Randomized trial of ambulation versus oxytocin for labor enhancement: a preliminary report

Polymorphism in the ADRB2 gene explains a small portion of intersubject variability in pain relative to cervical dilation in the first stage of labor

BACKGROUND

Variability in labor pain has been associated with demographic, clinical, and psychological factors. Polymorphisms of the β2-adrenergic receptor gene (ADRB2) influence sensitivity to experimental pain in humans and are a risk factor for chronic pain. The authors hypothesized that polymorphisms in ADRB2 may influence labor pain.

METHODS

After Institutional Review Board approval and written informed consent, the authors prospectively obtained hourly pain reports from 233 nulliparous parturients during the first stage of labor, of which 199 were included in the current analysis. DNA from blood samples was genotyped at polymorphisms in the genes for the β2-adrenergic receptor, the μ opioid receptor subtype 1, catechol-O-methyltransferase, fatty acid amide hydrolase, and the oxytocin receptor. Labor pain as a function of cervical dilation was modeled with previously described methods. Patient covariates, ADRB2 genotype, and obstetrical and anesthesia treatment were evaluated as covariates in the model.

RESULTS

Labor pain more rapidly became severe in parturients heterozygous or homozygous for the G allele at rs1042714 in the ADRB2 gene. Labor pain increased more rapidly after artificial rupture of membranes, augmentation with oxytocin, and in younger women. Inclusion of covariates explained approximately 10% of the variability between subjects. ADRB2 genotype explained less than 1% of the intersubject variability.

CONCLUSION

ADRB2 genotype correlates with labor pain but explained less than 1% of the intersubject variance in the model.

Maternal positions and mobility during first stage labour

BACKGROUND

It is more common for women in both high- and low-income countries giving birth in health facilities, to labour in bed. There is no evidence that this is associated with any advantage for women or babies, although it may be more convenient for staff. Observational studies have suggested that if women lie on their backs during labour this may have adverse effects on uterine contractions and impede progress in labour, and in some women reduce placental blood flow.

OBJECTIVES

To assess the effects of encouraging women to assume different upright positions (including walking, sitting, standing and kneeling) versus recumbent positions (supine, semi-recumbent and lateral) for women in the first stage of labour on duration of labour, type of birth and other important outcomes for mothers and babies.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2013).

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing women randomised to upright versus recumbent positions in the first stage of labour.

DATA COLLECTION AND ANALYSIS

We used methods described in the Cochrane Handbook for Systematic Reviews of Interventions for carrying out data collection, assessing study quality and analysing results. Two review authors independently evaluated methodological quality and extracted data for each study. We sought additional information from trial authors as required. We used random-effects analysis for comparisons in which high heterogeneity was present. We reported results using the average risk ratio (RR) for categorical data and mean difference (MD) for continuous data.

MAIN RESULTS

Results should be interpreted with caution as the methodological quality of the 25 included trials (5218 women) was variable.For Comparison 1: Upright and ambulant positions versus recumbent positions and bed care, the first stage of labour was approximately one hour and 22 minutes shorter for women randomised to upright as opposed to recumbent positions (average MD -1.36, 95% confidence interval (CI) -2.22 to -0.51; 15 studies, 2503 women; random-effects, T(2) = 2.39, Chi(2) = 203.55, df = 14, (P < 0.00001), I(2) = 93%). Women who were upright were also less likely to have caesarean section (RR 0.71, 95% CI 0.54 to 0.94; 14 studies, 2682 women) and less likely to have an epidural (RR 0.81, 95% CI 0.66 to 0.99, nine studies, 2107 women; random-effects, T(2) = 0.02, I(2) = 61%). Babies of mothers who were upright were less likely to be admitted to the neonatal intensive care unit, however this was based on one trial (RR 0.20, 95% CI 0.04 to 0.89, one study, 200 women). There were no significant differences between groups for other outcomes including duration of the second stage of labour, or other outcomes related to the well being of mothers and babies.For Comparison 2: Upright and ambulant positions versus recumbent positions and bed care (with epidural: all women), there were no significant differences between groups for outcomes including duration of the second stage of labour, or other outcomes related to the well being of mothers and babies.

AUTHORS' CONCLUSIONS

There is clear and important evidence that walking and upright positions in the first stage of labour reduces the duration of labour, the risk of caesarean birth, the need for epidural, and does not seem to be associated with increased intervention or negative effects on mothers' and babies' well being. Given the great heterogeneity and high performance bias of study situations, better quality trials are still required to confirm with any confidence the true risks and benefits of upright and mobile positions compared with recumbent positions for all women. Based on the current findings, we recommend that women in low-risk labour should be informed of the benefits of upright positions, and encouraged and assisted to assume whatever positions they choose.

Maternal positions and mobility during first stage labour

BACKGROUND

It is more common for women in both high- and low-income countries giving birth in health facilities, to labour in bed. There is no evidence that this is associated with any advantage for women or babies, although it may be more convenient for staff. Observational studies have suggested that if women lie on their backs during labour this may have adverse effects on uterine contractions and impede progress in labour, and in some women reduce placental blood flow.

OBJECTIVES

To assess the effects of encouraging women to assume different upright positions (including walking, sitting, standing and kneeling) versus recumbent positions (supine, semi-recumbent and lateral) for women in the first stage of labour on duration of labour, type of birth and other important outcomes for mothers and babies.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2013).

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing women randomised to upright versus recumbent positions in the first stage of labour.

DATA COLLECTION AND ANALYSIS

We used methods described in the Cochrane Handbook for Systematic Reviews of Interventions for carrying out data collection, assessing study quality and analysing results. Two review authors independently evaluated methodological quality and extracted data for each study. We sought additional information from trial authors as required. We used random-effects analysis for comparisons in which high heterogeneity was present. We reported results using the average risk ratio (RR) for categorical data and mean difference (MD) for continuous data.

MAIN RESULTS

Results should be interpreted with caution as the methodological quality of the 25 included trials (5218 women) was variable.For Comparison 1: Upright and recumbent positions versus recumbent positions and bed care, the first stage of labour was approximately one hour and 22 minutes shorter for women randomised to upright as opposed to recumbent positions (average MD -1.36, 95% confidence interval (CI) -2.22 to -0.51; 15 studies, 2503 women; random-effects, T(2) = 2.39, Chi(2) = 203.55, df = 14, (P < 0.00001), I(2) = 93%). Women who were upright were also less likely to have caesarean section (RR 0.71, 95% CI 0.54 to 0.94; 14 studies, 2682 women) and less likely to have an epidural (RR 0.81, 95% CI 0.66 to 0.99, nine studies, 2107 women; random-effects, T(2) = 0.02, I(2) = 61%). Babies of mothers who were upright were less likely to be admitted to the neonatal intensive care unit, however this was based on one trial (RR 0.20, 95% CI 0.04 to 0.89, one study, 200 women). There were no significant differences between groups for other outcomes including duration of the second stage of labour, or other outcomes related to the well being of mothers and babies.For Comparison 2: Upright and recumbent positions versus recumbent positions and bed care (with epidural: all women), there were no significant differences between groups for outcomes including duration of the second stage of labour, or other outcomes related to the well being of mothers and babies.

AUTHORS' CONCLUSIONS

There is clear and important evidence that walking and upright positions in the first stage of labour reduces the duration of labour, the risk of caesarean birth, the need for epidural, and does not seem to be associated with increased intervention or negative effects on mothers' and babies' well being. Given the great heterogeneity and high performance bias of study situations, better quality trials are still required to confirm with any confidence the true risks and benefits of upright and mobile positions compared with recumbent positions for all women. Based on the current findings, we recommend that women in low-risk labour should be informed of the benefits of upright positions, and encouraged and assisted to assume whatever positions they choose.

Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour

BACKGROUND

Slow progress in the first stage of spontaneous labour is associated with an increased caesarean section rate and fetal and maternal morbidity. Oxytocin has long been advocated as a treatment for slow progress in labour but it is unclear to what extent it improves the outcomes for that labour and whether it actually reduces the caesarean section rate or maternal and fetal morbidity. This review will address the use of oxytocin and whether it improves the outcomes for women who are progressing slowly in labour compared to situations where it is not used or where its administration is delayed.

OBJECTIVES

To determine if the use of oxytocin for the treatment of slow progress in the first stage of spontaneous labour is associated with a reduction in the incidence of caesarean sections, or maternal and fetal morbidity compared to situations where it is not used or where its administration is delayed.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 February 2013) and bibliographies of relevant papers.

SELECTION CRITERIA

Randomised controlled trials which compared oxytocin with either placebo, no treatment or delayed oxytocin in the active stage of spontaneous labour in low-risk women at term.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion, assessed risk of bias and extracted data. We sought additional information from trial authors.

MAIN RESULTS

We included eight studies in the review involving a total of 1338 low-risk women in the first stage of spontaneous labour at term. Two comparisons were made; 1) the use of oxytocin versus placebo or no treatment (three trials); 2) the early use of oxytocin versus its delayed use (five trials). There were no significant differences in the rates of caesarean section or instrumental vaginal delivery in either comparison. Early use of oxytocin resulted in an increase in uterine hyperstimulation associated with fetal heart changes. However, the early use of oxytocin versus its delayed use resulted in no significant differences in a range of neonatal and maternal outcomes. Use of early oxytocin resulted in a statistically significant reduction in the mean duration in labour of approximately two hours but did not increase the normal delivery rate. There was significant heterogeneity for this analysis and we carried out a random-effects meta-analysis; however, all of the trials are strongly in the same direction so it is reasonable to conclude that this is the true effect. We also performed a random-effects meta-analysis for the four other analyses which showed substantial heterogeneity in the review.

AUTHORS' CONCLUSIONS

For women making slow progress in spontaneous labour, treatment with oxytocin as compared with no treatment or delayed oxytocin treatment did not result in any discernable difference in the number of caesarean sections performed. In addition there were no detectable adverse effects for mother or baby. The use of oxytocin was associated with a reduction in the time to delivery of approximately two hours which might be important to some women. However, if the primary goal of this treatment is to reduce caesarean section rates, then doctors and midwives may have to look for alternative options.

Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour

BACKGROUND

Slow progress in the first stage of spontaneous labour is associated with an increased caesarean section rate and fetal and maternal morbidity. Oxytocin has long been advocated as a treatment for slow progress in labour but it is unclear to what extent it improves the outcomes for that labour and whether it actually reduces the caesarean section rate or maternal and fetal morbidity. This review will address the use of oxytocin and whether it improves the outcomes for women who are progressing slowly in labour compared to situations where it is not used or where its administration is delayed.

OBJECTIVES

To determine if the use of oxytocin for the treatment of slow progress in the first stage of spontaneous labour is associated with a reduction in the incidence of caesarean sections, or maternal and fetal morbidity compared to situations where it is not used or where its administration is delayed.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2011) and bibliographies of relevant papers.

SELECTION CRITERIA

Randomised controlled trials which compared oxytocin with either placebo, no treatment or delayed oxytocin in the active stage of spontaneous labour in low-risk women at term.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion, assessed risk of bias and extracted data. We sought additional information from trial authors.

MAIN RESULTS

We included eight studies in the review involving a total of 1338 low-risk women in the first stage of spontaneous labour at term. Two comparisons were made; 1) the use of oxytocin versus placebo or no treatment (three trials); 2) the early use of oxytocin versus its delayed use (five trials). There were no significant differences in the rates of caesarean section or instrumental vaginal delivery in either comparison. Early use of oxytocin resulted in an increase in uterine hyperstimulation associated with fetal heart changes. However, the early use of oxytocin versus its delayed use resulted in no significant differences in a range of neonatal and maternal outcomes. Use of early oxytocin resulted in a statistically significant reduction in the mean duration in labour of approximately two hours but did not increase the normal delivery rate. There was significant heterogeneity for this analysis and we carried out a random-effects meta-analysis; however, all of the trials are strongly in the same direction so it is reasonable to conclude that this is the true effect. We also performed a random-effects meta-analysis for the four other analyses which showed substantial heterogeneity in the review.

AUTHORS' CONCLUSIONS

For women making slow progress in spontaneous labour, treatment with oxytocin as compared with no treatment or delayed oxytocin treatment did not result in any discernable difference in the number of caesarean sections performed. In addition there were no detectable adverse effects for mother or baby. The use of oxytocin was associated with a reduction in the time to delivery of approximately two hours which might be important to some women. However, if the primary goal of this treatment is to reduce caesarean section rates, then doctors and midwives may have to look for alternative options.

High-dose vs low-dose oxytocin for labor augmentation: a systematic review

The objective of this systematic review was to estimate the efficacy and safety of high-dose vs low-dose oxytocin for labor augmentation on the risk of cesarean section and on indicators of maternal and neonatal morbidity. We searched PubMed, MEDLINE, EMBASE, and the Cochrane Library for randomized clinical trials published until January 2010. Ten randomized clinical trials, including 5423 women, met the inclusion criteria. High-dose oxytocin was associated with a moderate decrease in the risk of cesarean section (relative risk [RR], 0.85; 95% confidence interval [CI], 0.75-0.97), a small increase in spontaneous vaginal delivery (RR, 1.07; 95% CI, 1.02-1.12), and a decrease in labor duration (mean difference: -1.54 hours, 95% CI, -2.44 to -0.64). While hyperstimulation was increased with high-dose oxytocin (RR, 1.91; 95% CI, 1.49-2.45), there was no evidence of an increase in maternal or neonatal morbidity. We conclude that high-dose oxytocin for labor augmentation is associated with a decrease in cesarean section and shortened labor.

[Role of deambulation during labour: A prospective randomized study]

OBJECTIVE

To assess the effects of ambulation during the first stage of labor on the duration of labor and other maternal and infant outcomes.

PATIENTS AND METHODS

A prospective randomized trial conducted from 1st November 2008 to 31st March 2009 at the department of obstetrics and gynecology, CHU Farhat Hached, Sousse, Tunisia. Two hundred mothers with uncomplicated term pregnancies were randomly assigned to one of two groups: first group (100 parturients) authorized to ambulate until 6cm of cervical dilation and a second group (100 parturients) confined to bed in dorsal or lateral recumbence.

RESULTS

Upright position reduces significantly (for about 34%) the duration of the first stage of labor (P<0.0001), the pain intensity, the oxytocin consumption (P=0.001), the rate of delivery by cesarean section and of instrumental deliveries. Upright position leads also to a net improvement of the maternal outcome (7% side effects versus 13%) and the fetal outcome (net improvement of the Apgar's score at first and fifth minute, and reduction of a factor 5 of the rate of transfer to the neonatology clinical care unit.

CONCLUSION

Our study allowed to confirm the benefits of ambulation on labor progress as well as on the maternal comfort and the maternofetal outcome.

The vertical position during labor: pain and satisfaction

OBJECTIVES: to evaluate the vertical position adopted by nulliparous women during labor in terms of pain and satisfaction with the position. METHODS: the study was based on a secondary efficacy analysis of data from 107 nulliparous women enrolled in a randomized controlled trial in which the vertical position adopted during the dilation phase of labor was evaluated. The analysis involved comparing the median percentages of the duration for which women remained in the vertical position for each of the variables studied . The Kruskal-Wallis and Mann-Whitney tests were used to determine the difference s betwee n th e groups. Statistical significance was set at p<0.05. RESULTS: at 4cm of dilation , the women with a pain score < 5 remained longer in the vertical position during labor compared to those with a score > 7 (p=0.02) . At 4 and 6 cm of dilation , the women who reported greater satisfaction remained more than 50 % of the time in the vertical position (p=0.0 2 an d p=0.03 , respectively). CONCLUSIONS: the vertical position helped relieve labor pain and increased comfort and patient satisfaction.

The effect of early oxytocin augmentation in labor: a meta-analysis

OBJECTIVE

To estimate the effects of early augmentation with oxytocin for slow progress of labor on the delivery method and on indicators of maternal and neonatal morbidity.

DATA SOURCES

We conducted electronic database searches of PubMed, MEDLINE, EMBASE, and the Cochrane Library for articles published through February 2009 using the keywords "oxytocin," "augmentation," "active management of labor," "cesarean section," and "labor." Primary authors were contacted directly if the data sought were unavailable.

METHODS OF STUDY SELECTION

We included randomized controlled trials comparing early oxytocin augmentation with a more conservative approach to care in labor. We included only those studies in which membrane management was similar in the two groups. Early oxytocin augmentation was defined as immediate oxytocin administration when dystocia was identified. Data were extracted by two authors independently and evaluated for potential sources of bias. Relative risk (RR) and 95% confidence interval (CI) were calculated using fixed and random effects models.

TABULATION, INTEGRATION, AND RESULTS

Nine trials with 1,983 women met the inclusion criteria. Early oxytocin was associated with an increase in the probability of spontaneous vaginal delivery (RR 1.09, 95% CI 1.03-1.17). For every 20 patients treated with early oxytocin augmentation, one additional spontaneous vaginal delivery is expected. Although the point estimate for the effect on cesarean delivery (RR 0.87, 95% CI 0.71-1.06) and on operative vaginal delivery (RR 0.84, 95% CI 0.70-1.00) showed modest protective effects, the CIs for both estimates included the null effect. A decrease in antibiotic use (RR 0.45, 95% CI 0.21-0.99) was observed with early intervention. Early oxytocin was associated with an increased risk of hyperstimulation (RR 2.90, 95% CI 1.21-6.94) without evidence of adverse neonatal effects. Women in the early oxytocin group reported higher levels of pain and discomfort in labor.

CONCLUSION

Early oxytocin for augmentation in labor is associated with an increase in spontaneous vaginal delivery.

Exploring the effect of hospital admission on contraction patterns and labour outcomes using women's perceptions of events

OBJECTIVE

this study investigated the phenomenon of spontaneous labour contractions becoming less frequent on admission to hospital, which is observed anecdotally but is not evident in the literature. Anxiety in response to hospitalisation has been proposed to be responsible by initiating the biochemical response termed 'fight or flight'.

DESIGN

A non-experimental prospective design and a combination of quantitative and qualitative analysis. Data were collected using self-report labour diaries, postnatal questionnaires and hospital records of labour. Univariate analysis using t-test and chi(2)-test was performed to examine relationships between variables, and content analysis was undertaken on qualitative data regarding reactions to hospitalisation.

SETTING

hospital and community maternity services provided by a National Health Service hospital in Southern England in 1997.

PARTICIPANTS

about 87 women at least 37-week gestation, uncomplicated singleton pregnancy anticipating spontaneous labour with a live fetus.

MEASUREMENTS AND FINDINGS

labour diaries were analysed from 26 births. In three home births and 11 hospital births, labour contractions became more frequent, but in the remaining 12 labours, contractions decreased after admission to hospital. Women whose contractions slowed were not more anxious, but they rarely had cervical dilatation over 5cm and usually assumed a recumbent position in hospital. Artificial rupture of membranes was performed more frequently in these women, they used more pain relief and had a higher incidence of complicated childbirth; however, these differences were not statistically significant.

KEY CONCLUSIONS

labour contractions can increase or decrease in frequency following admission to hospital, and the change of frequency may be associated with stage of cervical dilatation and posture rather than anxiety.

IMPLICATIONS FOR PRACTICE

routine intervention to speed up labour on the basis of admission observations is called into question, and women should be made aware that slowing of contractions can occur as a normal part of changing the labour environment. Further research is needed to determine the physiological parameters of spontaneous labour and the role of posture in labour progress is needed.

Maternal positions and mobility during first stage labour

BACKGROUND

It is more common for women in the developed world, and those in low-income countries giving birth in health facilities, to labour in bed. There is no evidence that this is associated with any advantage for women or babies, although it may be more convenient for staff. Observational studies have suggested that if women lie on their backs during labour this may have adverse effects on uterine contractions and impede progress in labour.

OBJECTIVES

The purpose of the review is to assess the effects of encouraging women to assume different upright positions (including walking, sitting, standing and kneeling) versus recumbent positions (supine, semi-recumbent and lateral) for women in the first stage of labour on length of labour, type of delivery and other important outcomes for mothers and babies.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (November 2008).

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing women randomised to upright versus recumbent positions in the first stage of labour.

DATA COLLECTION AND ANALYSIS

We used methods described in the Cochrane Handbook for Systematic Reviews of Interventions for carrying out data collection, assessing study quality and analysing results. A minimum of two review authors independently assessed each study.

MAIN RESULTS

The review includes 21 studies with a total of 3706 women. Overall, the first stage of labour was approximately one hour shorter for women randomised to upright as opposed to recumbent positions (MD -0.99, 95% CI -1.60 to -0.39). Women randomised to upright positions were less likely to have epidural analgesia (RR 0.83 95% CI 0.72 to 0.96).There were no differences between groups for other outcomes including length of the second stage of labour, mode of delivery, or other outcomes related to the wellbeing of mothers and babies. For women who had epidural analgesia there were no differences between those randomised to upright versus recumbent positions for any of the outcomes examined in the review. Little information on maternal satisfaction was collected, and none of the studies compared different upright or recumbent positions.

AUTHORS' CONCLUSIONS

There is evidence that walking and upright positions in the first stage of labour reduce the length of labour and do not seem to be associated with increased intervention or negative effects on mothers' and babies' wellbeing. Women should be encouraged to take up whatever position they find most comfortable in the first stage of labour.

Evidence-based labor and delivery management

Our objective was to provide evidence-based guidance for management decisions during labor and delivery. We performed MEDLINE, PubMed, and COCHRANE searches with the terms labor, delivery, pregnancy, randomized trials, plus each management aspect of labor and delivery (eg, early admission). Each management step of labor and delivery was reviewed separately. Evidence-based good quality data favor hospital births, delayed admission, support by doula, training birth assistants in developing countries, and upright position in the second stage. Home-like births, enema, shaving, routine vaginal irrigation, early amniotomy, "hands-on" method, fundal pressure, and episiotomy can be associated with complications without sufficient benefits and should probably be avoided. We conclude that labor and delivery interventions supported by good quality data as just described should be routinely performed. All aspects with lower data quality should be researched with adequately powered and designed trials.

[Modality of fetal heart monitoring during labor (continuous or intermittent), telemetry and central fetal monitoring]

Fetal heart monitoring during labor is almost systematic today. Continuous monitoring decreases neonatal convulsions, but increases caesarean section and forceps deliveries without impact on long term neonatal prognosis. Overall, there is no proved impact of cardiac fetal monitoring (continuous or intermittent) on perinatal mortality. The most recent study shows neonatal benefits of continuous monitoring associated with an overall increase of caesarean section rate. Continuous fetal monitoring has a better sensitivity to detect acidosis. Many arguments for continuous fetal monitoring will be reported in this review. In specific conditions, intermittent fetal auscultation can be realised, but in current practice such conditions can rarely be applied. Telemetry has been poorly evaluated to date but experiences are currently undertaken. Central fetal monitoring does not improve neonatal issue but could increase caesarean section rate. Central of fetal monitoring could help in the organisation and the conservation of fetal heart monitoring.

Maternal position during the first stage of labor: a systematic review

Background

Policy makers and health professionals are progressively using evidence-based rationale to guide their decisions. There has long been controversy regarding which maternal position is more appropriate during the first stage of labor. This problem has been examined often and repeatedly and the optimal recommendation remains unclear.

Methods

This is a systematic review of the effect of maternal position during the first stage of labor. The main question addressed here is: Does encouraging women to adopt an upright position or to ambulate during the first stage of labor reduce the duration of this stage? All randomized controlled trials carried out to assess this effect were taken into consideration in this review. The following electronic databases were accessed to identify studies: MEDLINE, Popline, the Scientific Electronic Library On-line and the Latin American and Caribbean Health Science Information. Citation eligibility was independently assessed by two reviewers. The methodological quality of each trial was also evaluated independently by two reviewers and a trial under consideration was included only when consensus had been attained. Allocation concealment and screening for the occurrence of attrition, performance and detection biases were considered when studies were appraised. The decision whether to perform data pooling was based on the clinical similarity of studies.

Results

The search strategy resulted in 260 citations, of which 18 were assessed in full-text. Nine eligible randomized controlled trials were included in the systematic review. Randomization methods were not fully described in eight studies. The allocation concealment was considered adequate in four studies and unclear in five. The investigators pooled the data from seven studies in which the length of the first stage of labor and results were in favor of the intervention, but the high level of heterogeneity (I² = 88.4%) impaired the meaning of this finding. The intervention did not affect other outcomes studied (mode of delivery, use of analgesia, labor augmentation and condition of the child at birth).

Conclusion

Adoption of the upright position or ambulation during first stage of labor may be safe, but considering the available evidence and its consistency, it cannot be recommended as an effective intervention to reduce duration of the first stage of labor.

Ambulatory labor analgesia: what does an obstetrician need to know?

A simple statement that describes the degree of the patient's satisfaction with the pain relief from her labor epidural analgesia has often assessed the quality of labor analgesia as perceived by the patient. Many laboring parturients, midwives, obstetricians and anesthesiologists are increasingly concerned by the limitations of traditional epidural labor analgesia. In general, women dislike the inability to void, the often-dense motor block, the feeling of numbness of the lower body, the total lack of the urge to bear down, and the complete perineal anesthesia. Continuous search for balanced labor analgesia that provides relief from pain, while preserving motor function, has led to the development of an ambulatory labor analgesia technique. This article assesses the validity of various strongly advocated opinions as to whether parturients benefit from ambulation in labor and also reviews the current trends in ambulatory labor analgesia.

The effects of prolonged ambulation on labor with epidural analgesia

Ambulation during labor is becoming more popular, although its impact on the progress of labor and on pain intensity remains unclear. We wondered whether prolonged ambulation with epidural analgesia had a possible effect on duration of labor and pain. In this prospective, randomized trial, 61 parturients with uncomplicated term pregnancies were allocated to be recumbent (n = 31) or to ambulate (n = 30). Epidural analgesia was provided with intermittent administrations of 0.08% bupivacaine-epinephrine plus 1 microg/mL of sufentanil. Of the 30 women assigned to the ambulatory group, 25 actually walked. Their ambulating time was 64 +/- 34 min (mean +/- SD), i.e., 29% +/- 16% of the first stage. There were no differences between the two groups in the length of labor and in pain visual analog scale scores. However, the ambulatory group received smaller doses of bupivacaine (6.4 +/- 2.2 mg/h versus 8.4 +/- 3.6 mg/h; P = 0.01) and of oxytocin (6.0 +/- 3.7 mUI/min versus 10.2 +/- 8.8 mUI/min; P < 0.05). A greater ability to void was also found in the ambulatory group (P < 0.01). Although the duration of labor and pain relief was unchanged, these findings support that ambulation during labor may be advantageous.

IMPLICATIONS

This study compared the duration of labor and pain relief between parturients receiving epidural analgesia who were ambulated or were recumbent. Whereas walking had no impact on either duration of labor or pain relief, it was associated with a reduction in both bupivacaine and oxytocin requirements.

Ambulatory epidural anesthesia and the duration of labor

OBJECTIVES

Ambulatory epidural analgesia has become a common option for women in labor in France. We tested the hypothesis that a method of epidural analgesia that allowed women to walk had specific advantages regarding mode of delivery, consumption of local anesthetic, oxytocin requirement, and labor duration.

METHODS

Two hundred and twenty-one women with uncomplicated pregnancies who presented in spontaneous labor between 36 and 42 weeks of gestation or who were scheduled for induced labor were randomly divided into two groups, ambulatory and non-ambulatory. All were given intermittent epidural injections of 0.1% ropivacaine with 0.6 microg/ml sufentanil for analgesia during labor (P<0.05 was considered significant). None of the women had previous cesarean delivery.

RESULTS

There were no significant differences between the two groups in mode of delivery, consumption of local anesthetic, or oxytocin requirement. However, a significant difference was noted in labor duration (173.4+/-109.9 min vs. 236.4+/-130.6 min; P=0.001).

CONCLUSIONS

Walking with ambulatory labor analgesia shortens labor duration but has no other effect on the progress and outcome of labor.

Combined spinal-epidural analgesia for labor: breakthrough or unjustified invasion?

The combined spina-epidural (CSE) technique has become increasingly popular for labor analgesia. The advantages of the CSE include more rapid onset of analgesia, reduced total drug dosage, minimal or no motor blockade, and increased patient satisfaction. CSE has also been associated with more rapid cervical dilation when compared to epidural analgesia in nulliparous women in early labor. Despite these potential advantages, the indications for CSE versus epidural analgesia remain unclear and controversial. This review should allow better understanding of the benefits and risks of this technique, and bearing in mind that no ultimate neuraxial analgesic exists, it would seem that CSE should be considered a major breakthrough in the management of labor analgesia.

Upright versus recumbent position in the second stage of labour in women with combined spinal-epidural analgesia

Neuraxial blockade is widely used for pain relief in labour. This form of analgesia may be associated with an increase in instrumental delivery rates due to dystocia. 'Traditional' epidurals cause motor blockade and hence immobility. Using a low dose anaesthetic-opioid combination with either epidural or combined spinal-epidural, selective sensory blockade can be achieved, allowing mobility as well as pain relief. In this study, we randomised women with combined spinal-epidural analgesia either to mobilise (upright group n = 25) or to remain recumbent (n = 41) in the second stage of labour. We found women in the upright group had significantly shorter total second stage, (132 vs 109 min,P = 0.019) particularly during the pushing phase (73 vs 51 min, P = 0.011). Although there were fewer instrumental deliveries in the upright group, this was not statistically significant. Women who were randomised to the upright group, did actually mobilise. We conclude that mobilisation in the second stage of labour is possible, and may reduce the length of the second stage.

Maternal posture in labour

The position adopted naturally by women during birth has been described as early as 1882 by Engelmann. He observed that primitive woman, not influenced by Western conventions would try to avoid the dorsal position and was allowed to change position as and when she wished. Different upright positions could be achieved using posts, slung hammock, furniture, holding on to a rope, knotted piece of cloth, or the woman could kneel, crouch, or squat using bricks, stones, a pile of sand, or a birth stool. Today the majority of women in Western societies deliver in a dorsal, semi-recumbent or lithotomy position. It is claimed that the dorsal position enables the midwife/obstetrician to monitor the fetus better and thus to ensure a safe birth. This paper examines the historical background of the different positions used and its evolution throughout the decades. We have reviewed the available evidence about the effectiveness, benefits and possible disadvantages for the use of different positions during the first and second stage of labour.

Intrathecal sufentanil versus epidural lidocaine with epinephrine and sufentanil for early labor analgesia

Intrathecal sufentanil provides approximately 2 h of excellent labor analgesia with minimal motor blockade. Epidural sufentanil has received less scrutiny but may provide the same benefits as intrathecal sufentanil. In this study, we compared epidural sufentanil 40 microg after a lidocaine with an epinephrine test dose with intrathecal (i.t.) sufentanil 10 microg with respect to onset and duration of analgesia, degree of motor block, side effect profile, and mode of delivery. Seventy ASA physical status I or II parturients in early labor (< or = 4 cm cervical dilation) were randomized to receive either i.t. sufentanil 10 microg with a combined spinal-epidural technique (CSE) or epidural sufentanil 40 microg (e.p.) after epidural catheter placement and testing with 3 mL of 1.5% lidocaine with epinephrine (15 microg). After the administration of analgesia, pain scores and side effects were recorded for each patient at 5, 10, 15, 20, and 30 min, and every 30 min thereafter, by an observer blinded to the technique used. The study period was completed when the patients requested additional analgesia. All patients, except one, achieved adequate analgesia with the initial study dose and satisfactorily completed the study. There were no demographic differences between the two groups. Pain relief was rapid for all patients; pain scores were significantly lower at 5 and 10 min in the i.t. group versus the e.p. group. The mean duration of analgesia was similar between the e.p. group (127 +/- 40 min) and the i.t. group (110 +/- 48 min). No patient experienced any motor block. Side effects were similar between the two groups, except for pruritus-both the incidence and severity were significantly more profound at 5, 10, 15, 20, and 30 min in the i.t. group. There was no difference in time from analgesic to delivery, incidence of operative or assisted delivery, or cervical dilation at the time of redose. For early laboring patients, epidural sufentanil 40 microg after a lidocaine test dose provides analgesia comparable to that of i.t. sufentanil 10 microg with less pruritus.

IMPLICATIONS

We compared the efficacy and side effects of intrathecal sufentanil with epidural sufentanil with a local anesthetic test dose for analgesia during labor. Analgesia was equally good, although the intrathecal group experienced more itching.

Lack of effect of walking on labor and delivery

BACKGROUND AND METHODS

Walking during labor may reduce patients' discomfort and improve outcomes. We conducted a randomized trial of walking during active labor to determine whether it altered the duration of labor or other maternal or fetal outcomes. Women with uncomplicated pregnancies between 36 and 41 weeks' gestation and in active labor were randomly assigned either to walking or to no walking (usual care). Pedometers were used to quantify walking, and the time spent walking was recorded.

RESULTS

Of the 536 women assigned to the walking group, 380 actually walked. Their mean (+/-SD) walking time was 56+/-46 minutes. There were no significant differences between the women assigned to the walking group and the 531 women assigned to the usual-care group in the duration of the first stage of labor (6.1 hours in both groups, P=0.83), the need for labor augmentation with oxytocin (23 percent vs. 26 percent, P=0.25), and the use of analgesia (84 percent vs. 86 percent, P=0.59). Similarly, the percentages of women requiring delivery by forceps (4 percent vs. 3 percent, P=0.35) and cesarean section (4 percent vs. 6 percent, P=0.25) were not significantly different. These labor and delivery outcomes were unrelated to walking in both nulliparous and parous women. The infants' outcomes were also similar in the two study groups.

CONCLUSIONS

Walking neither enhanced nor impaired active labor and was not harmful to the mothers or their infants.

Effects of early augmentation of labour with amniotomy and oxytocin in nulliparous women: a meta-analysis

OBJECTIVES

To estimate the effects among nulliparae of early augmentation with amniotomy and oxytocin on caesarean delivery, and on other indicators of maternal and neonatal morbidity including transfusion. Apgar score < 7 at 5 minutes, and admission to the special care nursery.

DESIGN

Meta-analysis.

METHODS

Published studies were identified through manual and computerised searches. Two unpublished studies were identified through direct communication with the investigators. Twelve trials were identified which compared a policy of early labour augmentation including amniotomy followed by oxytocin with a less active form of management. Two methodologically unacceptable studies were excluded. Studies were grouped according to whether they admitted only women with abnormal progress (therapy trials: n = 3) or accepted women with normal labour (prevention trials: n = 7).

RESULTS

Unstratified analysis did not provide support for the hypothesis that early augmentation reduces the risk of caesarean section (typical odds ratio [OR] 0.9; 95% CI 0.7-1.1). The typical odds ratio for prevention trials was similar to that obtained in the unstratified analysis (typical OR 0.9, 95% CI 0.7-1.2). Although only a small number of women have been randomised in therapy trials, a trend toward a reduction in the rate of caesarean section with early intervention was seen in this group (typical OR 0.6, 95% CI 0.2-1.4).

CONCLUSIONS

Early augmentation does not appear to provide benefit over a more conservative form of management in the context of care of nulliparous women with mild delays in the progress of labour. In the context of established delay in labour, an active policy of augmentation may reduce the risk of caesarean section. However, only three small trials have been performed in this context, and they do not have adequate power to allow firm conclusions to be drawn.

Epidural analgesia compared with combined spinal-epidural analgesia during labor in nulliparous women

BACKGROUND

Among nulliparous women, there appears to be an association between the use of epidural analgesia during labor and an increased risk of dystocia. We tested the hypothesis that combined spinal-epidural analgesia, which permits ambulation during labor, is associated with a lower incidence of dystocia than continuous lumbar epidural analgesia.

METHODS

Between July 1995 and September 1996, we randomly assigned 761 nulliparous women in spontaneous labor at term who requested epidural analgesia to receive either continuous lumbar epidural analgesia or a combination of spinal and epidural analgesia. Among the women who received combined spinal-epidural analgesia, some were discouraged from walking and others were encouraged to walk. Maternal and neonatal outcomes, the incidence of dystocia necessitating cesarean section, and measures of patients' satisfaction were compared in the two groups.

RESULTS

There were no significant differences in the overall rate of cesarean section, the incidence of dystocia, the frequency of maternal or fetal complications, the patients' or nursing staff's assessment of the adequacy of analgesia, or the degree of overall satisfaction between the two groups. Significantly more women receiving combined spinal-epidural analgesia had pruritus (P<0.001) and requested additional epidural bolus doses of local anesthetic (P=0.01). For all the women, dystocia necessitating cesarean section was significantly more likely when analgesia was administered with the fetal vertex at a negative station (odds ratio, 2.5; P<0.001) or at less than 4 cm of cervical dilatation (odds ratio, 2.2; P<0.001).

CONCLUSIONS

As compared with continuous lumbar epidural analgesia, the combination of spinal and epidural analgesia is not associated with an overall decrease in the incidence of cesarean delivery.

Positioning during the second stage of labor: moving back to basics

The advantages of an upright position during labor are presented, with historic, physiologic, and psychosocial aspects discussed. The influences of modern obstetric practices such as electronic fetal monitoring and anesthesia practices are discussed with findings related to the use of upright positions from the Association of Women's Health, Obstetric, and Neonatal Nursing National Research Utilization Project on Second Stage Labor Management integrated. Recommendations for facilitating upright positions on the labor and delivery unit are presented.

Standards in fetal monitoring--practical requirements for uterine activity measurement and recording

External monitoring of uterine contractility in human labour can record contraction frequency accurately, but cannot determine true intra-uterine pressure reliably. It is therefore suitable for use in spontaneous labour where there is a need for a marker of contractions to aid in continuous fetal heart rate pattern interpretation. Intra-uterine pressure measurement can provide quantitative information more reliably over intervals of 10-60 minutes. Although active pressure values for individual contractions can vary by up to 50% when measured simultaneously by two or more intra-uterine catheters/transducers, this variation is not systematic and cumulative measures vary by less than 5%. The measurement of baseline tone is affected by variables not related to uterine activity and should therefore be excluded when quantitative measures are made.

Ambulation versus oxytocin in protracted labour: a pilot study

We compared ambulation with oxytocin in the treatment of protracted labour with a randomized, controlled trial of 57 patients. Sixty percent of the women in the ambulant group delivered their babies without oxytocin. In the ambulant group, the mean length of the second stage of labour was shorter and the women themselves held relatively positive views on their experiences. In the oxytocin group, on the other hand, the women experienced stronger contractions before pushing and also suffered from more excessively strong contractions. Our trial included too few women to judge which treatment is better for the infant's health. Nevertheless, the women's opinions and the quality of their contractions demonstrate that more attention should be paid to ambulation as a treatment for protracted labour.

Vaginal birth after cesarean

Recent studies prompted by the high cesarean birth rates have looked at the issue of vaginal birth after cesarean. The risk of attempting a vaginal birth after cesarean appears to be minimal for selected clients. As more and more obstetricians begin to offer vaginal birth after cesarean to their patients, nurses will need to be fully informed about this option. A review of the pertinent literature relating to vaginal birth after cesarean and nursing implications are presented.

The art of induction/augmentation of labor

To manage safely and effectively oxytocin administration, nurses must be knowledgeable in theory and skilled in technique. Current theory is explored regarding initiation of labor and cervical ripening. The pharmacology of oxytocin, uterine response to endogenous and exogenous stimulation of oxytocin, and current methods being used to induce/augment labor are discussed. A protocol to provide safe, effective guidelines for managing induction/augmentation of labor is provided. The goal in oxytocin administration is to use the minimum dose necessary to facilitate and maintain an effective uterine response and avoid hyperstimulation and fetal distress.

Application of a real-time microcomputer monitoring system: surveillance of induced labour by uterine activity quantitation

The uterine activity of women during induced labour was analysed with a real-time Commodore PET 2001 series microcomputer. The active contraction area was measured in torr-min (1 torr = 0.133 kPa) per 10 min epochs [uterine activity unit (UAU)/10 min]. Surgical induction was followed immediately by administration of a geometric oxytocin infusion and all patients received epidural analgesia. Twenty-eight primigravidae for whom inductographic and partographic progress were normal had a mean 'stable phase' uterine activity of 118 +/- 2 SD 43 UAU/10 min (identical to 942 +/- 2 SD 343 kPas/10 min) whereas 15 multiparae had a mean 'stable phase' of 83 +/- 2 SD 34 UAU/10 min (identical to 662 +/- 2 SD 271 kPas/10 min). This difference was significant (P less than 0.01). The construction of uterine activity charts is described and their clinical application discussed.