Recently Dr. Berghella et al published a paper on evidence -based medicine in obstetrics. Evidence-based medicine is an attempt to move from medicine as an art to a medicine as science. The objective of Dr. Berghella research was to provide evidence-based guidance for management decisions during labor and delivery. 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.
Now a bit more details:
Home birth
has never been studied in an adequately powered randomized trial. The only trial published on this subject randomly assigned just 11 women, and was too small to draw ant conclusions. Possibly because of this lack of data, there are diverging opinions on the safest, most effective setting for labor even in western countries, with about 30% of Dutch births occurring at home vs. 1% of US births. Women with risk factors for abnormal outcome should deliver in a hospital setting. The safetly and effectiveness of home birth needs further research.
Home-like birth
Birth centers represent the attempt at these home-like births. Compared with hospital births, home-like births are associated with decreased need for intrapartum analgesia-anesthesia and increased rates of spontaneous vaginal birth, preference for the same setting the next time, satisfaction with intrapartum care, and breastfeeding initiation and continuation.
Delayed admission
involves allowing admission to the labor and delivery suite only after certain criteria for active labor have been met. Active labor was defined as regular painful contractions and cervical dilation > 3cm. Compared with direct admission to hospital, delayed admission until active labor is associated with less time in labor ward, less intrapartum oxytocics, and less analgesia.
Aromatherapy
has only been evaluated in a small trial, including 22 women, and a pilot trial, including 533 women, with no significant differences in the outcomes studied, including pain and mode of delivery. A support person (doula) present during labor is associated with decreased use of analgesia, decreased incidence of operative birth, increased incidence of spontaneous vaginal delivery, and increased maternal satisfaction. If doula cannot be present or is not desired women should be still be encouraged to invite a family member or friend to commit to being present at the birth.
The need and/or frequency of cervical examinations
in labor have never been evaluated in a trial. Most studies, including trials of active management, usually perform cervical examinations every 2 hours in labor. The risk of chorioamnionitis though increases with the increasing number examinations. There are no trials to assess the effect of stripping of membranes at the time of cervical examinations during labor. Enemas have been assessed as an intervention at admission for term labor. Compared with women receiving no enemas, enemas in the first stage of labor are associated with similar length of labor and most maternal and neonatal outcomes.
Perineal shaving
on admission for labor is associated with similar maternal febrile morbidity, wound infection, and neonatal infection, compared with just selective clipping of hair. The potential for complications (redness, multiple superficial scratches, burning and itching of the vulva, and discomfort afterwards when the hair grows back) suggests that shaving should not be part of routine clinical practice.
Ambulation (walking) during labor at 3-5 cm of dilation is associated with similar length of the first stage of labor, use of oxytocin, rate of operative vaginal delivery, and neonatal outcomes compared with a policy of restrictive walking.
Water immersion
has been evaluated in 8 trials, involving 2939 women, mostly in the first stage of labor. Compared with no water immersion, water immersion is associated with decreases in the use of analgesia and in reported maternal pain, and similar labor duration, incidence of perineal trauma, incidence of operative delivery, and neonatal outcome (such as Apgar score <7 at 5 minutes, neonatal unit admissions, or neonatal infection rates.)
Delayed pushing
(waiting 1-3 hours or until “urge to push”) of term, single-ton, vertex gestations with epidural in place is associated with longer second stage, similar pushing time, significantly higher incidence of spontaneous vaginal delivery.
Perineal massage
from 34 weeks until delivery with sweet almond oil for 5-10 minutes daily is associated with a significantly higher chance of intact perineum compared with no massage in nulliparous, but probably not multiparous women.
Perineal massage and stretching
of the perineum in the second stage of labor with a water soluble lubricant is associated with similar rates of intact perineum, but decreased incidence of third degree lacerations.
Routine episiotomy
use is associated with more perineal trauma, suturing and healing complications, and later pain with intercourse, with decreased risk of anterior perineal trauma, and similar urinary and fecal incontinence, compared to restrictive episiotomy.
The need and/or frequency of cervical examinations in labor have never been evaluated in a trial. Most studies, including trials of active management, usually perform cervical examinations every 2 hours in labor. The risk of chorioamnionitis though increases with the increasing number of examinations. There are no trials to assess the effect of stripping of membranes at the time of cervical examinations during labor.
Pushing method using a closed glottis (Valsalva)
is associated with a significantly shorter (by 13-18 min) duration of the second stage of labor, and similar neonatal outcomes compared with using a woman’s own urge (open glottis).