New Labor Guidance, Part 3

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Also check out for reading for this podcast specifically:
- Committee Opinion 766 on Approaches to Limiting Intervention in Labor and Birth

  • Continuous labor support

    • Defined: continuous presence of support personnel or the continuous presence of a one-on-one person for support. 

      • This support comes in many forms, including:

        • Emotional support

        • Information about labor progress

        • Advice about  coping techniques

        • Providing/facilitating comfort measures

        • Speaking up on behalf of the pregnant individual, when needed

    • Noted in CPG8 as “one of the most effective tools to improve labor and delivery outcomes.”

      • Systematic review: pregnant women allocated to continuous support benefitted from:

        • More likely to have SVD (RR 1.08, 95% CI 1.04 - 1.12)

        • Less likely to have negative feelings of childbirth experience (RR 0.69, CI 0.59 - 0.79)

        • Less likely to use any intrapartum analgesia (RR 0.90, 95% CI 0.64 - 0.88).

        • Have shorter labors (-0.69 hrs; 95% CI -1.04 to -0.34)

        • Less likely to have cesarean birth (RR 0.75, CI 0.64 - 0.88)

        • Less likely to have operative vaginal delivery (RR 0.90, CI 0.85 - 0.96)

        • Less likely to have neonate with 5-min Apgar < 7 (0.62, CI 0.46 - 0.85)

      • CPG 8 notes that OB/Gyns and health care providers/organizations should strive to develop policies and programs to integrate trained support personnel into intrapartum care to provide one-to-one support for laboring persons.

  • The Peanut Ball

    • Elongated, peanut-shaped ball, typically placed between a patient’s legs during labor while the patient is side-lying in order to “open up the pelvis.”

      • In theory, this mimics upright positioning with the opening of the pelvis.

    • A systematic review of four randomized trials of 648 patients found no significant difference for time in labor or incidence of vaginal delivery/cesarean delivery with peanut ball use. 

      • There were nonsignificant trends towards improving vaginal delivery rates and shortening first stage length

      • However, evidence is further limited as guidance for how to use, what size to use, how long to use, when to use…

        • How the peanut ball is implemented in labor courses is heterogenous and driven a lot by personal/nursing experience. 

        • More studies are needed to understand when/if it might be efficacious in particular scenarios.

    Position Change and Ambulation

    • Similarly to the peanut ball, there are many opinions on this!

      • Observational studies find that patients assume many different positions during labor when left to their own devices on what is comfortable.

    • A meta-analysis comparing upright positioning (sitting/standing/kneeling), ambulation, or both with recumbent, lateral, or supine positions during first stage of labor found that upright positions:

      • Reduced first stage length by approximately 1h 22 min (95% CI -2.22 to -0.51 hr)

      • Less likely to undergo cesarean (RR 0.71, 95% CI 0.54-0.94)

    • A separate review found no differences in these factors, but found reduced trauma to pelvic floor for those in kneeling position.

    • CPG 8 encourages position changes to enhance maternal comfort and promote optimal fetal positioning.

  • Hydration modalities

    • CPG 8 notes that IV hydration is safe, but limits freedom of movement and overall may not be necessary

      • Oral hydration can be encouraged to meet caloric and hydration needs.

    • They review a systematic review comparing 250cc/hr of IV fluid to 125cc/h in low risk patients in spontaneous labor at term, demonstrating a lower risk of cesrean for any indication in the 250cc/hr group (12.5% vs 18.1%, RR 0.70).

      • Higher fluid rates also shortened duration of labor by mean of about 1 hour, and second stage specifically by just under 3 mins. 

      • Also did not observe increasing maternal or neonatal morbidities, including pulmonary edema.

        • Recommended increased hydration for nulliparous women when oral intake is restricted.

        • Further study is needed to compare when oral intake / oral hydration is not restricted; when patients are undergoing induction of labor; or if comorbidities exist.

  • Cervical examinations

    • Frequency of cervical examination is frequently cited as a concern for infection, and has to be balanced against understanding labor progress and preventing arrest/dystocia.

    • The CPG authors note a retrospective cohort study of 2400 patients over 4 years showing no significant association between number of cervical exams in labor and intrapartum fever.

      • The association was also not present when confined to exams after amniotomy.