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  • Nathan Riley, MD

Obgyno Wino Podcast Episode 10 - Approaches to Limit Intervention During Labor and Birth

"The first principle is that you must not fool yourself — and you are the easiest person to fool.” -Richard Feynman

2015 Gentleman’s collection Red Blend from Lindeman’s Winery

CO#766 - Published February 2019

In a rush? Here is the skinny

- for low-risk pregnancies w/ fetus in vertex presentation, labor management may be individualized: intermittent auscultation of fetal heart tones (e.g. handheld Doppler) and delayed admission

- nonpharmacologic methods of pain relief

- PROM: IOL should be recommended, but reasonable to offer expectant management for 12-24 hrs if GBS negative

- women’s choice of how to breathe during pushing (e.g. valsalva or open glottis)

- frequent position changes to enhance maternal comfort and promote optimal fetal positioning

- gentle c-section

- one-to-one emotional support throughout labor (e.g. doula)

- DOES NOT support “laboring down”

- DOES NOT support routine amniotomy if labor progressing normally

Definition of “low risk”

- Goal of this document is not to assist with risk stratification, but for our purposes, low-risk is characterized as: “a clinical scenario for which there is not clear demonstrable benefit for a medical intervention”

- generally: no meconium staining, intrapartum bleeding, or abnormal or undetermined fetal test results; no fetal factors that would predispose the fetus to acidemia during labor (eg congenital anomalies, IUGR); no significant maternal conditions (eg prior hysterotomy, diabetes, HTN); and no requirement for oxytocin induction or augmentation

- The purpose of this document? To empower obstetricians to tailor labor interventions to meet clinical safety requirements and the individual woman’s preferences

- cost savings, improved outcomes, improved patient satisfaction

Admission in latent labor

- admission in latent phase of labor → more arrest of labor and cesarean births in the active phase, greater use of oxytocin, IUPCs, and antibiotics for intrapartum fever (observational data)

- however “these outcomes reflected [EITHER] longer exposure to the hospital environment or a propensity for dysfunctional labor among women who present for care during the latent phase”

- an RCT comparing immediate admission versus delayed admission found the latter associated with: lower rates of epidural use and augmentation of labor and greater patient satisfaction

- expectant management (versus admission) recommended for women at 4-6 cm dilation and considered to be in latent labor, as long as fetal and maternal status is reassuring

- admission for pain management or maternal fatigue may be reasonable

Term PROM: expectant management versus immediate induction?

- ~80% of women will go into spontaneous labor within 12 hrs, 95% in ~24 hrs (observational)

- TERMPROM trial (RCT): median time to delivery with expectant management was 33 hrs; 95% had delivered by ~100 hrs

- Cochrane: no difference in CD rates or definite early-onset sepsis but did find an increased risk of chorio and endometritis and decreased NICU admission in PROM managed expectantly (all low quality evidence)

- expectant management thus reasonable with appropriate counseling

- we know that the longer a person remains pregnant and ruptured, the greater the risk for infection, but the optimal duration of expectant management is unknown

- this document suggests 12-24 hrs as a reasonable compromise

- recommend against delaying antibiotic administration if GBS positive

Continuous support during labor

- continuous one-on-one support improves outcomes (RCTs): shortened labor, decreased need for analgesia, fewer operative deliveries, and greater patient satisfaction with the labor experience

- also reviewed by Cochrane, which was in agreement that it shortens labor (albeit modest effect) and improves rate of SVD (also modest effect)

AROM

- Cochrane: amniotomy alone doesn’t shorten duration of spontaneous labor or lower CD rate; similar patient satisfaction, frequencies of 5-minute Apgar score less than 7, umbilical cord prolapse, and abnormal FHR patterns

- When combined with oxytocin augmentation, it was found by meta-analysis of 14 trials that amniotomy is associated with modest reduction in CD rate and duration of first stage of labor (mean difference -1 hr)

Intermittent auscultation

- “The widespread use of continuous EFM has not been shown to significantly affect such outcomes as perinatal death and cerebral palsy when used for women with low-risk pregnancies”

- Continuous EFM:

- Increased CD rate

- Increased operative VD rate

- Decrease neonatal seizures

- consider use of handheld Doppler devices

- “In considering the relative merits of intermittent auscultation and continuous EFM, patients and obstetrician-gynecologists and other obstetric care providers also should evaluate how the technical requirements of each approach may affect a woman’s experience in labor”

Techniques for coping with labor pain

- “Some nonpharmacologic methods seem to help women cope with labor pain rather than directly mitigating the pain”

- Pall care pearl: consider inquiring about fears and concerns; consider pain scale mild/moderate/severe

- water immersion, intradermal sterile water injections, relaxation techniques, acupuncture, and massage: lower pain scores without evidence of harm (limited evidence)

- coping techniques: childbirth education, transcutaneous electrical nerve stimulation, aromatherapy, audioanalgesia

- big picture: As MDs, we can’t be experts in everything. Why not include some of the experts in these methods to help our patients?

Oral intake in labor - aspiration risk?

- available evidence supports intake of clear fluids, but particulate-containing fluids and solid food should be avoided

- these restrictions have recently been questioned as risk of aspiration is exceedingly low

Maternal position during labor

- “observational studies of maternal position during labor have found that women spontaneously assume many different positions during the course of labor” - duh

- supine position: hypotension and more frequent fetal heart rate decelerations

- upright positions shorten duration of the 1st stage of labor by ~1.36 hrs (to compare: routine amniotomy + oxytocin decreased 1st stage by ~1.11 hrs); also less likely to have CD

- Cochrane also looked at 2nd stage: upright position led to fewer abnormal FHR tracing patterns, a reduction in episiotomies, and a decrease in the incidence of operative vaginal births (also increased in 2nd degree lacs and EBL >500 ml)

Pushing technique

- open glottis is what many women do by default, yet we coach against this

- Cochrane: 8 RCTS - spontaneous compared to Valsalva pushing found no difference in rates of operative vaginal delivery, cesarean delivery, episiotomy, or perineal lacerations (shorter duration of pushing w/ Valsava by ~20 minutes AND one of those RCTs found an increased frequency of abnormal urodynamics 3 months after giving birth associated with Valsalva)

- Conclusion? Encourage a woman to do what feels best

“Laboring down”

- argument: delayed pushing allows fetus to rotate and descend while conserving woman’s energy for pushing efforts

- 2 meta-analyses found: laboring down for 1-2 hrs decreased time of pushing by a mere 20 minutes

- if looking only at high quality RCTs, no change in SVD rate

- a recent large retrospective study found a positive association between delaying pushing by 60 minutes or more and CD rates, operative vaginal delivery, PPH, and transfusion

- another recent multicenter RCT of more than 2400 nulliparous women w/ epidurals comparing immediate pushing with 60 minute delay

- No change in SVD rate

- Decreased PPH, chori, and neonatal acidemia (both in favor of immediate pushing)

Gentle c-section

- the protocol:

- low lighting

- clear drapes

- minimal extraneous noise

- positioning women to allow better access to newborn (e.g. not strapping down arms)

- slowed delivery of the neonate through the hysterotomy to allow autoresuscitation

- delayed umbilical cord clamping

- early skin-to-skin

- studies have shown higher rates of exclusive breastfeeding after initiation of this protocol, though there was a significant increase in unplanned nursery admissions (21% versus 7%)

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