Labour

STUDIES

Part of an alternative approach to childbirth is an inquiring attitude about common childbirth practices. A number of conventional medical and other means have been used to bring on labour.  A series of Cochrane reviews examines a large number of medical drugs (for example, oxytocin) and other (for example, breast stimulation) interventions to bring on labour. Summaries of two alternative treatments are given here.

Inducing labour: A number of conventional medical and other means have been used to bring on labour in various circumstances.  A series of Cochrane reviews examines a large number of medical drugs (for example, oxytocin) and other (for example, breast stimulation) interventions to bring on labour, and these provide a more thorough overview of labour-inducing methods: two alternative treatments were evaluated in Cochrane reviews.

Managing labour: Part of an alternative approach to childbirth is an inquiring attitude about common childbirth practices. For this reason, it is relevant to summarize here some of the evidence about labour management practices.  Some women want relief from childbirth pain but would prefer not to use epidurals or other anaesthesia. A number of alternative and complementary practices have been tried to relieve childbirth pain.

After birth: Women who have given birth often suffer persistent pain in the area between the vagina and anus (the perineum) afterwards, because of tears and cuts (episiotomy) in the area when giving birth. Having sex may become painful (dyspareunia). A sometimes-used alternative treatment is ultrasound. A preventive alternative treatment is massage during late pregnancy.

We present some of the evidence from Cochrane systematic reviews about complementary and alternative treatments related to pregnancy. This evidence comes from carefully researched reviews of information about clinical trials done to evaluate medical treatments. Studies are only included in these reviews if they meet pre-defined criteria.

ACUPUNCTURE FOR INDUCTION

It is frequently considered desirable or necessary, for various reasons, to induce labour. Reasons may include medical problems, past-due delivery date, and convenience. Once labour induction is decided upon, there are many different methods used for this purpose; it is important to evaluate their effectiveness, safety, and side effects. A series of Cochrane reviews examines a large number of chemical (for example, oxytocin, prostaglandins, smooth muscle stimulants such as herbs or castor oil), mechanical (for example, artificial rupture of membranes, use of various gadgets such as balloon dilators, and breast stimulation), and other (for example, homeopathy and acupuncture) interventions to bring on labour. These reviews in toto provide a more thorough overview of labour-inducing methods.

It’s critically important also to understand benefits and downsides of labour induction in specific clinical situations, but Cochrane reviews have not yet been done on most of these questions. One completed review does address induction of labour for big babies and did not find the expected benefit based on clinical trials to date. 

What is known

Acupuncture is a widely used alternative therapy with increasing popularity in Western countries although it has been in use for over 2000 years in China and Japan. The therapy involves the insertion of very fine needles into specific points of the body.  It is sometimes used to ‘ripen’ the cervix (make it softer, shorter, and more open) and induce labour.

Three observational studies from the 1970s suggest that acupuncture to induce labour may be effective. The three studies used acupuncture with and without electrical stimulation and labour was reported to have been induced in 63 of 84 women. However, these studies did not have a control group that did not receive acupuncture.

Two trials with control groups that did not assign women randomly to the active or control group, also done in the 1970s, reported positive results.

What the synthesised research says

There is no evidence from randomized clinical trials to validate or disprove the hypothesis that acupuncture is effective for induction of labour. More research is needed. One study is currently being undertaken in Australia.

How it was tested

The researchers made a thorough search of the medical literature to identify controlled trials that assigned women randomly to acupuncture versus sham acupuncture or no treatment for induction or labour. Four studies were identified but only one, involving 56 women, met pre-set requirements. That study randomised women to receiving acupuncture at two points for twenty minutes on their due date or to no treatment. However, there were quality problems with the study – a number of women were given medical inductions of labour and not followed up on. No conclusions could be drawn.

Side effects and general cautions

Acupuncture is generally considered safe, including for the induction of labour.  Data about its use for this purpose and any possible effects on the mother or baby are scant. It is often considered undesirable to have acupuncture earlier in pregnancy, especially acupuncture at points believed to be related to uterine activity. 

There are many techniques and styles of acupuncture and it is important that the exact practice used be precisely reported in clinical trials.

Acupuncture where needles are not properly sterilized can cause infection or communicate diseases such as HIV or hepatitis. Very rarely, serious injuries from acupuncture done improperly have been reported, such as lung collapse and bleeding around the heart. 

Sources

CA Smith, CA Crowther. Acupuncture for induction of labour. The Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD002962.pub2. DOI: 10.1002/14651858.CD002962.pub2.

GJ Hofmeyr, Z Alfirevic, T Kelly, J Kavanagh, J Thomas, P Brocklehurst, JP Neilson. Methods for cervical ripening and labour induction in late pregnancy: generic protocol. The Cochrane Database of Systematic Reviews 2000, Issue 2. Art. No.: CD002074. DOI: 10.1002/14651858.CD002074. [This review provides the general procedures used for a number of Cochrane studies of various methods of bringing on labour, including the one above.]A Kelly, Z Alfirevic, GJ Hofmeyr, J Kavanagh, JP Neilson, J Thomas. Induction of labour in specific clinical situations: generic protocol. The Cochrane Database of Systematic Reviews 2001, Issue 4. Art. No.: CD003398. DOI: 10.1002/14651858.CD003398.Gülmezoglu AM, Crowther CA, Middleton P.

Induction of labour for improving birth outcomes for women at or beyond term.Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004945. DOI: 10.1002/14651858.CD004945.pub2.

 O Irion, M Boulvain. Induction of labour for suspected fetal macrosomia. The Cochrane Database of Systematic Reviews 1998, Issue 2. Art. No.: CD000938. DOI: 10.1002/14651858.CD000938.

HOMEOPATHY FOR INDUCTION OF LABOUR

It is frequently considered desirable or necessary, for various reasons, to induce labour. Reasons to do so may include medical problems, past-due delivery date, and for convenience. A series of Cochrane reviews examines a large number of chemical (for example, oxytocin, prostaglandins, smooth muscle stimulants such as herbs or castor oil), mechanical (for example, artificial rupture of membranes, use of various gadgets, and breast stimulation), and other (for example, homeopathy and acupuncture) interventions to bring on labour.

What is known

Homeopathy is a widely used alternative therapy. A homeopathic remedy called Caulophyllum thalictroides  that is taken orally is sometimes used to get labour started and to improve a woman’s uterine contraction patterns in early labour.

What the synthesised research says

There is no evidence from randomized clinical trials thus far to support the use of homeopathic preparations to induce labour.  

How it was tested

The researchers made a thorough search of the medical literature to identify controlled trials that assigned women randomly to homeopathy versus no treatment, placebo, or a different treatment for induction or labour. A German study compared caulophyllum D4 administered hourly for seven hours against a placebo in 40 women whose membranes had ruptured but who had not started labour. No differences in the start of labour contractions or other results were found.

A French study compared five different homeopathic remedies with placebo in 93 women and examined the effect on length and ease of labour. No differences between treatment and placebo groups were found.

The studies were too few with only a small number of participants. They were not felt to be of high quality, with insufficient information on some important factors including side effects and how women were assigned to groups.

Side effects and general cautions

The limited studies done did not have adequate information about side effects.

The treatment strategy used in the one trial in which caulophyllum was evaluated may not reflect routine homeopathy practice even though it is a commonly used homeopathic therapy to induce labour.

There are many homeopathic remedies and methods of administering them and it is important that the exact practice used be precisely reported in clinical trials.

Source

CA Smith. Homoeopathy for induction of labour. The Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD003399. DOI: 10.1002/14651858.CD003399.

GJ Hofmeyr, Z Alfirevic, T Kelly, J Kavanagh, J Thomas, P Brocklehurst, JP Neilson. Methods for cervical ripening and labour induction in late pregnancy: generic protocol. The Cochrane Database of Systematic Reviews 2000, Issue 2. Art. No.: CD002074. DOI: 10.1002/14651858.CD002074. [This review provides the general procedures used for a number of Cochrane studies of various methods of bringing on labour, including the one above.]

A Kelly, Z Alfirevic, GJ Hofmeyr, J Kavanagh, JP Neilson, J Thomas. Induction of labour in specific clinical situations: generic protocol. The Cochrane Database of Systematic Reviews 2001, Issue 4. Art. No.: CD003398. DOI: 10.1002/14651858.CD003398.

Gülmezoglu AM, Crowther CA, Middleton P. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004945. DOI: 10.1002/14651858.CD004945.pub2.

O Irion, M Boulvain. Induction of labour for suspected fetal macrosomia. The Cochrane Database of Systematic Reviews 1998, Issue 2. Art. No.: CD000938. DOI: 10.1002/14651858.CD000938. 

ENEMAS DURING LABOUR

Enemas are frequently used early in labour as a hygienic practice, with the aim of lessening contact of mother and newborn with faeces. In theory, this might reduce infection, but is there actual confirmed proof of its value in practice? The use of enemas depends a lot on the preference of physicians or midwives.

Enemas are uncomfortable for the mother and increase costs of delivery. They can be administered in different ways; with high or low volume of fluid, and differing types of fluid including saline solutions, soapsuds, medicated or tap water.

What the synthesised research says

There is insufficient evidence to recommend enemas during labour. Since they cause discomfort and generate costs, their use should be discouraged without more evidence.

The quality of existing evidence is low, but high-volume enemas did seem to reduce the risk of lower respiratory tract infections and the need for systemic antibiotics in newborns and mothers in one trial. This conclusion is not sufficient to recommend enemas without further study and an economic analysis.

How it was tested

The researchers made a thorough search of the medical literature to identify studies of controlled trials that assigned women giving birth randomly to routine enemas or no enema. Two trials of this type were identified, involving 665 women. One used a high-volume saline solution enema and the other used a low-volume disposable phosphate enema. Conclusions could not be reached about some results in the high-volume enema trial because the number of women involved was not large enough. The trial that used a low-volume enema was considered to be of poor quality and no conclusions could be drawn.    

Side effects and general cautions

None were noted.

Source

LG Cuervo, MN Rodríguez, MB Delgado. Enemas during labour. The Cochrane Database of Systematic Reviews 1999, Issue 4. Art. No.: CD000330. DOI: 10.1002/14651858.CD000330.

ROUTINE PERINEAL SHAVING ON ADMISSION IN LABOUR

Shaving the pubic hair of women in labour is done routinely before birth as a hygienic practice in some settings. This practice should be evaluated to see whether it really has value or not.

What is known

In some settings, women in labour are routinely shaved upon admission to hospital The aim is to minimize infection risk if there is tearing or cutting of the area between the vagina and anus (which is common) during the birth process. It also has been suggested that a shaved area may make stitching tears or cuts easier. 

Shaving can create tiny tears or lacerations in the skin and is unpleasant or embarrassing for many women. Regrowth of the pubic hair often creates discomfort for the woman.

What the synthesised research says

There is no support from the existing evidence to justify the practice of routine perineal shaving for women in labour, and no proven benefit of this practice. Shaving also has proven drawbacks in that consequences for women are unpleasant.

In the research trials done, clipping of long hairs was permitted on an as-needed basis during the birth process in women assigned to the ‘no-shaving’ group, for example to facilitate stitching of a tear or cut.

How it was tested

The researchers made a thorough search of the medical literature to identify controlled trials that assigned women in labour to routine pubic shaving or no shaving. Two trials of this type were identified, involving 539 women. In one trial, fewer bacteria of one type (gram negative) but not the other type (gram positive) were found in shaved women. In the other trial there was no such microbiological evidence to suggest an advantage to shaving. These are ‘surrogate’ endpoints and no clear differences were found in the number of mothers who had fevers typical of a response to infection in either trial.   

Side effects and general cautions

Both perineal shaving and regrowth of shaven pubic hair are disagreeable for many women. One trial found irritation, redness, superficial scratches, and vulval burning and itching in the shaved women; the other trial did not look at these consequences. The existing trials were limited in scope, and provide no basis for firm conclusions.

Source

V Basevi, T Lavender. Routine perineal shaving on admission in labour. The Cochrane Database of Systematic Reviews 2000, Issue 4. Art. No.: CD001236. DOI: 10.1002/14651858.CD001236.

CONTINUOUS SUPPORT FOR WOMEN DURING CHILDBIRTH

In most settings in the past, women have been attended by other women during labour. However, as births have moved into hospitals worldwide, women are often alone during long stretches of labour. There is some concern that the birth experience and birth outcomes may be worse when women lack assistance, moral support, and information from more experienced women. It is theorized that support from another woman may buffer the effects of an anxiety-provoking clinical environment and provide the birthing woman with an advocate as well as providing reassuring information, touch and comfort measures, and help with coping techniques. In theory, the mother’s increased comfort and decreased anxiety may help labour proceed better, without as much reliance on technological medical measures such as epidural pain relief, electronic fetal monitoring, intravenous (IV) drips, artificial oxytocin, vacuum extraction or forceps.

To know whether these supposed benefits of supportive female companionship through labour really hold up is important in determining public policy and whether it is important to promote labour companionship to achieve better birth results. When also should labour companionship ideally begin, early on or only during active labour?

It is also important to know whether companionship from employees of a health institution (who have other responsibilities and owe that institution allegiance to its aims) is as effective as independent companionship. Some hospitals do not allow persons external to the hospital in the delivery room, which can be a major impediment to labour companionship.

There are many types of labour companionship possible, including by a trained person, healthcare professional, relative, friend or other person. Women have most often provided labour companionship across cultures, but in the United States and other countries companionship by a male partner has become increasingly common and male labour companionship should be evaluated also.

What is known

Although continuous labour support has become less common in the modern world, there are movements toward change. Uruguay passed a 2001 law mandating a woman’s right to companionship by a person of her choice during labour; the City of Buenos Aires passed a similar law in 2003; and the Argentinian national congress did likewise in 2004. The Better Births Initiative is active in a number of countries including China and some African countries and encourages labour companionship. In the United States (and more recently in Canada and other countries) there is a movement for doula training and involvement of a doula during childbirth. Doulas are women specially trained to provide companionship and assistance during childbirth. A 2002 survey of US childbearing women showed 5% had used doula services during their most recent labour. 

What the synthesised research says

Effects of continuous labour support are positive and all women should have continuous support during labour and birth. For maximum benefit, such support is best provided by women who are not hospital employees and who can focus exclusively on support for the birthing woman. Support should ideally begin early in labour.

Analysis of 15 trials involving 12,791 women (see below for details) showed that women with continuous labour support were somewhat more likely to have a smooth vaginal birth without need for a forceps or vacuum-assisted vaginal delivery, or a caesarian section, and were less likely to use analgesia and anaesthesia. They were in general more satisfied with the birth experience and were less likely to report low level of personal control during labour and birth. In a North American trial, labour support was associated with a slight decrease in use of electronic fetal monitoring.

The women with labour companions used comparable levels of artificial oxytocin, reported comparable levels of severe labour pain, and had similar length of labour and degree of perineal trauma (damage to the muscular area between the vagina and anus) as women without labour companions. No clear differences were found for the newborn baby.

There seemed to be a dose-response effect of labour support (that is to say, labour companionship improved the labour experience most when it was of longer duration). The greatest comparative benefit was in settings where it began early in labour, when the provider was not a hospital staff member, and when epidural analgesia was not routinely available. Labour support provided by a hospital staff member was not as effective in lowering operative birth rates.

How it was tested

The researchers made a thorough search of the medical literature to identify controlled trials that randomly assigned women to continuous labour support versus routine care. In some cases the labour companion was a trained person or a healthcare professional and in others she was a female relative, friend, or other person. No studies were found that used a man or male partner as a labour companion.

Fifteen trials were located involving 12,791 women. The trials took place in Australian, Belgian, Botswanan, Canadian, Finnish, French, Greek, Guatemalan, Mexican, South African, and US hospitals. Usual care across hospital settings varied considerably: for example as to whether medical interventions such as electronic fetal monitoring were routine, as to whether epidural analgesia was available, and as to whether husbands or partners and other family members were permitted in the delivery room. 

A variety of maternal and infant outcomes were assessed, including rates of vaginal birth (spontaneous, or forceps and vacuum-assisted), satisfaction with the birth experience, use of analgesia or anesthesia, reports of severe labour pain, condition of the baby (admission to special care nursery or low Apgar scores). It is desirable to evaluate postpartum depression but only one trial had sufficient data on this. 

Side effects and general cautions

No trials addressed attendance by men as labour companions. Use of a labour companion has no known risks or side effects. The clinical trials took place in a wide variety of hospital settings not always strictly comparable to one another.

Source

ED Hodnett, S Gates, G J Hofmeyr, C Sakala. Continuous support for women during childbirth. The Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.

Other sources 

Belizán J, Cafferata M. The Right to Be Accompanied at Birth: New Laws in Argentina and Uruguay. Reproductive Health Matters 2005;13(26):158-9.

ELECTRONIC MONITORING OF A BABY’S HEART RATE DURING LABOUR

Continuous electronic fetal monitoring (EFM) is used to produce a real-time tracing of the baby’s heartbeat and is used to guide decisions during labour. It provides the ability to continuously monitor the fetal heartbeat rather than listening to it at intervals through a stethoscope (intermittent auscultation). External electronic fetal monitoring (using ultrasound on the mother’s abdomen) is generally the sort used in low-risk pregnancies on a routine basis. Internal EFM is also sometimes done, with a probe on the baby’s head. Because there are now other forms of electronic fetal monitoring besides tracking the baby’s heartbeat (for instance, monitoring a baby’s electrocardiogram or fetal pulse oximetry), a more precise and up-to-date technical term for what has traditionally been called EFM is cardiotocography. 

Those adhering to an alternative or complementary view of childbirth are often very critical of routine electronic fetal monitoring. They believe that false positive EFM results lead to adverse effects such as unneeded Caesareans, and that EFM does not provide real benefit. They also criticize EFM because it can force the woman to remain lying down in one position, preventing her from moving around freely, perhaps thereby making birth more painful. It may also focus the birth attendants on the heartbeat tracing rather than on the woman giving birth.

Monitoring the baby’s heartbeat during labour in one way or another has become a routine part of labour. Continuous electronic fetal monitoring (EFM) provides a physical record of the heartbeat which can be consulted straight away for making decisions about required actions or at a later time for clinical audits or court cases. EFM restricts mobility, use of different birth positions, and the choice to be immersed in water.

What the synthesised research says

Monitoring of the baby’s heart rate during labour does not reduce the number of babies with cerebral palsy or who die (about 1 in 300 babies) or change other standard measures of newborn wellbeing.

Seizures in newborns are rare (about 1 in 500 babies) but are reduced by about half when continuous electronic fetal monitoring is used. The real-life significance of reducing the infant seizure rate is not very clear. Possible long-term effects of neonatal seizures are uncertain. One study looked at the progress of newborn infants that had seizures; as five-year olds and adolescents they were generally normal and of normal intelligence or IQ but with some abnormal results on detailed neuropsychological testing.

The benefit of reducing infant seizures is bought at the cost of increasing rates of Caesarean births (relative risks 1.7) and rates of instrumental (forceps or vacuum-assisted) births (relative risk 1.2). Although difficult to quantify precisely, there are risks to the mother and baby when Caesarean section is done. The baby may more likely have respiratory problems or cuts from the procedure, and the mother has an increased risk of bladder injury, need for further surgery, problems in future pregnancy, blood clots, and other surgical risks.

It is estimated that if 628 women in labour received continuous EFM instead of intermittent auscultation, their babies would have one fewer seizure but there would be 11 additional caesarean sections.

It is frequently recommended to use EFM for high-risk mothers and to permit more flexibility in its use with low-risk mothers yet risks and benefits appear to be quite similar in both groups from the present evidence. It might seem logical that high-risk mothers would benefit more from monitoring, but the evidence does not support this.

How it was tested

The researchers searched for randomized controlled trials of electronic fetal monitoring and found twelve trials involving over 37,000 women that met pre-set criteria. Only two trials were considered to be of high quality and the review was dominated by one large, well-conducted trial involving almost 13,000 women. The studies compared continuously monitoring the baby’s heart beat to listening to the baby’s heart with a stethoscope (intermittent auscultation).

Side effects and general cautions

The rigorous time schedules used for listening to the baby’s heart in the trials might be difficult to comply with in practice in some hospital settings, given workload constraints.

The use of electronic monitoring could possibly encourage a false belief that all birth complications for the baby can be prevented. This is not the case.

The increased rates of Caesarean births caused by EFM are higher in settings where there is a relatively high percentage of Caesarean births in general. A choice to use EFM in those environments may mean that a woman is running a high risk of a possibly unneeded caesarean birth than the rate estimated above.

It is a real challenge for healthcare practitioners to explain to women the tradeoffs involved in EFM and to enable them to make informed choices about its use.

Source

Alfiervic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) as a form of electronic heart rate monitoring (EFM) for fetal assessment during labor. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD006066. DOI: 10.1002/14651858.CD006066.

COMPLEMENTARY AND ALTERNATIVE THERAPIES FOR PAIN MANAGEMENT

Childbirth pain can be intense, and worsened by anxiety and fear, but many women would like to cope without using pharmaceutical drugs during labour. It is important to evaluate the evidence for effectiveness of various complementary and alternative methods that can be used with the intent of reducing the pain of childbirth. 

A number of alternative methods have been used to manage labour pain. These include listening to music, massage and aromatherapy, yoga and relaxation techniques, hypnosis and acupuncture.    

What the synthesised research says

There is some evidence that hypnosis and acupuncture may help relieve labour pain.

Two trials of acupuncture (288 women) showed a decreased need for pain relief (relative risk (RR) 0.70, 95% confidence interval (CI) 0.49 to 1.00).

Women taught self-hypnosis (five trials, 749 women) had decreased requirements for pain relief, including epidural analgesia, and were more satisfied with their pain management in labour compared with controls (RR 2.33, 95% CI 1.15 to 4.71, one trial).

Hypnosis may also contribute to an increased rate of vaginal delivery and both hypnosis and acupuncture may reduce the use of oxytocin. 

Two trials compared acupressure treatment (pressure at acupuncture points) with a control (touch, without pressure, at the same point). There may be a slight lessening of pain and anxiety with acupressure, but the results were insignificant. Interestingly, length of active labour to birth was significantly shorter in the acupressure groups (weighted mean difference -52.60 minutes, 95% CI 85.77 to -19.43).

One small trial (83 women) found a reduction in women’s perception of pain in all three phases of labour and a reduction in anxiety when allocated to the massage group, as compared to the control group.

Studies of music, white noise, relaxation, and aromatherapy did not show benefit. Randomised controlled trials of other interventions such as reflexology and yoga were not found.   

How it was tested

The researchers made a search of the medical literature to identify controlled trials that assigned women randomly to complementary or alternative methods of labour pain relief along with, or instead of, other interventions for pain. Fourteen trials met pre-set criteria for inclusion: 2 studied acupressure, 3 acupuncture, 1 ‘white noise’ (a sea noise), 1 aromatherapy, 5 hypnosis, 1 massage and 1 relaxation.

In the aromatherapy trial, the 22 participants were randomised to either ginger or lemongrass essential oils and asked to bathe for at least an hour.

All five trials involving hypnosis, in 649 women, involved the pregnant women herself learning in advance to perform self-hypnosis (rather than having an experienced hypnotist present during labour).

Side effects and general cautions

Because of the nature of some of the interventions, it was very difficult to conceal from the women or their carers whether they were receiving an active treatment or not. 

There are few well-designed trials that evaluate complementary therapies for pain management in labour. Of the few trials found, limited numbers of women were included (with the exception of hypnosis and acupuncture). There is therefore insufficient evidence to make a conclusion about most of the therapies studied.

Source

Smith CA, Collins CT, Cyna AM, Crowther CA. Complementary and alternative therapies for pain management in labour.Cochrane Database of Systematic Reviews2006, Issue 4. Art. No.: CD003521. DOI: 10.1002/14651858.CD003521.pub2.

LABOUR POSITION FOR WOMEN NOT USING EPIDURAL ANAESTHESIA

Many different positions can be assumed by a woman giving birth. A woman may lie on her back, stand up (perhaps grasping onto something), squat, assume an all-fours position, for example. More often than not, labour positions are determined by whatever is customary and normal in the woman’s community.

There are tensions and controversy about advantages and disadvantages of various labour positions for women and their babies. 

Labour can be divided into several stages. In the first stage of labour, the neck of the womb (the cervix) becomes softer, springier, and more open to allow the baby to move down the birth canal. Once the cervix has widened to 10 centimeters (about 4 inches), the second stage of labour has begun. During this phase the baby moves down the birth canal and is born. The third stage of labour is after the baby’s birth when the placenta is expelled.

Although there is a huge variety of postures that can be used in the second stage of labour, they can be broadly grouped into positions where the woman is more or less vertical or more or less horizontal. It would be valuable to know the advantages and disadvantages of horizontal versus vertical positions.

Women giving birth more vertically are sometimes supported by a birth cushion, stool or chair. Most Western women would have difficulty maintaining any type of squatting position, particularly without support. Kneeling is another upright birthing position that may be more feasible than squatting.

Most doctors have been trained to expect women to give birth on their backs, with their heads and shoulders propped up and sometimes with their feet in stirrups. This can provide easy access to the doctor to do electronic fetal monitoring, to do episiotomies, and to use forceps or vacuum suction to assist birth. However, it is unclear whether this is the most effective or comfortable position for the birthing woman and whether it may extend the length of the second stage of labour.

What the synthesised research says

There is no clear advantage to the usual practice of having women give birth on their back, and some women may find it uncomfortable or humiliating.    

Based on a number of medical trials generally of rather poor quality, it can tentatively be concluded that vertical positions for labour may shorten the average duration of the second phase of labour. Vertical positions may also somewhat reduce the percentage of instrumental births and episiotomies. A vertical position may also lead to increased perineal tearing and greater blood loss. One trial that examined these results found lower rates of severe birth pain in women giving birth upright (relative risk 0.7) and lower rates of abnormal fetal heart rhythms (relative risk 0.3).

In the trials that looked at the following, the birth position did not change the need for pain reducing drugs (seven trials), rates of caesarean section (12 trials), need for blood transfusion (two trials), unpleasant birth experience (one trial), newborn’s admission to neonatal intensive care unit (two trials), birth injuries (one trial), or death of the baby (three trials).

In light of the evidence to date, the review authors recommend that women be encouraged to deliver in whatever position is most comfortable for them. Many women may want to change positions during the second stage of labour rather than remain in any fixed position.

How it was tested

The researchers made a thorough search of the medical literature to identify controlled trials that assigned women randomly to different birth positions during the second stage of labour. They then evaluated selected outcomes for mother and child in women not receiving epidural anaesthesia (since an epidural can make a woman numb from the waist down and reduce flexibility in positions for labour).

The 19 trials included in the review involved 5,764 women. The trials were of mixed quality and all results should be interpreted cautiously.    

Side effects and general cautions

This review involved labour position during the second stage of labour. Another Cochrane review is planned to investigate labour position at the start of labour but has yet not been completed. 

Source

JK Gupta, GJ Hofmeyr. Position in the second stage of labour for women without epidural anaesthesia. The Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD002006.pub2. DOI: 10.1002/14651858.CD002006.pub2.

IMMERSION

Immersion in water has a long history and may be recommended during labour and birth for some women. Those who support its use believe water is relaxing and can reduce pain during birth. Immersion in water may also be used during pregnancy for reduction of swelling and blood pressure. 

Some people are concerned that immersion in water might lead to an infection risk for mother or infant, or to a newborn baby being harmed by breathing in water. There is controversy about whether a newborn baby will attempt to breathe if it is born in water.

Solid evidence about whether immersion in water is safe and effective in pregnancy, labour and birth is important in making decisions about this therapy. 

What is known

Birthing pools and tubs are very popular in some localities. The British House of Commons Health Committee in 1992 recommended that all hospitals should offer women birthing pools, despite the absence of adequate scientific evaluation of the safety of this practice.

What the synthesised research says

The evidence thus far, from some imperfect clinical trials, suggests that water immersion during the first stage of labour may be helpful for some women. This first stage is before the neck of the uterus (the cervix) dilates to about 10 centimeters (four inches) and before the baby begins to descend into the birth canal. The immersion may decrease pain and the use of an epidural to control labour pain.

Reassuringly, the pain benefit of first-stage immersion did not appear to be associated with worse outcomes for babies or a longer duration of labour. The evidence did not show statistically significant differences with or without water immersion in the condition of the newborn, in rates of caesarean and instrumental (forceps or vacuum-assisted) deliveries, or in rates of cuts and tears to the area between vagina and anus. The incidence of clear differences between groups were not found for Caesarean births, instrumental (forceps or vacuum-assisted) births, or perineal injuries (cuts and tears to the area between vagina and anus). Water immersion did appear to lower blood pressure in the mother.

There is insufficient evidence to draw any conclusions about the safety and benefit of water immersion during the second stage of labour and births in water.

And no evidence at all is available about water immersion during pregnancy or in the third stage of labour when the placenta is delivered. Thus, trials do not address the issue of actual underwater birth and possible breathing problems for the baby.

How it was tested

The researchers made a thorough search of the medical literature to identify controlled trials that assigned women randomly to immersion versus no immersion during their pregnancy, labour, or delivery of the placenta. Eight relevant trials were found, involving a total of 2939 women.

Seven trials were found of water immersion during the first stage of labour. Six compared immersion to no immersion. One compared immersion early in the first stage of labour (before the cervix was dilated much) to later immersion.

Only one trial was found involving immersion during the second stage of labour.

No trials evaluated using different types of tubs or pools, one against another.     

Side effects and general cautions

The limited number of studies mostly had small sample sizes and a high risk of bias, making clear findings difficult. Most trials involved the first stage of labour and so did not involve underwater births.

It was difficult or impossible for women, their carers, and those who evaluated the outcomes to be unaware of which women received the intervention. Comparisons across trials can be difficult as tubs or pools may be of different sizes, allow women more or less mobility (some have moulded seats), have moving water (such as jets) or not, and women may be immersed to a greater or lesser degree.

Some women randomized to immersion did not in fact enter the water - for several reasons including unavailability of the pool, a woman’s change of mind, or they had an epidural.

The temperature of water is another important management factor that was not reported in some trials. Three trials used very warm water, up to 38° C (100° F). 

Salts or essential oils as additives to the water are sometimes used; no trial that met the reviewers’ criteria for good data for analysis looked at water additives.

No trial reported on side effects for caregivers but a survey showed back strain in some who attended immersed women. However, caregiver back problems could also occur during a non-water birth.

The issue of a possibly heightened infection risk for babies or mothers was not looked at in these trials.

The two researchers responsible for the Cochrane overview have themselves been involved in doing studies related to this issue.

Source

E R Cluett, VC Nikodem, RE McCandlish, EE Burns. Immersion in water in pregnancy, labour and birth. The Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000111.pub2. DOI: 10.1002/14651858.CD000111.pub2.

EPISIOTOMY

There is clear evidence that a policy of selective use of episiotomy is more beneficial than and preferable to a policy of routine episiotomy.

The stretching and pulling of the vaginal area that occurs during childbirth can cause some tissue to tear of its own accord. A doctor may also take a pair of scissors or scalpel and cut to widen the vaginal opening just as the baby is about to be born. This cut is called an episiotomy. Two styles of episiotomies are in common use: midline (the cut is made straight down toward the anus, common in North America) and mediolateral (the cut is made downward but angled to one side away from the anus, common in Europe).

How often an episiotomy is performed varies widely. In some countries and settings episiotomies are used routinely, in most or all non-Caesarean births. In others, they are used only if the attending doctor believes there is some special reason during this particular birth to do the procedure. For example, the doctor might want to enlarge the opening for a very large baby or one with a stuck shoulder, to make a breech birth or forceps-assisted birth easier, or to more quickly deliver a baby in distress.

An episiotomy, once made, must be sutured (that is, stitched), is painful and awkward for the woman, and takes time to heal. At times the episiotomy cut can tear further at the end, sometimes into or through the anal sphincter (this is known as a third or fourth-degree tear). Naturally-occurring tears can, however, also be painful and require sutures and are likely to be jagged.

Episiotomies became adopted as common practice without much attention to actual confirmed proof of various presumed benefits. Worldwide rates of episiotomy increased substantially when there was a trend for women to give birth in hospitals and for physicians rather than midwives to become involved in normal uncomplicated births. Little is generally known about the actual results of routine episiotomy. This is a reason that the procedure has become controversial.   

What the synthesised research says

There is clear evidence that a policy of selective use of episiotomy is more beneficial than and preferable to a policy of routine episiotomy.

This conclusion is clear after analysis of six trials where birthing women were randomly assigned to groups where procedures favored routine or selective use of episiotomy. Seventy-three per cent of women randomized to routine episiotomy received an episiotomy; while 28% of the selective episiotomy group got them. The group where episiotomies were done only selectively had less suturing (relative risk 0.7), fewer healing complications seven days later (relative risk 0.7), and less damage to the posterior area of the perineum (the area nearest the anus) (relative risk 0.9).

No overall difference was found between groups in pain, tissue injury, discomfort during intercourse, or urinary incontinence; or on newborn outcomes.

Both midline and mediolateral episiotomies were used in different studies (but were not compared head-to-head against each other in any of the qualifying studies). Outcome differences between the techniques are not apparent from these results.   

How it was tested

The researchers made a thorough search of the medical literature to identify controlled trials that assigned women randomly to routine versus restrictive use of episiotomy, whether midline or mediolateral. Six studies of this type that were done in various countries and involved a total of 4,850 women qualified for inclusion.    

Researchers also looked for trials that compared midline to mediolateral episiotomy head-to-head against each other. Two trials making this comparison were located but were not taken into account as they were evaluated as being of poor quality.   

Results from the six trials were combined and analyzed. A number of maternal outcomes were assessed such as number of episiotomies, trauma to the vagina or perineum (the area of muscle and tissue between the vagina and anus), need for sutures, pain, use of painkilling drugs, painful intercourse, bruising, healing complications, urinary incontinence, and perineal infection. However, maternal satisfaction with the childbirth experience was not evaluated. Newborn outcomes investigated were Apgar scores and need for admission to special care. 

Side effects and general cautions

Although the vast majority of outcomes favored selective use of episiotomy, women receiving episiotomy selectively did have more trauma (relative risk 1.8) to the anterior portion of the perineum (the part nearest the vagina). 

Further research should be done on various commonly-used indications for episiotomy (imminent tearing, breech birth, forceps or vacuum suction birth, preterm birth, etc) and which ones are associated with benefits that truly warrant the procedure.  Research is definitely needed also to determine whether midline or mediolateral episiotomy is generally preferable.  

A policy of selective over routine episiotomy is not only better for the mother and equally good for the child, but also saves expense because it avoids some costs.

Source

G Carroli, J Belizan. Episiotomy for vaginal birth. The Cochrane Database of Systematic Reviews 1999, Issue 3. Art. No.: CD000081. DOI: 10.1002/14651858.CD000081.

MASSAGE OF THE PERINEAL AREA BEFORE BIRTH TO REDUCE TEARS AND INJURIES

The stretching and pulling of the vaginal area that occurs during childbirth can cause some tissue to tear of its own accord. An attending doctor may also take a pair of scissors or scalpel and cut to widen the vaginal opening just as the baby is about to be born. These tears and cuts are extremely common and need stitching up. Both the injuries and stitching can cause the woman pain as they heal and can make intercourse painful.

Massage of the perineal area (the muscular area between the vagina and anus) during the last month of pregnancy is sometimes used with the intention of preventing its damage during birth.

What the synthesised research says

There is good evidence that perineal massage helps reduce damage to the perineum during birth and pain afterwards. Massage by the woman or her partner done as little as once or twice a week and as late as at 35 weeks of pregnancy can have good effects. The positive impact on avoiding perineal damage appeared greater and more certain for women having their first baby.

Women would do well to be informed about potential benefits of perineal massage. It is estimated that one out of sixteen women (around 6%) who practice perineal massage will avoid needing stitches in the perineal area. 

How it was tested

The researchers made a thorough search of the medical literature to identify trials randomly assigning women expecting birth to massage or no massage. Three good-quality trials involving 2434 women were found. The women of course were unavoidably aware of which group they were assigned to, but they were instructed not to let their birth attendant know. Women using perineal massage were less likely to have an episiotomy or to require stitches. No differences were found between the massage and the non-massage groups in rates of vacuum or forceps-assisted births. Differences were also not found in sexual satisfaction, nor in incontinence (urinary or fecal) after the birth. One study involving 376 women found a reduction in pain three months after birth in women who had previously had a vaginal delivery and used massage. There appeared to be a relationship between the frequency of massaging and the level of pain later on, that is women who massaged more had better pain relief.     

All the trials used finger massage rather than a mechanical massaging device. For example, the exact technique in one study was a daily 5 to 10 minute perineal massage from 34 weeks using 1 or 2 fingers inserted 3 to 4 cm into the vagina, using almond oil, and alternating downward and sideward pressure.

Side effects and general cautions

Most women found massage acceptable. However, massage initially was often unpleasant and sometimes it even produced a painful or burning sensation. Most women found that this diminished or disappeared by the second or third week of massage. Seventy-nine per cent said they would massage again and 87% said they would recommend it to another pregnant woman.

Source

MM Beckmann, AJ Garrett. Antenatal perineal massage for reducing perineal trauma. The Cochrane Database of Systematic Reviews2006, Issue 1. Art. No.: CD005123.pub2. DOI: 10.1002/14651858.CD005123.pub2.

THERAPEUTIC ULTRASOUND FOR CONTINUING PERINEAL PAIN AND DISCOMFORT

After childbirth, pain in the muscular area between the vagina and anus (the perineum) is extremely common. This may be because of bruising and tearing of the area during childbirth, cuts made by the attending doctor with scissors or a scalpel, and from stitches used to repair tears and cuts. A woman may also find sexual intercourse and other activities such as sitting and climbing stairs painful for a few weeks. But sometimes the pain continues for months or even as long as a year after childbirth. 

Perineal pain is most often treated with medications to relieve pain (analgesics) taken by mouth. Remedies are sometimes also applied directly to the painful tissue. One such remedy is ultrasound.

When ultrasound is used to speed up injury healing, a gel is first applied to the injured area and the ‘head’ of a machine that produces sounds beyond the range of the human ear is positioned and moved around the area. It would be useful to know how effective ultrasound is to speed up the healing of the perineum after childbirth and to ease pain and discomfort in that area. 

What the synthesised research says

There is insufficient evidence without further research for recommending ultrasound for postpartum perineal pain. Trials so far suggest a possible benefit, but they are of variable quality, too few and involve only a limited number of women. No real conclusions can be drawn. 

Two placebo-controlled trials found more pain improvement in women treated with ultrasound for perineal pain within six weeks after birth. Another trial (that compared ultrasound with pulsed electromagnetic energy) found less pain but more bruising in the ultrasound group 10 days after treatment, as well as less pain in the ultrasound group three months later. In one trial, ultrasound-treated women reported less pain with intercourse (dyspareunia) than a placebo group; however, fewer women in the ultrasound-treated women had attempted to have sex.

How it was tested

The researchers made a thorough search of the medical literature to identify controlled trials that assigned women randomly to ultrasound versus a placebo, no treatment, or another treatment for perineal pain after childbirth. Four trials involving 659 women were found.  

Side effects and general cautions

The trials of ultrasound that were found failed to report whether there were any adverse treatment effects, nor did they directly assess the safety of therapeutic ultrasound. 

Further research is needed on whether ultrasound is effective for wound healing. If there were solid evidence that ultrasound could assist in healing wounds that would go a long way toward validating its use to treat perineal pain after giving birth.

Source

EJC Hay-Smith. Therapeutic ultrasound for postpartum perineal pain and dyspareunia. The Cochrane Database of Systematic Reviews1998, Issue 3. Art. No.: CD000495. DOI: 10.1002/14651858.CD000495.