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.