in the last few years her fetus. Selection
by evidence-based research.1,2 The aim We aspire to stimulate better clinical The review was limited to the healthy
of this article is to review the evidence for management, promote education, and woman, carrying a singleton healthy ges-
the management of labor and delivery, foster research trials in areas of uncer- tation in vertex presentation, entering
and offer recommendations that are tainty, focusing on prevention of possi- spontaneous labor at term (37-41 6/7
based (where available) on randomized ble complications rather than treatment. weeks). We organized the management
trials. Proper choice of interventions, We intended to provide obstetricians aspects related to her care into stages:
proven to be associated with the highest with evidence-based guidance for man- early labor, first stage, and second stage
safety and effectiveness, with avoidance agement decisions made in labor and de- (Table 1). We excluded specific aspects,
of less safe and effective ones, will mini- livery suites throughout the world. We such as induction, intrapartum fetal
mize the morbidity, and possibly the did not seek to review other aspects of monitoring (and related interventions)
labor and delivery, such as technique of other than admission tests, group B
cesarean delivery, which has been previ- streptococcus prophylaxis, meconium,
From the Division of Maternal-Fetal ously reported.3 We assume that during anesthesia, operative delivery, multiple
Medicine, Department of Obstetrics and labor and delivery, obstetricians would
Gynecology (Drs Berghella and Baxter), gestations, early neonatal care, and man-
adhere to the best medical care to agement of the third stage of labor be-
Jefferson Medical College of Thomas
decrease infection, minimize tissue cause each of these topics would require
Jefferson University, Philadelphia, PA; and
trauma, and avoid ischemia and inflam-
Aurora Health Care (Dr Chauhan), an extensive review beyond the previ-
Milwaukee, WI. mation. We present one aspect of the la-
ously described scope of this article. We
bor and delivery at a time, to show the
Received Feb. 12, 2008; revised April 21, also excluded management aspects re-
2008; accepted June 30, 2008. effect of each management step
lated to cesarean delivery, because the
Reprints not available from the authors.
individually.
technical aspects have been covered be-
0002-9378/$34.00 Materials and methods fore.3 Each retrieved article or Cochrane
© 2008 Mosby, Inc. All rights reserved. review was carefully evaluated, and any
Searching
doi: 10.1016/j.ajog.2008.06.093
To achieve our aim, we performed mul- pertinent references from the articles
tiple MEDLINE, PubMed, EMBASE, were obtained and reviewed as well.
For Editors’ Commentary,
see Table of Contents and COCHRANE searches with the
terms labor, delivery, pregnancy, random- Data abstraction
See related editorial, page 441 ized trials, plus each management aspect Data abstraction was performed in
(eg, early admission, early rupture of duplicate.

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TABLE 1
Evidenced-based recommendations for labor and delivery
Intervention Recommendationa Qualitya Commentb
First stage
.......................................................................................................................................................................................................................................................................................................................................................................
Self-diagnosis of active labor I Poor Fewer visits to L&D suite
.......................................................................................................................................................................................................................................................................................................................................................................
Radiographic pelvimetry D Good Higher CD
.......................................................................................................................................................................................................................................................................................................................................................................
Home births I Poor No trials
.......................................................................................................................................................................................................................................................................................................................................................................
Home-like births D Good Trend for higher perinatal mortality
.......................................................................................................................................................................................................................................................................................................................................................................
Midwife vs conventional care C Good 1/100 less CD, 1/1000 more perinatal mortality
.......................................................................................................................................................................................................................................................................................................................................................................
Teamwork training I Fair One cluster RCT: no effect
.......................................................................................................................................................................................................................................................................................................................................................................
Delayed admission B Fair Trend for less CD
.......................................................................................................................................................................................................................................................................................................................................................................
Fetal admissions tests
..............................................................................................................................................................................................................................................................................................................................................................
Fetal heart rate tracing C Good Similar neonatal
..............................................................................................................................................................................................................................................................................................................................................................
Amniotic fluid volume D Good outcomes
.......................................................................................................................................................................................................................................................................................................................................................................
Estimate of fetal weight I Poor No effect on outcome
.......................................................................................................................................................................................................................................................................................................................................................................
Enemas D Fair Similar neonatal outcomes
.......................................................................................................................................................................................................................................................................................................................................................................
Perineal shaving D Fair Old trials
.......................................................................................................................................................................................................................................................................................................................................................................
Chlorhexidine vaginal irrigation D Good No benefit
.......................................................................................................................................................................................................................................................................................................................................................................
Ingestion of liquids/ nutrition C Poor No trials of solid foods
.......................................................................................................................................................................................................................................................................................................................................................................
Intravenous fluids C Fair 250 or 125 mL/h studied
.......................................................................................................................................................................................................................................................................................................................................................................
Ambulation (walking) C Good Let the woman choose
.......................................................................................................................................................................................................................................................................................................................................................................
Water immersion
..............................................................................................................................................................................................................................................................................................................................................................
First stage C Good Decrease in analgesia
..............................................................................................................................................................................................................................................................................................................................................................
Second stage I Poor Trial too small
.......................................................................................................................................................................................................................................................................................................................................................................
Massage I Fair Only 1 small trial
.......................................................................................................................................................................................................................................................................................................................................................................
Aromatherapy I Fair Insufficiently powered trials
.......................................................................................................................................................................................................................................................................................................................................................................
Support person (doula) A Good One of the most effective interventions
.......................................................................................................................................................................................................................................................................................................................................................................
Routine early AROM D Good Trend for higher CD
.......................................................................................................................................................................................................................................................................................................................................................................
Partogram C Fair Most trials compared different “action lines” of Partogram
.......................................................................................................................................................................................................................................................................................................................................................................
Cervical examinations I Poor No specific trials
.......................................................................................................................................................................................................................................................................................................................................................................
Oxytocin augmentation I Poor No specific trials
.......................................................................................................................................................................................................................................................................................................................................................................
Active management of labor B Good Individual intervention should be tested, analyzed, and
used clinically separately
.......................................................................................................................................................................................................................................................................................................................................................................
Training of birth assistants A Good In developing countries
.......................................................................................................................................................................................................................................................................................................................................................................
IUPC I Poor No trials
.......................................................................................................................................................................................................................................................................................................................................................................
Meperidine for abnormal progression of labor D Fair Worse perinatal outcome
................................................................................................................................................................................................................................................................................................................................................................................
Second stage
.......................................................................................................................................................................................................................................................................................................................................................................
Prophylactic oxygen D Fair Lower cord pH
.......................................................................................................................................................................................................................................................................................................................................................................
Prophylactic tocolysis D Fair Labor prolongation
.......................................................................................................................................................................................................................................................................................................................................................................
Upright position A Good Includes sitting, semirecumbent, kneeling, and squatting
.......................................................................................................................................................................................................................................................................................................................................................................
Delayed pushing B Good Similar outcomes
.......................................................................................................................................................................................................................................................................................................................................................................
Pushing using a “closed” glottis C Good Similar neonatal outcomes
.......................................................................................................................................................................................................................................................................................................................................................................
Perineal massage from 34 wks on A Good Higher chance of intact perineum for nulliparous women
.......................................................................................................................................................................................................................................................................................................................................................................
Perineal massage during second stage B Good Lower chance of third-degree lacerations
Continued on page 447.

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TABLE 1
Evidenced-based recommendations for labor and delivery
Continued from page 446.
Intervention Recommendationa Qualitya Commentb
Warm packs B Good Lower incidence of third- and fourth-degree lacerations
.......................................................................................................................................................................................................................................................................................................................................................................
Operative delivery for abnormal progression I Poor No specific trials
.......................................................................................................................................................................................................................................................................................................................................................................
“Hands on” method D Good Higher incidence of third-degree lacerations and
episiotomies
.......................................................................................................................................................................................................................................................................................................................................................................
Fundal pressure D Good Women less satisfied
.......................................................................................................................................................................................................................................................................................................................................................................
Episiotomy D Good Episiotomy should be avoided if at all possible
................................................................................................................................................................................................................................................................................................................................................................................
AROM, artificial rupture of membranes; CD, cesarean delivery; IUPC, intrauterine pressure catheter; L&D, labor and delivery; RCTs, randomized controlled trials.
a
Level of evidence was based on the US Preventive Services Task Force recommendations (Table 2).4
b
See text for more details.
Berghalla. Evidence-based labor and delivery management. Am J Obstet Gynecol 2008.

Study characteristics Quantitative data synthesis new method outlined by the US Preventive
All randomized trials covering manage- The principal measure of effect was relative Services Task Force4 (Table 2).
ment aspects of labor and delivery were risk. Significance was inferred if confi- Our evidence-based review integrates
included in the review (Table 1). In the dence intervals did not cross unity. Out- individual clinical expertise with the best
absence of trials adequately covering the comes appropriate for the intervention available external clinical evidence from
aspect, analytic data were reviewed. In studied were reviewed, with emphasis on systematic research.5 Because this re-
the absence of experimental or analytic maternal and perinatal morbidity and view evaluates several interventions,
data, observational data were evaluated. mortality. After each technical step is re- QUOROM reporting was followed as
Each step of labor and delivery was re- viewed, evidence levels and recommenda- appropriate, but could not be totally ap-
viewed separately. tion levels are reported according to the plied. Because this was a review of the

TABLE 2
Standard recommendation language and quality of evidence according
to the method outlined by the US Preventive Services Task Force4
Recommendation:
.......................................................................................................................................................................................................................................................................................................................................................................
A: The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the
service] improves important health outcomes and concludes that benefits substantially outweigh harms.
.......................................................................................................................................................................................................................................................................................................................................................................
B: The USPSTF recommends that clinicians provide [this service] to eligible patients. The USPSTF found at least fair evidence that [the
service] improves important health outcomes and concludes that benefits outweigh harms.
.......................................................................................................................................................................................................................................................................................................................................................................
C: The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the
service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general
recommendation.
.......................................................................................................................................................................................................................................................................................................................................................................
D: The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that
[the service] is ineffective or that harms outweigh benefits.
.......................................................................................................................................................................................................................................................................................................................................................................
I: The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that the
[service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
................................................................................................................................................................................................................................................................................................................................................................................
Quality of evidence:
.......................................................................................................................................................................................................................................................................................................................................................................
Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess
effects on health outcomes.
.......................................................................................................................................................................................................................................................................................................................................................................
Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or
consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.
.......................................................................................................................................................................................................................................................................................................................................................................
Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in
their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.
................................................................................................................................................................................................................................................................................................................................................................................
USPSTF, US Preventive Services Task Force.
Berghalla. Evidence-based labor and delivery management. Am J Obstet Gynecol 2008.

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literature, this study is exempt from in- ined through randomized trials by eval- of this intervention (recommendation: I;
stitutional review board approval. uating the evidence for “home-like quality: fair; Table 2).
births” (recommendation: I; quality: Delayed admission involves allowing
Results poor; Table 2). admission to the labor and delivery suite
Results were by each management aspect Home-like birth has been assessed to only after certain criteria for active labor
of labor and delivery.
see if outcomes for physiologic term la- have been met. Active labor was defined
Before labor bor could still be the same in a less “hos- as regular painful contractions and cer-
Self-diagnosis of active labor involves pital-like” environment. Birth centers vical dilatation ⬎ 3 cm. Compared with
education during pregnancy (eg, antena- represent the attempt at these home-like direct admission to hospital, delayed ad-
tal classes) on detection of contractions births. Compared with hospital births, mission until active labor is associated
and timing of presentation for assess- home-like births are associated with de- with less time in the labor ward, less in-
ment for false or active labor. Education creased need for intrapartum analgesia/ trapartum oxytocics, and less analgesia
for self-diagnosis of active labor is com- anesthesia and increased rates of sponta- in 1 randomized trial, involving 209
pared with no such education in 1 ran- neous vaginal birth, preference for the women.17 Women in the labor assess-
domized trial involving 245 women.6 same setting the next time, satisfaction ment and delayed admission group re-
Self-diagnosis of active labor was associ- with intrapartum care, and breastfeed- port higher levels of control during la-
ated with a decrease in the number of ing initiation and continuation to 6-8 bor. CD rates are similar, with a
visits to the labor suite (0.29 vs 0.58 vis- weeks in 6 trials, including 8677 nonsignificant 30% decrease. A 30-40%
its) compared with controls. It is not women.9 Allocation to a home-like set- decrease in CD has been reported in ret-
possible, because of how the data are re- ting decreased the likelihood of episiot- rospective studies with delayed vs direct
ported, to analyze separately women omy. There was a strong trend toward a admission. Suggested criteria for admis-
whose fetuses have a cephalic or nonce- 87% higher perinatal mortality in the sion based on these studies are a cervix of
phalic presentation, or have a previous home-like setting. It is important to note at least 3-4 cm dilatation and regular
cesarean delivery (CD) or not. There is that, of all low-risk women randomly as- painful contractions. Pregnant women
not much information on the effects of signed to home-like births, about 50% should be informed of these data during
antenatal classes (recommendation: I; have to be transferred to the hospital be- prenatal care (recommendation: B; qual-
quality: poor; Table 2). cause of risks or complications arising ity: fair; Table 2).
Radiographic pelvimetry was evalu- during labor9 (recommendation: D; Fetal admission tests assessed for effi-
ated in 4 randomized trials including quality: good; Table 2). cacy have been fetal heart rate tracing and
895 women to assess the “passage” Midwife-led labor and delivery is as- sonographic amniotic fluid volume. Com-
through the maternal pelvis (in com- sociated with similar incidences of CD pared with intermittent monitoring, fetal
parison with the fetus, or “passenger”). (4.8% vs 5.8%) and neonatal mortality heart rate tracing for 20 minutes on admis-
Compared with no such procedure, ra- (0.36% vs 0.28%) compared with obste- sion is associated with similar neonatal
diographic pelvimetry is associated trician-led labor and delivery in 6 trials, morbidity and mortality, with increased
with an increase in CD (56% vs 39%). including more than 16,500 low-risk incidences of epidural anesthesia, continu-
Magnetic resonance imaging (MRI) women carrying singleton gestations at ous fetal monitoring, and fetal blood sam-
pelvimetry has not been studied in a term. These numbers equate to 1 less CD pling in 3 trials, involving 11,259 low-risk
randomized trial7 (recommendation: per 100 births and about 1 more neona- women18,19 (recommendation: C; quality:
D; quality: good; Table 2). tal death in 1000 births associated with good; Table 1).
First stage midwife-led management. In these tri- Compared with no such assessment,
Home birth has never been studied in an als, more than 40% of women assigned assessment of amniotic fluid volume as a
adequately powered randomized trial. to midwifery care were transferred to fetal admission test is associated with an
The only trial published on this subject conventional obstetrician-led care10-15 increased risk of CD and similar neona-
randomly assigned just 11 women, and (recommendation: C; quality: good; Ta- tal outcomes in 1 trial, involving 883
was too small to draw any conclusions.8 ble 2). women.20 Neither a 2 ⫻ 1-cm pocket
Possibly because of this lack of data, Teamwork training based on crew re- (abnormal in 8%) nor an amniotic fluid
there are diverging opinions on the saf- source management principles is associ- index (AFI) ⱕ 5 cm (abnormal in 25%)
est, most effective setting for labor even ated with no effect on maternal and peri- on admission for labor identifies a preg-
in western countries, with about 30% of natal outcomes in a cluster randomized nancy at risk for adverse outcome such as
Dutch births occurring at home, vs ⬍ trial, including 28,536 women.16 Given nonreassuring fetal heart rate (NRFHR)
1% of US births. Women with risk fac- the possibilities of ineffective training, or CD for NRFHR in 1 trial, involving
tors for abnormal outcome should de- inadequate follow-up, Hawthorne effect, 499 women21 (recommendation: D;
liver in a hospital setting. The safety and inadequate outcome measures, or lack of quality: good; Table 1). Vibroacoustic
effectiveness of home birth needs further power in this single trial, there is insuffi- stimulation and Doppler ultrasound
research, and for now can only be exam- cient evidence to assess the effectiveness have not been evaluated in trials as fetal

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admission tests (recommendation: I; erative procedures, which is itself usually significant decreases in length of the first
quality: poor; Table 2). unnecessary and can lead to complica- stage (by 71 minutes), and in labor last-
Estimate of fetal weight may be more tions (recommendation: D; quality: fair; ing ⱖ 12 hours in 1 trial, involving 195
accurate by clinical estimation than by Table 2). women.30 Although the data in preg-
ultrasound, based on 1 trial, including Chlorhexidine vaginal irrigation in nancy is limited to this single trial, the
758 women admitted for labor with sin- labor has been associated with similar benefits are substantiated by the fact that
gleton gestations at term.22 Neither esti- rates of infection, including chorioam- several trials in nonpregnant adults dem-
mate was very accurate, as only 58% vs nionitis, endometritis, and neonatal sep- onstrate that increased fluid intake im-
32% of estimations were within 10% of sis compared with no irrigation in 3 tri- proves exercise performance (recom-
actual birthweight, respectively. No ef- als, involving 3012 women.26 The mendation: C; quality: fair; Table 2).
fect of the knowledge of these estimates incidence of perinatal mortality is also Ambulation (walking) during labor
on any maternal or perinatal outcome similar. The effectiveness of vaginal at 3-5 cm of dilatation is associated with
was reported. There is no trial compar- chlorhexidine might depend on the con- similar length of the first stage of labor,
ing fetal weight estimation to no such es- centration and volume of the solution use of oxytocin, rate of operative vaginal
timation. Therefore, there is insufficient used. Chlorhexidine solution is inexpen- delivery, and neonatal outcomes com-
evidence to assess the effect of fetal sive and safe, and vaginal irrigation is pared with a policy of restrictive walking
weight estimation on labor outcomes easy to perform, but apparently not ben- in the largest, best trial evaluating 1067
(recommendation: I; quality: poor; Ta- eficial (recommendation: D; quality: women.31 Walking in other groups of la-
ble 2). good; Table 2). boring women evaluated in 4 older trials,
Enemas have been assessed as an in- Nutrition is usually very limited for either small (3 trials involving a total of
tervention at admission for term labor. the laboring woman. There are no trials 132 women)32-34 or evaluating walking
Compared with women receiving no en- evaluating the ingestion of solid foods in together with amniotomy in 630
emas, enemas in the first stage of labor labor. A carbohydrate drink (mean in- women,35 supports these results. On the
are associated with similar length of la- take 44 g in 350 mL) in early labor is as- basis of this evidence, women should be
bor and most maternal and neonatal sociated with an increased risk of CD allowed to choose freely regarding the
outcomes in 2 trials, involving 665 compared with placebo in women al- duration (if any) of walking during labor
women.23 There is a trend for lower in- lowed to drink “at-will” in 1 trial, involv- (recommendation: C; quality: good; Ta-
fection rates, and significance for less ing 202 women,27 but a carbohydrate ble 2).
need for postpartum systemic antibiot- drink (25 g) in late (8-10 cm) labor is Water immersion has been evaluated
ics. The newborn children have less associated with similar rates of CD com- in 8 trials, involving 2939 women, mostly
lower respiratory tract infections and pared with placebo in 1 randomized trial in the first stage of labor.36 Compared
also less need for systemic antibiotics. by the same group, involving 201 with no water immersion, water immer-
These benefits are very modest, as the in- women.28 There are no other trials on sion is associated with decreases in the
cidence of each of these complications in nutrition in labor, and so current man- use of analgesia and in reported maternal
the no enema groups is ⬍ 3%. This in- agement is based mostly on expert opin- pain, and similar labor duration, inci-
tervention (enema) generates discom- ion. Ice chips to moisten the mouth and dence of perineal trauma, incidence of
fort in women and increases the costs of sips of clear liquids are the only oral in- operative delivery, and neonatal out-
delivery, so that the small benefits do not take recommended by US authorities come (such as Apgar score ⬍ 7 at 5 min-
supplant these limitations. The 2 trials (the American Society of Anesthesiolo- utes, neonatal unit admissions, or neo-
were not blinded23 (recommendation: gist Task Force on Obstetrical Anesthe- natal infection rates). Blinding is not
D; quality: fair; Table 2). sia).29 Some experts also allow sport possible (recommendation: C; quality:
Perineal shaving on admission for la- drinks, yogurt, or sherbet. In The Neth- good; Table 2).
bor is associated with similar maternal erlands, women in labor are allowed to One trial explores delivery (second
febrile morbidity, wound infection, and eat and drink. Maternal glucose may po- stage) in water, but is too small (n ⫽ 120)
neonatal infection compared with just tentially increase neonatal lactic acidosis. to determine significant differences in
selective clipping of hair in 3 randomized The reason given for avoiding solid food outcomes for women or neonates.37 The
trials, involving 997 women.24,25 The po- is risk of aspiration, which is rare. Airway effects of immersion in water during the
tential for complications (redness, mul- precautions are the most important third stage are unclear, given the absence
tiple superficial scratches, burning and methods to avoid aspiration (recom- of trials (recommendation: I; quality:
itching of the vulva, embarrassment, and mendation: I; quality: poor; Table 2). poor; Table 2).
discomfort afterwards when the hair Intravenous (IV) fluids have not been Massage is associated with less subjec-
grows back) suggests that shaving should compared with no IV fluids in labor. The tive pain scores up to 7 cm in labor com-
not be part of routine clinical practice. data on IV fluids type and infusion rate is pared with no massage in a small trial,
Two of the trials are old (1922 and 1965), insufficient for a strong recommenda- involving 60 women.38 This is insuffi-
and all included the clipping of long tion. Compared with 125 mL/hour, a cient evidence to make a recommenda-
hairs in their control groups to aid in op- rate of 250 mL/hour is associated with tion, given also the impossibility of

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blinding (recommendation I; quality: that is, labors with failure to progress half-lives) before deciding that dosing is
fair; Table 2). (recommendation: D; quality: good; Ta- inadequate is unproven in prospective
Aromatherapy has only been evalu- ble 2). trials (recommendation: I; quality: poor;
ated in a small trial, including 22 The Partogram is associated with sim- Table 2).
women,39 and a pilot trial, including 533 ilar incidence of interventions and CD Active management of labor was de-
women,40 with no significant differences compared with progress of labor charted vised originally to prevent prolonged la-
in the outcomes studied, including pain in written notes in a trial of 1932 primip- bor, not to affect the rate of CD.50 Active
and mode of delivery (recommendation: arous term women.43 In this study nei- management has been usually defined as
I; quality: poor; Table 2). ther group had a mandatory manage- antenatal classes (including self-diagno-
A support person (doula) present ment of labor protocol. Another trial sis of active labor), doula support, rou-
during labor is associated with decreased compared outcomes “before” and “af- tine early AROM, use of Partogram, and
use of analgesia, decreased incidence of ter” introduction of the Partogram for oxytocin augmentation. Unfortunately,
operative birth, increased incidence of labor management.44 The 3 other trials not all studies or trials define active man-
spontaneous vaginal delivery, and in- evaluating the Partogram compared dif- agement similarly. We have analyzed
creased maternal satisfaction in 15 trials, ferent action lines (ie, different Parto- previously the individual interventions
including 12,791 women.41 The most ef- grams), and so did not assess its effect of active management of labor for which
fective form of support starts early in la- compared with a “sham” arm.45-47 specific trials are available. As these in-
bor, is continuous, and is not provided Therefore, there is insufficient evidence terventions can have differing outcomes
by a member of the hospital staff. The to recommend the routine use of the (eg, early AROM: trend for increase in
mother should be encouraged to select Partogram (recommendation: C; quali- CD; doula support: significant decrease
her doula during pregnancy; they estab- ty: fair; Table 2). in CD), trials of active management are
lish a relationship (which is likely to in- The need and/or frequency of cervi- difficult to interpret.
volve the woman’s partner, if any) and cal examinations in labor has never been Nonetheless, overall, 4 trials of active
discuss the mother’s and partner’s pref- evaluated in a trial. Most studies, includ- management of labor involving 3676
erences and concerns before labor. The ing trials of active management, usually women have shown: (1) a decreased du-
doula brings her experience and training perform cervical examinations every 2 ration of labor of about 50-100 minutes,
(often to the level of certification) to the hours in labor. The risk of chorioamnio- mostly in the first stage, probably sec-
labor support role during childbirth, and nitis though increases with the increas- ondary to early AROM; (2) a reduction
the mother and doula frequently have ing number of examinations.48 There are in prolonged (lasting ⬎ 12 hours) labor;
telephone and/or face-to-face contact in no trials to assess the effect of stripping of (3) less maternal fever; (4) no significant
the early postpartum period. Other membranes at the time of cervical exam- effect on incidence of CD (possibly a bal-
models of support, for which there are inations during labor. Transvaginal ul- ance of differing effects); (5) similar peri-
little or no data, include support by a fe- trasound assessment of the cervix has natal outcomes; and (6) similar maternal
male family member and support by the not been compared in a trial with tradi- satisfaction.51-54 Interestingly, dissimilar
husband/partner.41 If a doula cannot be tional digital manual cervical assessment results were observed between the
present or is not desired, women should in term laboring women. Therefore, United States and Europe, which may
still be encouraged to invite a family there is insufficient evidence to assess the have resulted from bias because the in-
member or friend to commit to being need and/or best frequency of cervical vestigators could not blind the random-
present at the birth and assuming this examinations during labor (recommen- ized intervention.
role (recommendation: A; quality: good; dation: I; quality: poor; Table 2). Individual interventions part of active
Table 2). Oxytocin augmentation has not been management should be tested and ana-
Routine early artificial rupture of studied as a primary isolated interven- lyzed separately. There are no trials to
membranes (AROM, or amniotomy) is tion for human labor. In fact, dozens of evaluate the timing and dosing of oxyto-
associated with shorter duration of labor different doses have been used in differ- cin in labor per se. There are also no trials
(ⱕ 60 min, mostly because of shorter ent studies, without direct comparison to evaluate specifically the best frequency
first stage), decrease in use of oxytocin, in a randomized trial. Therefore, there is of cervical examinations in labor. Most
similar incidence of NRFHR monitor- insufficient evidence to assess the effect studies, including those with active man-
ing, a trend for a 26% increase in CD, of any specific regimen (eg, starting dose, agement, perform cervical examinations
and similar neonatal outcomes com- rate of increase, maximum dose) for every 2 hours in labor. The risk of intra-
pared with selective (later or no) AROM oxytocin use in labor. A reasonable ap- uterine infection though increases with
in 9 specific trials, including more than proach based on oxytocin’s pharmacol- the increasing number of examinations
4000 women with singleton, vertex, term ogy includes the use of a starting dose of (recommendation: B; quality: good; Ta-
gestations.42 Given this evidence of both 2 mU/min, increasing by 2 mU/min ev- ble 2).
benefits and risks of routine early ery 45 minutes until adequate contrac- Training of birth assistants in the de-
AROM, this intervention should proba- tions or a maximum of 20-30 mU/min.49 veloping world is associated with a 26%
bly be reserved just for abnormal labors, The necessity of awaiting a steady state (5 trend for a decrease in maternal mortal-

450 American Journal of Obstetrics & Gynecology NOVEMBER 2008


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ity, and a 30% trend for a decrease in als, including 245 women.60 There are no tive vaginal and CD, and similar neona-
perinatal mortality in 1 trial, including differences in other outcomes. Brief ox- tal outcomes, compared with early (im-
20,557 Pakistani women.55 Given these ygen for treating NRFHR is potentially mediate on entering second stage)
results, several governmental and non- beneficial (recommendation: D; quality: pushing in 9 trials, including 2953
governmental organizations (eg, non- fair; Table 2). women.65 Careful monitoring, with as-
profit foundations) are in the process of Prophylactic tocolysis for preventing surance of reassuring fetal status, should
organizing and starting programs for the NRFHR monitoring has been studied in be used during delayed pushing (recom-
training of birth assistants, which is the a small (n ⫽ 100) trial that evaluated mendation: B; quality: good; Table 2).
most promising of all interventions ritodrine, a beta-mimetic drug. It was as- Pushing method using a closed glot-
studied so far to successfully decrease sociated with prolongation of labor and tis (Valsalva) is associated with a signif-
maternal and perinatal mortality56 (rec- an increased incidence of forceps deliv- icantly shorter (by 13-18 min) duration
ommendation: A; quality: good; Ta- ery, probably because the trial protocol of the second stage of labor, and similar
ble 2). required forceps to be used if the second neonatal outcomes compared with using
Intrauterine pressure catheter (IUPC) stage of labor exceeded 30 minutes, in a woman’s own urge (open glottis) in 2
has not been evaluated in any randomized both groups.61 There were no other sig- trials, including 670 women.66,67 Urody-
trials. Abnormal progression of labor, in- nificant effects associated with this inter- namics 3 months after delivery are
cluding terms such as dystocia, dysfunc- vention (recommendation: D; quality: slightly worse in the closed glottis group
tional labor, failure to progress, cephalo- fair; Table 2). in 1 trial, involving 128 women.68 Given
pelvic disproportion and others, is the The upright position in the second this evidence, each woman’s own choice
most common problem in labor, and the stage is associated in women without should be supported. Most women
reason for the majority of CDs. Risk factors epidural anesthesia with a 4-minute spontaneously choose Valsalva in the
for dystocia are: obesity, induction, Bishop shorter interval to delivery, less pain, second stage of labor (recommendation:
score ⬍ 5 at start of labor, station higher lower incidences of NRFHR monitoring C; quality: good; Table 2).
than -2, persistent occiput posterior, and of operative vaginal delivery, as well Perineal massage from 34 weeks until
macrosomia, and epidural anesthesia.57 as higher rates blood loss of ⬎ 500 mL delivery with sweet almond oil for 5-10
Athough these variables are predictive of compared with other positions in 20 tri- minutes daily is associated with a signif-
a higher chance for operative/CD, no in- als, including 6135 women.62 The up- icantly higher chance of intact perineum
tervention has been tested by a trial. In right positions studied include sitting compared with no massage in nullipa-
the active phase of the first stage of labor, (obstetric chair/stool); semirecumbent rous, but probably not multiparous
in a woman at term with epidural and (trunk tilted backwards 30° to the verti- women in 3 trials, including 2434
oxytocin, the fifth percentile dilatation is cal); kneeling; squatting (unaided or us- women69 (recommendation: A; quality:
about 0.5 cm/h. Proposed cutoffs for ing squatting bars); and squatting aided good; Table 2).
failure to progress in the active phase of with birth cushion. The benefits of the Perineal massage and stretching of
the first stage are arrest for ⱖ 4 hours if upright position may be related to grav- the perineum in the second stage of la-
uterine activity ⬎ 200 Montevideo units, ity, less aortovagal compression, im- bor with a water soluble lubricant is as-
and arrest for ⱖ 6 hours if ⬎ 200 Mon- proved fetal alignment, and larger ante- sociated with similar rates of intact peri-
tevideo units cannot be sustained.58 rior-posterior and transverse pelvic neum, but decreased incidence of third
These suggestions assume normal fetal outlets. The higher blood loss may be degree lacerations in 1 trial, involving
heart rate (FHR) monitoring (recom- secondary to easier collection of blood in 1340 women.70 In this trial, perineal
mendation: I; quality: poor; Table 2). the upright position. In women with massage before labor was not performed,
Meperidine 100 mg IV, in women at mostly epidural anesthesia, 1 small trial so it is unknown if the combination of
term with singleton gestations and re- assessed lateral vs supported sitting posi- “prelabor” and “in-labor” perineal mas-
quiring oxytocin by obstetrician be- tion, without enough power for mean- sage are beneficial. In another trial, per-
cause of “dystocia” at 4-6 cm, does not ingful conclusion63; another trial com- ineal massage in the second stage was as-
affect operative delivery rates and pared 2 upright positions, and associated sociated with similar very low (⬍ 2%)
worsens neonatal outcomes compared kneeling with no difference in duration incidence of third- or fourth-degree lac-
with placebo in 1 trial involving 407 of second stage but less pain compared erations in 807 women managed by mid-
women59 (recommendation: D; qual- with sitting64 (recommendation: A; wives71 (recommendation: B; quality:
ity: fair; Table 2). quality: good; Table 2). good; Table 2).
Delayed pushing (waiting 1-3 hours Warm pack applied to the perineum
Second stage or until “urge to push”) of term, single- in the second stage of labor is associated
Prophylactic oxygen for preventing ton, vertex gestations with epidural in with a reduction in the incidence of
NRFHR monitoring given continuously place is associated with longer second third- and fourth-degree lacerations in 2
to the mother is associated with a 350% stage, similar pushing time, significantly trials, involving 1525 women (odds ratio
increase in the incidence of low umbili- higher incidence of spontaneous vaginal [OR], 0.52; 95% CI, 0.29-0.92),71,72 with
cal artery cord pH ⬍ 7.20 in 2 small tri- delivery but similar incidences of opera- only the study with the higher incidence

NOVEMBER 2008 American Journal of Obstetrics & Gynecology 451


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of perineal lacerations72 reporting signif- Fundal pressure applied manually to proper technique put both the mother
icant benefit (recommendation: B; qual- aid in vaginal delivery has never been and fetus at unnecessary but significant
ity: good; Table 2). studied in a trial. In the second stage of risks.
Operative intervention for abnormal labor, fundal pressure can be provided Table 1 summarizes our evidence-
progression of the second stage has not with an obstetric belt wrapped around based recommendations for manage-
been evaluated in any trials, so that effec- the woman’s abdomen above the level of ment of labor and delivery for the
tive management of the prolonged sec- the uterine fundus. The belt inflates with healthy woman carrying a vertex, single-
ond stage is unclear. Operative interven- each contraction to a maximum of 200 ton, term gestation entering spontane-
tion is not warranted just because a set mm Hg for 30 seconds. Compared with ous labor. Clinically, good quality rec-
number of hours have elapsed in the sec- no belt, the inflatable obstetric belt is as- ommendations favor hospital births,
ond stage. The length of the second stage sociated with similar incidence of spon- delayed admission, support by doula,
is not associated with poor neonatal out- taneous vaginal delivery in nulliparous training birth assistants in developing
come, as long as fetal testing is reassur- women with singleton term pregnancies countries, and upright position in the
ing. If contractions are adequate, the and an epidural at term in 1 trial, involv- second stage. These labor and delivery
chance of vaginal delivery decreases pro- ing 500 women. All other maternal and techniques should be routinely per-
gressively after 3-5 hours of pushing in neonatal outcomes are similar, but formed. Home-like births, enema, shav-
the second stage. Therefore, studies have women with no belt have greater satis- ing, routine vaginal irrigation, early am-
proposed as minimal cutoffs to begin faction77 (recommendation: D; quality: niotomy, “hands-on” method, fundal
considering dystocia: ⱖ 3 hours with good; Table 2). pressure, and episiotomy can be associ-
epidural and ⱖ 2 hours without an epi- Routine episiotomy use is associated ated with complications without suffi-
dural for nulliparous women; and ⱖ 2 with more posterior perineal trauma, su- cient benefits, and should probably be
hours with epidural and ⱖ 1 hour with- turing and healing complications, and avoided. Ingestion of ice or liquids, walk-
out an epidural for multiparous later pain with intercourse, with de- ing, water immersion, delayed vs early
creased risk of anterior perineal trauma, pushing, and method of pushing should
women.73 If there are no signs of infec-
and similar urinary and fecal inconti- probably be left for the woman to decide.
tion (maternal or fetal), no maternal ex-
nence, compared to restrictive episiot- All technical aspects that have recom-
haustion, and normal fetal heart moni-
omy, in 7 trials, involving 4,996 mendations with less than good quality
toring, labor can be allowed to continue
women.78,79 The episiotomy use in these should be researched properly with ade-
beyond these limits as long as some
studies was about 73% for routine use quately powered and designed trials.
progress has been made.73 Mandatory
and 28% for restrictive use. There is in- There are several limitations to our re-
second opinion is associated with 22
sufficient evidence to evaluate if there are view. Existing search strategies for re-
fewer intrapartum CDs per 1000 deliver-
(if any) indications for the use of episiot- trieving randomized studies and meta-
ies, without affecting maternal or perina- omy, such as assisted delivery (forceps or analyses in various databases are limited,
tal outcome, in 1 large cluster random- vacuum), abnormal fetal testing, pre- and this may have impacted our find-
ized trial, involving 149,276 women74 term delivery, breech delivery, predicted ings, especially regarding publication
(recommendation: I; quality: poor; Ta- macrosomia, and presumed imminent bias and the overreporting of positive tri-
ble 2). tears. Episiotomy should be avoided if at als.80 Although we emphasized results
The “hand-on” method described by all possible, but, if used, it is unknown related to maternal and perinatal mor-
Ritgen in 1855 usually involves pressure which episiotomy technique (mediolat- bidity and mortality, some of these have
on the infant’s head on crowning, and eral or midline) provides the best (or not been well reported for some inter-
support with the other hand of the peri- worst) outcome (recommendation: D; ventions, especially long-term out-
neum, with the aim of protecting for lac- quality: good; Table 2). comes. For most of the issues described,
erations. In the “hands poised” method, outcomes for nulliparous and multipa-
the fetal head and perineum are not Comment rous patients can differ significantly,
touched or supported by the delivering Quality in labor and delivery manage- such that the findings may not be valid
personnel. These 2 methods are associ- ment should always be judged by the for both groups. In addition, for some of
ated with similar incidences of perineal lowest maternal and perinatal morbidity the outcomes, the recommendation lack
and vaginal tears, but the hand-on and mortality, not by preset limits on effect size or draw conclusions based on a
method is associated with higher inci- specific interventions. Even after dozens single study. Because this review evalu-
dence of third-degree tears and episioto- of trials and hundreds of excellent ates several interventions, QUOROM re-
mies in 1 trial, involving 5471 women.75 manuscripts, experts’ opinions fre- porting was followed as appropriate,
A policy of “hands-poised” has also been quently guide decisions as to the man- especially given its advantages in struc-
supported by a quasi-randomized study, agement details of labor and delivery. turing the Methods sction, but could not
reporting less third-degree tears com- Too often we do not take advantage of all be totally applied.
pared with “hands-on”76 (recommenda- the knowledge already available. Com- Obstetricians in practice or training
tion: D; quality: good; Table 2). plications that occur because of im- should be educated to be better aware of

452 American Journal of Obstetrics & Gynecology NOVEMBER 2008


www.AJOG.org Reviews

these clinical and research recommenda- 8. Dowswell T, Thornton JG, Hewison J, Lilford 23. Cuervo LG, Rodríguez MN, Delgado MB.
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suring outcomes other than safety is feasible.
tive of review is based on some degree of BMJ 1996;312:753. shaving on admission in labour. Cochrane Da-
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and delivery requires a team approach, tings for birth. Cochrane Database Syst Rev ized controlled trial of perineal shaving versus
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454 American Journal of Obstetrics & Gynecology NOVEMBER 2008

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