by Louell L. Sala, MD
How sound are current practices on maternal and child care? In this section we take a look at some of these expert practices and recommendations comparing their evidences vis a vis methods used and conclusions drawn from related research and clinical observations.
NPO
Fasting in labor is common practice among our attending physicians as we always see the word NPO (short for nil per os) among patients going through labor. But is there really evidence to suggest that if fasting is not done during labor, patients will aspirate gastric contents during induction of anesthesia?
The evidence does not support this common belief. In a systematic review done by Singata et al. at the University of Fort Hare/East London Complex, East London South Africa, and using the Cochrane Pregnancy and Childbirth Group Trials Register of 2009, the authors found that there was no benefit or harm done to these patients. Using randomized controlled trials (RCT) and quasi-RCTs, they identified 5 studies with a total population of 3130 women. All studies looked at women in active labor and at low risk of potentially requiring a general anaesthetic.
One study looked at complete restriction versus giving women the freedom to eat and drink at will; two studies looked at water only versus giving women specific fluids and foods and two studies looked at water only versus giving women carbohydrate drinks. When comparing any restriction of fluids and food versus women given some nutrition in labor, the meta-analysis was dominated by one study undertaken in a highly medical oriented environment. There were no statistically significant differences identified in: cesarean section (average risk ratio (RR) 0.89, 95% confidence interval (CI) 0.63 to 1.25, five studies, 3103 women), operative vaginal births (average RR 0.98, 95% CI 0.88 to 1.10, five studies, 3103 women) and Apgar scores less than seven at five minutes (average RR 1.43, 95% CI 0.77 to 2.68, three studies, 2574 infants), nor in any of the other outcomes assessed.
The study included only low risk women, consistent in the recommendation of the Philippine Obstetric Gynecology Society Clinical Practice Guideline 2009 that states that ordering NPO for women in labor is not justified. At present, there are no studies that looked specifically atwomen at increased risk complications.
Sources: Sleutel, M., and Golden, S., Fasting in labor: relic or requirement. J Obstet Gynecol Neonatal Nurs, 28, 507-512, 1999
Philippine Obstetrical and Gynecological Society Clinical Practice Guidelines on Normal Labor and Delivery, 2009
Singata et al., Restricting oral fluid and food intake during labour. Cochrane Database Systematic Review 2010; Issue 1. CD003930
Fundal Pressure
It is not known when the practice of fundal pressure in labor started. Then again, we were lead to believe that it helps the mother with the expulsion of the fetus. However, we also know that uterine rupture, fetal brachial plexus injuries, cord compression and spinal cord injuries are just some of the more common injuries encountered with this practice. We therefore have to ask ourselves if fundal pressure is really warranted.
In a prospective cohort study by Simpson et. al. at the St. Johns Mercy Medical Center in Missouri it was suggested that a plan which includes risks, benefits and alternative use of fundal pressure should be reviewed by an interdisciplinary perinatal team. The data about maternal – fetal injuries related to fundal pressure were not published for medico-legal reasons; however anecdotal reports do suggest that these risks do happen.
Simpson KR and Knox E. Fundal pressure during the second stage of labor, MCN Am J Matern Child Nurs 2001 Mar-Apr; (26)2: 64-70.
Schulz-Lobmeyr, I., et.al., Use of fundal pressure during the second stage of labor: a prospective pilot study, Geburtshilfe und Frauenheilkunde, vol 59 no. 11: 558-561 1999
Maternal Position
In the 51-hospital observational study, all women delivered while lying flat on their backs. Is there merit to this practice? In a systematic Review done by Lawrence et al. in the Townsville Hospital in Queensland, Australia using the Cochrane Pregnancy Childbirth Group Trials Register (2008), the effects of encouraging women to assume different upright positions (including walking, sitting, standing and kneeling) versus recumbent positions (supine, semi-recumbent and lateral) for women in the first stage of labor in terms of length of labor, type of delivery and other important outcomes for mothers and babies were assessed.
With a population of 3706, which includes 21 randomized and quasi - randomized trials, they found no differences between 2 groups for outcomes including length of the second stage of labor, mode of delivery, or other outcomes related to the well – being of mothers and babies. Overall, the first stage of labor was approximately one hour shorter for women randomized to upright as opposed to recumbent positions (MD -0.99, 95% CI -1.60 to -0.39). For women who had epidural analgesia, there were also no differences between those randomized to upright versus recumbent positions for any of the outcomes examined in the review. However, little information on maternal satisfaction was collected, and none of the studies compared different upright or recumbent positions.
In the absence of such complications and since there is no evidence that women in strict bed rest and supine position are better off in terms of length of labor and type of delivery, women should be allowed to assume whatever position they find most comfortable.
Lawrence A, Lewis L, Hofmyer GJ, Dowswell T, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews 2009, Issue 2: Art. No.: CD003934.
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