Unnecessary Intervention:
Early Amniotomy and Oxytocin Augmentation
Dystocia or prolonged labor especially in the nulliparous woman usually results in the mother undergoing cesarean section. Early amniotomy with early oxytocin augmentation is commonly employed in these cases with the aim of preventing operative delivery. A systematic review was done by Wei et al in 2009 which included 12 trials involving 7792 women. The unstratified analysis found early intervention with amniotomy and oxytocin to be associated with a modest reduction in the risk of cesarean section; however the confidence interval crossed 1 - compatible with no effect (RR 0.89, 95% CI 0.79-1.01). Although only a small number of women have been randomized in therapy trials, a trend toward a reduction in the rate of cesarean section with early intervention was seen in this group (typical OR 0.6, 95% CI 0.2-1.4). They further identified that early augmentation does not appear to provide benefit over a more conservative form of management in the context of care of nulliparous women with mild delays in the progress of labor. In the context of established delay in labor, an active policy of augmentation may reduce the risk of cesarean section. However, only three small trials have been performed and they do not provide conclusive evidence for firm conclusions to be drawn.
Source: Wei S, Wo BL, Xu H, Luo ZC, Roy C, Fraser WD. Early amniotomy and early oxytocin for prevention of, or therapy for, delay in first stage spontaneous labour compared with routine care. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD006794. DOI: 10.1002/14651858.CD006794.pub2
Pain relief plays a crucial role during labor. Epidural anesthesia is widely used but there are concerns that it is accompanied by adverse effects on both the mother and infant. A systematic review by Anim – Somuah last updated in June 2010 looked at the effects of all modalities of epidural anesthesia (including combined spinal epidural) on the mother and the baby, compared with non-epidural or no pain relief during labor. 21 studies involving 6664 women found epidural anesthesia to be better for pain relief than non-epidural anesthesia (weighted mean difference (WMD) -2.60, 95% confidence interval (CI) -3.82 to -1.38), but was associated with an increased risk of instrumental vaginal birth (RR 1.38, 95% CI 1.24 to 1.53). There was no evidence of a significant difference in the risk of cesarean delivery (RR 1.07, 95% CI 0.93 to 1.23), long term backache (RR 1.00, 95% CI 0.89 to 1.12), low neonatal Apgar scores at 5 minutes (RR 0.70, 95% CI 0.44 to 1.10), and maternal satisfaction with pain relief (RR 1.18 95% CI 0.92 to 1.50).
Source: Roberts D, Dalziel SR. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004454
Continuous Support During Childbirth
Recommended Practices:
Pain Relief in Labor and Use of Antenatal Steriods
Source: Anim-Somuah M, Smyth RMD, Hoewll CJ. Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD000331.
Use of Antenatal Steroids
Respiratory Distress Syndrome (RDS) is a serious and expensive complication among premature babies and the primary cause of early neonatal morbidity and disability. A systematic review by Roberts and Daziel done in 2006 included 21 studies involving 3885 women and 4269 infants. It was found that treatment with antenatal corticosteroids does not increase risk to the mother of death, chorioamnionitis or puerperal sepsis.
Treatment with antenatal corticosteriods is associated with a 31% overall reduction in risk of neonatal death (RR 0.69, 95% CI 0.58 - 0.81) and a 34% reduction risk of dreaded RDS (RR 0.66, 95% CI 0.59 - 0.73). The risks of cerebroventricular hemorrhage (RR 0.54, 95% CI 0.43 - 0.69), necrotising enterocolitis (RR 0.46, 95% CI 0.29 - 0.74) and systemic in the first 48 hours of life (RR 0.56, 95% CI 0.38 to 0.85). were approximately halved. Requirement for respiratory support and intensive care admissions were likewise significantly reduced (RR 0.80, 95% CI 0.65 - 0.99). Because of these strong evidence of benefit, antenatal corticosteroid use is indicated in women with premature rupture of membranes and pregnancy related hypertension syndromes. This study supports the continued use of a single course of antenatal corticosteroids to accelerate fetal lung maturation in women at risk of preterm birth. A single course of antenatal corticosteroids should be considered routine for preterm delivery with few exceptions.
In today’s hospital setting, continuous support of women during labor has become the exception rather than the rule. In a 2007 systematic review by Hodnett et.al of 21 trials involving 15061 women, the effects of continuous one-to-one intrapartum support was compared with usual care wherein women are subjected to institutional routines which may have adverse effects on the progress of labor. Women who received continuous support were more likely to have a spontaneous vaginal birth (RR 1.08, 95% CI 1.04 to 1.12) and were more satisfied (RR 0.69, 95% CI 0.59 to 0.79), and were less likely to have intrapartum analgesia (RR 0.90, 95% CI 0.84 to 0.97). In addition the duration of labor was shorter (mean difference -0.58 hours, 95% CI -0.86 to -0.30). The likelihood of delivery via cesarean section (RR 0.79, 95% CI 0.67 to 0.92) or instrumental vaginal birth (RR 0.90, 95% CI 0.84 to 0.96), use of regional analgesia (RR 0.93, 95% CI 0.88 to 0.99), or delivering a baby with a low 5-minute Apgar score (RR 0.70, 95% CI 0.50 to 0.96) were all significantly reduced. There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, or on breastfeeding. Subgroup analyses suggested that continuous support was most effective when provided by a woman who was neither part of the hospital staff nor the woman’s social network, and in settings in which epidural analgesia was not routinely available. Thus, continuous support during labor clearly has clinically meaningful benefits for women and infants and no known harm.
Source: Hodnett ED, et al. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2011, Issue 2. Art. No.: CD003766.
No comments:
Post a Comment