Updates on Delivery Room

5 May 2016

During the first stage of labor, what is the effect of maternal positioning on duration of the first stage of labor, type of delivery, maternal satisfaction, and neonatal and maternal outcomes? Evidence-Based Answer

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Upright positions include sitting, standing, walking, and kneeling. Based on heterogenous results, women who maintained upright positions had a first stage of labor that was about one hour less than women who were supine or reclined. There were no differences in type of delivery, and there were insufficient data on maternal satisfaction and maternal and neonatal outcomes. (Strength of Recommendation = A, based on consistent and good quality patient-oriented evidence). Practice Pointers

Most women in the United States deliver their babies in hospitals. To facilitate intravenous infusions, epidurals, and maternal and fetal monitoring, women often spend much of the first stage of labor in supine or recumbent positions. In this Cochrane review, the authors found 21 studies (n = 3,706) comparing upright with recumbent maternal positions during the first stage of labor.

Overall, compared with recumbent positions, women who maintained upright positions had a duration that was approximately one hour less for the first stage of labor (mean difference = −0.99; 95% confidence interval [CI], −1.60 to −0.39). Participants in upright positions also were less likely to have epidural analgesia (risk ratio = 0.83; 95% CI, 0.72 to 0.96).

In a related Cochrane review, assuming a hands and knees maternal position for 10 minutes at a time in late pregnancy did not appear to help rotate babies who presented in occipitoposterior positions, which was based on an analysis of three trials (n = 2,794) that found the maternal position rotates babies temporarily, but the babies do not maintain their occipitoanterior position.

1 Maternal positioning on hands and knees may be beneficial in labor to reduce backache, but there is insufficient evidence that it improves labor outcomes. Studies of maternal positioning in labor are challenging because it is not possible to have participants blinded to allocation groups, and it is difficult to standardize the intervention.

Many women cannot easily maintain the position to which they were randomized once their cervical dilation is greater than 5 to 6 cm. Also, the measures taken to encourage adherence to protocols can vary by study. Other Cochrane reviews have documented the benefit of continuous intrapartum support from early labor in decreasing labor duration, likelihood of spontaneous vaginal birth, likelihood of intrapartum analgesia, and dissatisfaction with childbirth experiences.2,3

It is especially beneficial to have continuous support from a person who is not a member of the hospital staff.2 For low-risk deliveries, home-like birth settings in proximity to medical wards are associated with reduced medical intervention, higher rates of spontaneous vaginal birth, and increased maternal satisfaction.

3 These studies lend support to the recommendation that women should be encouraged to labor in the position they find most comfortable.1–3 CLARISSA KRIPKE, MD

Author disclosure: Nothing to disclose.

Source Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev. 2009;(2):CD003934.

REFERENCES
1. Hunter S, Hofmeyr GJ, Kulier R. Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior). Cochrane Database Syst Rev. 2007;(4):CD001063. 2. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth.Cochrane Database Syst Rev. 2007;(3):CD003766. 3. Hodnett ED, Downe S, Edwards N, Walsh D. Home-like versus conventional institutional settings for birth. Cochrane Database Syst Rev. 2005;(1):CD000012.

Instruments for Assisted Vaginal Delivery
Am Fam Physician. 2011 Jul 1;84(1):26-27.
Related letter: Increased Risks with Serial Vacuum Forceps for Assisted Vaginal Delivery. Clinical Question
For assisted vaginal delivery, does the use of forceps or vacuum devices result in lower morbidity for the mother and newborn? Evidence-Based Answer
Use of forceps is more likely to result in a vaginal delivery than use of vacuum devices (relative risk [RR] = 1.5; 95% confidence interval [CI], 1.1
to 2.2), but has a higher rate of perineal trauma, tears, pain, and incontinence, and a trend toward more cesarean deliveries. Use of metal-cup vacuum devices is more likely to result in a vaginal delivery than use of soft-cup devices, but is more likely to cause neonatal scalp injury and cephalohematoma. (Strength of Recommendation = A, based on consistent, good-quality patient-oriented evidence) Practice Pointers

Assisted vaginal deliveries are recommended for fetal distress, failure to deliver after a prolonged second stage of labor, or maternal factors that would make pushing dangerous, such as exhaustion or medical problems. The choice of instrument depends on factors such as the training of the physician, fetal position, and the degree of anesthesia. Vacuum extraction does not require as much anesthesia for the mother as forceps.1 To determine the safest delivery method for the mother and newborn, the authors of this Cochrane review searched for randomized controlled trials comparing methods of assisted vaginal delivery at term. The authors found 32 studies including 6,597 women. Seventeen of the studies compared types of vacuum devices, and 13 studies compared forceps with vacuum devices. Although the failure rate was lower with forceps than with vacuum devices, third- and fourth-degree perineal tears were more common with forceps (RR = 1.9; 95% CI, 1.6 to 3.9). Facial injuries in newborns were also more common with forceps (RR = 5.1; 95% CI, 1.1 to 23). There were no differences between forceps and vacuum devices in Apgar score, shoulder dystocia, need for intubation, severe morbidity, death, or use of maternal analgesia.

Compared with soft-cup vacuum devices, use of metal cups was more likely to result in a vaginal delivery but had higher rates of neonatal bruising, cephalohematoma, and scalp injury. There are risks and benefits with different assisted vaginal delivery methods, with no clear superiority of one device over another. However, this review supports the use of vacuum extraction with a soft cup as the first-line method because of its lower risk of harming the newborn. [corrected] CLARISSA KRIPKE, MD

Author disclosure: No relevant financial affiliations to disclose. SOURCE
O’Mahony F, Hofmeyr GJ, Menon V. Choice of instruments for assisted vaginal delivery. Cochrane Database Syst Rev. 2010;(11):CD005455.

REFERENCE
1. Operative vaginal delivery. ACOG Technical Bulletin Number 196—August 1994 (replaces No. 152, February 1991). Int J Gynaecol Obstet. 1994;47(2):179–185.

7 Alternative ways to prepare for childbirth and cope with the intensity of labor. Carlsbad, CA (PRWEB) — As the shift toward self-education continues to grow, large numbers of American women are choosing  alternative ways to prepare for childbirth and cope with the intensity of labor.

Instead of waiting for the doctor to tell them what they need to know, women are doing more research on their options and exploring ways to make pregnancy and birth less painful. Here is what they are choosing:

1. Birth Networks – These organized, regional groups of pregnant women and birthing professionals meet regularly to educate, empower and support each other and advocate for the improvement of maternity care in their communities. What started as a grassroots movement has exploded across the county.

Evidence of a growing trend: Amy Romano of Lamaze International estimates that the number of birth networks has doubled in the past year. Since 2004, the Lamaze Institute for Normal Birth has awarded grants to form and expand birth networks. It also offers organizational resources for birth networks through their website, www.normalbirth.lamaze.org.

2. Birth Stories – Expectant women are hungry for information on labor and birth, and the mainstream media is responding with birth stories. These stories offer much more than entertainment; they provide information on birth options, tools, classes and techniques. The impact of birth stories on expectant parents is quickly coming to the attention of the birth professionals, and many are actively discouraging patients from watching the highly-dramatized birth programs on cable television.

Because the level of fear in a laboring woman directly impacts the progression of her labor, birthing professionals are directing patients to read only empowering, inspiring birth stories, such as those found in Journey into Motherhood: Inspirational Stories of Natural Birth http://www.journeyintomotherhood.com (White Heart Publishing, 2005). Evidence of a growing trend:

There are now 7 programs on cable television that highlight the experience of labor and delivery. Most pregnancy magazines now feature birth stories on a regular basis, and many birth networks and childbirth educators now sponsor birth-story nights.

3. Hypnosis for Childbirth – Since a 1999 segment on NBC’s Dateline featured hypnosis for childbirth, interest has steadily grown. The HypnoBirthing Method and Hypnobabies are two of the oldest and most popular programs, but with the growing interest in this method, there are now several different programs available, as well as supplemental products such as Journey into Childbirth: Hypnosis for Empowered Birthing by Sheri Menelli. While no program promises a pain-free birth, this is a frequent result.

Evidence of a growing trend: In the late 19990s there were only a few hundred educators, and as of this year, there are over 3000. 4. Prenatal yoga – Prenatal yoga strengthens and stretches the muscles that are used in childbirth, and teaches breathing and focusing techniques that help women through labor.

Evidence of a growing trend:In San Diego, California, prenatal yoga instructors are reporting an increase in class attendance of approximately 50% over the last three years. Much of the increase is attributed to growing support from doctors, midwives and childbirth educators who send their clients to yoga classes to relieve back pain, reduce tension, and cope with high blood pressure.

A number of prenatal yoga videos are now available to women who prefer to practice at home. 5. Water-assisted labor – Widely known as “nature’s epidural,” warm water can ease the discomfort of labor by helping a woman relax.

A “birthing tub” counters the effect of gravity on her contracting muscles, and even a warm shower can provide soothing comfort to tired and tense women. Evidence of a growing trend: In the last 10 years, water-assisted labor has grown exponentially. In 1995 there were only three hospitals in the country that offered it. Now it is offered in more than 260 hospitals – 15% of all U.S. hospitals. In the last year alone there was a 4% increase, and this number is expected to grow in the coming year.

6. Doulas – A doula is a professional who is trained to provide emotional and tactical support a family through pregnancy, labor, delivery, and newborn care. Studies show that the presence of a doula reduces the need for medication, as well as the possibility of a Cesarean-section birth. Evidence of a growing trend: Every doula organization reports phenomenal growth in membership, and in the number of students in doula training classes.

Doulas of North America (DONA), just one of several doula organizations reported a 10-fold increase in the number of certified doulas in the last 7 years. 7. Pregnancy Massage – A specialized form of bodywork, pregnancy massage addresses the specialized needs of a rapidly changing body. It enhances the function and alignment of muscles and joints, improves circulation and muscle tone, and relieves mental and physical fatigue.

These benefits translate to lower levels of stress hormones, as reported in a study by Dr. Tiffany Field at the University of Miami School of Medicine. Evidence of a growing trend: Instructor Elien Alexander from The School of Healing Arts in San Diego, California, reported a 10-fold increase in the number of students becoming certified in pregnancy massage in the last 5 years.

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