Labour and delivery – Related resources

Cochrane reviews

Induction of labour

• Intracervical prostaglandins appear to be effective for induction of labour compared to placebo, but may be inferior when compared to vaginal prostaglandins .
• Vaginal misoprostol is effective for induction of labour compared to placebo, but may cause more uterine hyperstimulation than conventional methods .
• Oral misoprostol is more effective than placebo and as effective as vaginal misoprostol at inducing labour, and when used at a dosage of 20 mcg two-hourly results in fewer caesarean sections than vaginal dinoprostone. With low doses of oral misoprostol rates of uterine hyperstimulation seem to be equivalent to both placebo and vaginal dinoprostone, and may be lower compared with vaginal misoprostol..
• Oxytocin appears to be less effective than either intravaginal or intracervical PGE2 for induction of labour. Oxytocin induction may increase the rate of interventions (caesarean sections and epidurals).
• Routine amniotomy may not be effective for shortening the first stage of spontaneous labour in a clinically significant amount .
• Sweeping of membranes for induction of labour reduces the use of more formal methods of induction in women at term, and at weeks 41 reduces the risk of post-term pregnancy. Discomfort, bleeding and irregular contractions are more frequent .
• There is insufficient evidence of induction of labour for suspected fetal macrosomia in non-diabetic women .

Management during delivery

• In women making slow progress in spontaneous labour, oxytocin appears to reduce the time to delivery of approximately two hours without increasing caesarean sections compared with no treatment or delayed oxytocin treatment .
• For nulliparous women in normal spontaneous labour, early amniotomy and oxytocin if slow progress in labour ensues may slightly reduce the rate of caesarean section and may decrease the duration of labour compared to expectant management .
• There may be no difference between internal or external tocodynamometry during induced or augmented labour for any of the maternal or neonatal outcomes .
• Use of the admission cardiotocograph (CTG) for low-risk women on admission in labour appears not to be effective compared with intermittent auscultation .
• Continuous CTG during labour is effective in reducing neonatal seizures compared with intermittent auscultation. However, continuous CTG may not reduce infant mortality or cerebral palsy. It appears to increase caesarean sections and instrumental vaginal births .
• Fetal pulse oximetry (FPO) appears not to reduce overall caesarean section rate when added to cardiotocography (CTG) even if the rate may be decreased when FPO is used in the presence of a nonreassuring CTG .
• Traditional or computerised cardiotocography seems not to improve fetal outcomes, although the data are insufficient for important clinical outomes .
• Partogram use in spontaneous labour at term seems not to be effective compared to no partogram, although the evidence is limited .
• Walking and upright positions in the first stage of labour may reduce the length of labour and do not seem to be associated with increased intervention or negative effects on mothers’ and babies’ wellbeing .
• Upright posture during the second stage of labour may provide several possible benefits; however, there may be an increased risk of blood loss greater than 500 ml. Women should be encouraged to give birth in the position they find most comfortable .
• Free intake of oral fluid and food during labour may not increase complications in women at low risk of complications .
• Enemas during labour may not improve puerperal or neonatal infection rates or maternal satisfaction .
• The rapid negative pressure application for vacuum assisted vaginal birth appears to reduce duration of the procedure compared with stepwise procedure without difference in maternal or neonatal outcomes .
• Active management in labour seems to be effective for slightly reducing the caesarean section rates in low-risk pregnancies compared to routine care, but at the cost of increasing interventions .
• For nulliparous women in normal spontaneous labour, early amniotomy and oxytocin if slow progress in labour ensues seems to slightly reduce the rate of caesarean section and may decrease the duration of labour compared to expectant management .
• Trial of labour appears to be at least as safe for most outcomes as repeat caesarean section .
• Continuous suturing techniques for perineal closure after childbirth, compared to interrupted methods, are associated with less short-term pain .
• Primary end-to-end repair of obstetric anal sphincter injury may be as effective as primary overlap repair for preventing perineal pain, dyspareunia and faecal incontinence .
• Delayed cord clamping may increase early haemoglobin concentrations and iron stores in infants compared to early clamping in term infants. However, access to treatment for jaundice requiring phototherapy should be available .
• Delaying umbilical cord clamping by up to two minutes may reduce the need for transfusion and the occurrence of intraventricular haemorrhage in preterm infants .
• Tranexamic acid might possibly decrease postpartum blood loss after vaginal birth or caesarean section compared with placebo or no treatment .
• Active management of the third stage of labour may reduce the mother´s risk of haemorrhage greater than 1000 ml compared to expectant management .
• Intravenous carbetocin appears to be as effective as oxytocin for preventing postpartum haemorrhage .

Pain management

Discontinuation of epidural analgesia late in labour appears not to reduce the rate of instrumental delivery or other unwanted delivery outcomes .
• There appears to be little overall difference between combined spinal-epidural (CSE) and epidural analgesia in labour despite a slightly faster onset with CSE and less pruritus with epidurals .
• Transcutaneous electrical nerve stimulation (TENS) seems not to be effective for pain relief in labour .
• Epidural analgesia appears to be more effective than opioids in reducing pain during labour, but appears to be associated with an increased risk of instrumental vaginal birth .
• Restrictive episiotomy policies appear to have a number of benefits compared to routine episiotomy policies

Caesarean section

• The combination of antacids plus H2 antagonists appears to be more effective than no intervention, and superior to antacids alone in preventing low gastric pH in women having caesarean section under general anaesthesia .
• Caesarean section may not be benenficial compared to vaginal delivery for the prevention of anal incontinence in average risk women .Closure of the subcutaneous fat in caesarean section may reduce wound complications but whether this affects the well-being and recovery of the patients is unclear .
• Epidural or spinal anaesthesia for caesarean section appear not to differ from general anaesthesia in terms of major maternal or neonatal outcomes .
• Prophylactic betamethasone before elective caesarean section at term may not reduce overall rate of admission to neonatal special care units, even if admissions due to respiratory complications may be reduced .

Antibiotics

• Intrapartum antibiotic prophylaxis for known maternal group B streptococcal colonization appears to reduce early onset group B streptococcus disease in the newborn .Routine use of intramuscular penicillin to prevent early-onset group B streptococcal disease in newborn infants is probably not effective .
• Vaginal chlorhexidine during labour appears not to be effective in preventing maternal and neonatal infections .

Others

• Anti-D, given within 72 hours after childbirth, reduces the risk of RhD alloimmunisation in Rhesus negative women who have given birth to a Rhesus positive infant .
• Midwife-led (licensed) care for pregnant women may be more effective than other models of care for pregnant women at low or mixed risk .
• Interventions that involve health workers in analysing and modifying their practice seem to be effective for reducing caesarean section rates .
• Local cooling treatments (ice packs, cold gel pads, cold/iced baths) applied to the perineum following childbirth seem to have some effect on pain relieving compared to no treatment, although the evidence is limited .
• Hospital-based alternative birth settings compared to conventional settings may be associated with increased likelihood of spontaneous vaginal birth, reduced medical interventions and increased maternal satisfaction, but it is important to watch for signs of complications .
• Antibiotic prophylaxis given during the second or third trimester of pregnancy may reduce the risk of prelabour rupture of membranes and postpartum endometritis, but there is absence of evidence of a benefit on neonatal morbidity and mortality .
• Plastic wraps or bags, plastic caps, skin-to-skin care and transwarmer mattresses all keep preterm infants warmer, leading to higher temperatures on admission to neonatal units and less hypothermia .
• Early discharge of healthy mothers and term infants may be safe after uncomplicated delivery for well-informed mothers when accompanied by a policy of offering women at least one nurse-midwife home visit post discharge .

Other evidence summaries

• The benefits of routine amniotomy may include a reduction in labour duration and possible reduction in abnormal 5-minute Apgar scores. An association between early amniotomy and caesarean delivery for foetal distress was noted in one large trial, suggesting that amniotomy should be reserved for patients with abnormal labour process .
• Trial of labour appears to be at least as safe for most outcomes as repeat caesarean section .