New Labor Guidance, Part 3

Previous podcasts:

Part 2 of Preventing the Primary Cesarean (old - for comparison)

Limiting Interventions in Labor and Birth (based on CO 766)

CPG 8 Part 1, CPG 8 Part 2

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Also check out for reading for this podcast specifically:
- Committee Opinion 766 on Approaches to Limiting Intervention in Labor and Birth

• Continuous labor support

• Defined: continuous presence of support personnel or the continuous presence of a one-on-one person for support. 

• This support comes in many forms, including:

• Emotional support

• Information about labor progress

• Advice about  coping techniques

• Providing/facilitating comfort measures

• Speaking up on behalf of the pregnant individual, when needed

• Noted in CPG8 as “one of the most effective tools to improve labor and delivery outcomes.”

• Systematic review: pregnant women allocated to continuous support benefitted from:

• More likely to have SVD (RR 1.08, 95% CI 1.04 - 1.12)

• Less likely to have negative feelings of childbirth experience (RR 0.69, CI 0.59 - 0.79)

• Less likely to use any intrapartum analgesia (RR 0.90, 95% CI 0.64 - 0.88).

• Have shorter labors (-0.69 hrs; 95% CI -1.04 to -0.34)

• Less likely to have cesarean birth (RR 0.75, CI 0.64 - 0.88)

• Less likely to have operative vaginal delivery (RR 0.90, CI 0.85 - 0.96)

• Less likely to have neonate with 5-min Apgar < 7 (0.62, CI 0.46 - 0.85)

• CPG 8 notes that OB/Gyns and health care providers/organizations should strive to develop policies and programs to integrate trained support personnel into intrapartum care to provide one-to-one support for laboring persons.

• The Peanut Ball

  • Elongated, peanut-shaped ball, typically placed between a patient’s legs during labor while the patient is side-lying in order to “open up the pelvis.”

  • In theory, this mimics upright positioning with the opening of the pelvis.

  • A systematic review of four randomized trials of 648 patients found no significant difference for time in labor or incidence of vaginal delivery/cesarean delivery with peanut ball use. 

  • There were nonsignificant trends towards improving vaginal delivery rates and shortening first stage length

  • However, evidence is further limited as guidance for how to use, what size to use, how long to use, when to use…

    • How the peanut ball is implemented in labor courses is heterogenous and driven a lot by personal/nursing experience. 

  • More studies are needed to understand when/if it might be efficacious in particular scenarios.

  Position Change and Ambulation

• Similarly to the peanut ball, there are many opinions on this!

• Observational studies find that patients assume many different positions during labor when left to their own devices on what is comfortable.

• A meta-analysis comparing upright positioning (sitting/standing/kneeling), ambulation, or both with recumbent, lateral, or supine positions during first stage of labor found that upright positions:

• Reduced first stage length by approximately 1h 22 min (95% CI -2.22 to -0.51 hr)

• Less likely to undergo cesarean (RR 0.71, 95% CI 0.54-0.94)

• A separate review found no differences in these factors, but found reduced trauma to pelvic floor for those in kneeling position.

• CPG 8 encourages position changes to enhance maternal comfort and promote optimal fetal positioning.

• Hydration modalities

• CPG 8 notes that IV hydration is safe, but limits freedom of movement and overall may not be necessary

  • Oral hydration can be encouraged to meet caloric and hydration needs.

• They review a systematic review comparing 250cc/hr of IV fluid to 125cc/h in low risk patients in spontaneous labor at term, demonstrating a lower risk of cesrean for any indication in the 250cc/hr group (12.5% vs 18.1%, RR 0.70).

• Higher fluid rates also shortened duration of labor by mean of about 1 hour, and second stage specifically by just under 3 mins. 

• Also did not observe increasing maternal or neonatal morbidities, including pulmonary edema.

• Recommended increased hydration for nulliparous women when oral intake is restricted.

• Further study is needed to compare when oral intake / oral hydration is not restricted; when patients are undergoing induction of labor; or if comorbidities exist.

• Cervical examinations

• Frequency of cervical examination is frequently cited as a concern for infection, and has to be balanced against understanding labor progress and preventing arrest/dystocia.

• The CPG authors note a retrospective cohort study of 2400 patients over 4 years showing no significant association between number of cervical exams in labor and intrapartum fever.

• The association was also not present when confined to exams after amniotomy.

Limiting Intervention in Labor and Birth

Check out ACOG CO 766 for more on this subject!

Patients in labor and delivery have more information (whether accurate or inaccurate) than ever before to inform their opinions, choices, and risk tolerance.

• One certainty - more patients are choosing birth centers and home birth as a perceived way to reduce intervention and promote physiologic labor

• Today we review practices that are worth reviewing on your unit to limit intervention, when appropriate, in a generally low-risk patient; we are not advocating for non-intervention, to be clear! 

Coping in Labor Techniques

Continuous Emotional Support in Labor

• Randomized trial evidence supports use! 

• Continuous labor support:

  • Shorter labor

  • Decreased need for analgesia

  • Fewer operative deliveries

  • Fewer reports of dissatisfaction with experience 

  • Less cesarean (RR 0.75 in Cochrane review) → suggesting potential for cost-effectiveness

  • Less likely to have 5-minute Apgar <7 (RR 0.62)

• Continuous labor support can come in the form of:

  • Doulas: individuals with some degree of training in continuous labor support

    • There are official doula certification programs, as well as those who are truly “lay doulas” if you will.

  • Friends/family: an RCT of 600 patients demonstrated teaching labor support techniques to friends/family in labor room was effective, reducing labor duration and had higher Apgar scores.

  • Tech? The pandemic has definitely increased interest in virtual or mobile doula apps… though evidence is sparse.

Nonpharmacologic Techniques for Coping

• “Coping” -- a better and more complete way to assess labor pain, and denotes some normal, physiologic discomfort with labor. 

  • Asking the patient how they are “coping” also can provide a way to assess other factors which may influence pain or its experience, such as anxiety or support.

• Few non-pharmacologic techniques have been well-studied to determine effectiveness or comparative effectiveness. There are trials, but with substantial heterogeneity in their techniques and application. 

  • However, some options:

    • Water immersion: has been shown in observational trials to lower pain scores without evidence of harm in 1st stage of labor

    • Intradermal sterile water injections

    • Acupuncture/massage

    • TENS (transcutaneous electrical nerve stimulation)

    • Aromatherapy

    • Audioanalgesia

      • Shout out to one of the coolest studies we have seen in recent memory - Melissa Wong at Cedars-Sinai in LA, exploring virtual reality as a way to improve coping.

    • Additional shout out to Rebcca Dekker, PhD RN, who runs the Evidence Based Birth website and has a really excellent and frequently updated series on pain management in labor. 

      • Her book, Babies Are Not Pizzas, is also a worthwhile look at our own potential biases as obstetricians / trainees from a combined patient and birth professional perspective.

Obstetrical Management of Labor and Delivery

Latent Labor: When to admit?

• We’ve all been there: on the fence about whether and when to admit the patient in latent or early labor.

• Observational trials associate early admission with:

  • More labor arrest

  • More oxytocin use

  • More IUPC use

  • More antibiotic use for fevers

  • More cesarean delivery in active phase

    • Importantly, these studies cannot determine whether this was directly associated with presenting to the hospital for care, or if those with a “dysfunctional” latent phase are more likely to present and thus skew these results.

• RCTs:

  • Delayed (awaiting active phase) vs early (on presentation) admission:

    • Delayed group had lower rates of epidural use and labor augmentation

    • Delayed group had greater satisfaction

    • Delayed group spent less time in L&D

    • NO difference in operative delivery, cesarean delivery, and newborn outcomes (though too small to be powered sufficiently).

  • ARRIVE trial

    • Induction at 39 weeks versus awaiting spontaneous labor/medical induction

      • LESS cesarean delivery in 39 week IOL group (18.6 vs 22.2%)

      • NO difference in neonatal outcomes

        • Rates of spontaneous labor in the expectant management group are not reported/compared, and admission practices in this group are not reported (i.e., rate of early admission in latent labor / need for augmentation / etc)

        • So ARRIVE trial does not answer the question of whether spontaneous labor is better, but does provide a data point to suggest equipoise/potential benefit between 39 week induction and awaiting spontaneous labor, whether it comes or not. 

          • Important to keep in mind as you counsel patients re: 39 week inductions.

  • Admission may be necessary for a variety of reasons, including pain management and fatigue, and this can be used as a time to implement/supplement coping strategies (as previously discussed)

Term Prelabor Rupture of Membranes (PROM): To Induce or Not to Induce?

• A super common scenario, in which there are a number of potential patient questions:

  • Do I need to induce right away, or can I wait for spontaneous labor?

  • If I wait, how long can I wait?

  • If I don’t wait, what is the best method to start labor?

• Historical studies have demonstrated ~78% of patients will labor within 12 hours, and 95% in 24-28 hours after PROM.

  • TERMPROM RCT: induction vs expectant management of PROM

    • 4-armed RCT: immediate induction arms (oxytocin vs prostin gel), and expectant mgmt arms (where given up to 4 days PROM’d or clinical concern for chorio before being induced).

    • Median time to delivery for expt mgmt arms were 33 hrs, 95% delivering by 94-107 hours after rupture.

• However, immediate induction can reduce other risks (based on systematic review, where 60% of patients were TERMPROM trial):

  • Decreased time to delivery by 10 hours

  • Chorioamnionitis / endometritis decreased (RR 0.49)

  • Early onset neonatal sepsis decreased (RR 0.73)

  • NICU admission decreased (RR 0.75)

    • Importantly, the overall quality of evidence for neonatal outcomes in particular is low, and additional RCTs in this space are welcomed! 

• In terms of methods, TERMPROM noted that # of vaginal exams and fever risks were slightly less overall with oxytocin

  • Though the prostaglandin used here was vaginal gel, so likely increased # of exams

  • Time to delivery was similar in both groups

  • Other trials have not found significant benefits to prostaglandin vs oxytocin

  • Some other trials have evaluated balloon catheter use in PROM

    • Potentially increased infection risk, especially if used alone (9.7% vs 2.9% in oxytocin alone)

    • With respect to combining balloon with pharmacologic agent, appears to be no benefit to ballon + oxytocin vs oxytocin alone (though small numbers overall evaluating this)

• So back to our initial questions:

  • Do I need to induce right away, or can I wait for spontaneous labor?

  • If I wait, how long can I wait?

  • If I don’t wait, what is the best method to start labor?

    • It’s reasonable to wait some time for spontaneous labor, based on TERMPROM data suggesting almost 80% of patients will labor by 12 hours after PROM. 

      • However, patients should be aware of potentially increased risk 

      • If GBS+, patients should be started on PCN to reduce neonate GBS sepsis risk.

    • Oxytocin seems to be the best agent, though evidence is somewhat limited overall.

Intermittent Auscultation of Fetal Heart Rate

• cEFM has unfortunately not been shown to significantly affect outcomes like perinatal death or cerebral palsy rates, but has become entrenched in OB practice.

• IA can be used in low risk patients and potentially decrease risk of cesarean:

  • Cochrane review of 13 RCTs, cEFM vs IA. cEFM:

    • Increased CD risk (RR 1.63)

    • Increased operative vaginal delivery risk (RR 1.15)

    • Decreased risk of early neonatal seizures (RR 0.50)

    • No difference in rates of CP or neonatal death, and no difference in outcomes at 4 years of age.

  • Low risk is very important to define! Inclusion criteria for IA varies by institution, but generally:

    • No meconium staining, intrapartum bleeding, or abnormal fetal testing before admission

    • No fetal conditions that may increase risk (i.e., anomalies, FGR)

    • No maternal conditions that may increase risk (i.e., TOLAC, DM, HTN)

    • No requirement for induction or augmentation of labor (i.e., spontaneous normal labor only)

• ACNM and Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) have excellent guidelines and protocols for IA for nursing in particular.

Routine Amniotomy

• Depending on where you are and practice patterns, this might be one of the most controversial things in labor management! 

• “Routine amniotomy in spontaneous labor” 

  • Notably, this separates out when amniotomy is indicated, such as to facilitate FSE/IUPC or for slow labor progress in combination with oxytocin. 

  • This essentially is looking at just the role of amniotomy then in spontaneous labor. 

• Amniotomy alone:

  • Doesn’t shorten duration of spontaneous labor

  • Doesn’t reduce incidence of cesarean

  • Doesn’t reduce patient satisfaction

  • Doesn’t reduce rates of 5 min Apgar score <7

  • Doesn’t increase rates of abnormal FHR pattern

  • Doesn’t increase rates of cord prolapse

• So is there a reason?

  • Not to do routinely -- reserve in spontaneous labor to facilitate monitoring or interventions if indicated. 

• How about within the context of labor induction?? -- that’s what you’re really wanting to know!

  • 14 trial meta-analysis:

    • When used alongside oxytocin:

      • Decreased length of first stage of labor (1.11 hrs)

      • Modest reduction in cesarean birth rate (RR 0.87 vs expectant mgmt)

  • 4 trial meta-analysis comparing “early” vs “late” amniotomy after cervical ripening:

    • Early = before active phase; late = after active phase, or awaiting SROM

      • Similar rates of cesarean (RR 1.05)

      • Early amniotomy with faster interval to delivery (5 hours)

      • SVD rates overall similar between groups, though technically reduced in early group on basis of single trial (67.5% vs 69.1%)

      • No increased risk of cord prolapse, hemorrhage, abruption, chorio, neonatal outcomes 

    • Takeaway:

      • AROM is reasonable, when indicated to facilitate monitoring, especially if oxytocin already started.

      • May reduce time to delivery without necessarily increasing other risks.

      • Very little data to guide this overall, so more study welcomed!

Immediate versus Delayed Pushing

• The CO qualifies and speaks specifically to nulliparous patients with epidural analgesia being allowed to “passively descend” or “labor down” once identified to be 10cm.

  • The potential benefit to this is to allow the fetus to passively rotate and descend in the pelvis and conserve maternal energy.

• Importantly, studies that have looked at risk of adverse outcomes with length of second stage (i.e., Consortium on Safe Labor data informing the ACOG/SMFM Obstetric Care Consensus about recommended length of time to push) do not take into account duration of passive descent vs active pushing, just total time in 2nd stage.

• Data reviewed in the CO:

  • 2 meta-analyses of RCTs demonstrate delayed pushing 1-2 hours:

    • Increases length of 2nd stage by approx 1 hour

    • Decreases pushing length by approx 20 minutes

    • No difference in SVD rate

  • Recent 2018 RCT that you probably saw in JAMA, delay pushing 60 mins vs immediate pushing (again in nullips with an epidural):

    • Trial stopped before intended recruitment because of increased morbidity in the delayed group.

    • No difference in SVD rate

    • Immediate pushing resulted in:

      • Lower rates of chorio (RR 0.7)

      • Lower rates of PP hemorrhage (RR 0.6)

      • Lower risk of neonatal acidemia (RR 0.7)

• Overall, delayed pushing in the nullipara with an epidural seems to not confer benefit, and likely increases risk for harm.