CD 007715

Intravenous uids for reducing the duration of labour in low risk nulliparous women (Review)
Dawood F, Dowswell T, Quenby S
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2013, Issue 6 http://www.thecochranelibrary.com
Intravenous uids for reducing the duration of labour in low risk nulliparous women (Review) Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 4.1. Comparison 4 Intravenous uids + oral intake versus oral intake alone, Outcome 1 Mean duration of labour. Analysis 4.2. Comparison 4 Intravenous uids + oral intake versus oral intake alone, Outcome 2 Caesarean section. . Analysis 4.4. Comparison 4 Intravenous uids + oral intake versus oral intake alone, Outcome 4 Fluid overload. . . Analysis 4.5. Comparison 4 Intravenous uids + oral intake versus oral intake alone, Outcome 5 Admission to neonatal unit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 4.6. Comparison 4 Intravenous uids + oral intake versus oral intake alone, Outcome 6 Low Apgar scores (< 7 at 5 mins). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.1. Comparison 5 125 mL/hour intravenous uids + oral intake versus 250 mL/hour intravenous uids + oral intake, Outcome 1 Mean duration of labour in minutes. . . . . . . . . . . . . . . . . . . . Analysis 5.2. Comparison 5 125 mL/hour intravenous uids + oral intake versus 250 mL/hour intravenous uids + oral intake, Outcome 2 Caesarean section. . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.3. Comparison 5 125 mL/hour intravenous uids + oral intake versus 250 mL/hour intravenous uids + oral intake, Outcome 3 Assisted delivery. . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.4. Comparison 5 125 mL/hour intravenous uids + oral intake versus 250 mL/hour intravenous uids + oral intake, Outcome 4 Fluid overload. . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.5. Comparison 5 125 mL/hour intravenous uids + oral intake versus 250 mL/hour intravenous uids + oral intake, Outcome 5 Admission to neonatal unit. . . . . . . . . . . . . . . . . . . . . . . Analysis 5.6. Comparison 5 125 mL/hour intravenous uids + oral intake versus 250 mL/hour intravenous uids + oral intake, Outcome 6 Low Apgar scores (< 7 at 5 mins). . . . . . . . . . . . . . . . . . . . . Analysis 6.1. Comparison 6 125 mL/hour uids versus 250 mL/hour uids (restricted oral intake in both arms), Outcome 1 Mean duration of labour in minutes. . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.2. Comparison 6 125 mL/hour uids versus 250 mL/hour uids (restricted oral intake in both arms), Outcome 2 Caesarean section. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.3. Comparison 6 125 mL/hour uids versus 250 mL/hour uids (restricted oral intake in both arms), Outcome 3 Assisted delivery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.4. Comparison 6 125 mL/hour uids versus 250 mL/hour uids (restricted oral intake in both arms), Outcome 4 Fluid overload. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.5. Comparison 6 125 mL/hour uids versus 250 mL/hour uids (restricted oral intake in both arms), Outcome 5 Admission to neonatal unit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.6. Comparison 6 125 mL/hour uids versus 250 mL/hour uids (restricted oral intake in both arms), Outcome 6 Low Apgar scores (< 7 at 5 mins). . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 8.1. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 1 Mean duration of labour in minutes. Analysis 8.2. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 2 Caesarean section. . . . . . Analysis 8.3. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 3 Assisted delivery. . . . . . Analysis 8.4. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 4 Fluid overload. . . . . . . Analysis 8.5. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 5 Admission to neonatal unit. .
1 1 2 3 5 5 9 9 10 14 15 16 16 19 34 39 40 40 41 41 42 43 43 44 45 45 46 47 48 48 49 50 50 51 52 52 53
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Analysis 8.6. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 6 Low Apgar scores (< 7 at 5 mins). Analysis 8.9. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 9 Maternal hyponatraemia (sodium level < 135 mmol/L). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 8.12. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 12 Neonatal hyponatraemia (cord sodium level < 135 mmol/L). . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 8.13. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 13 Neonatal hyperbilirubinaemia. Analysis 8.14. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 14 Neonatal hypoglycaemia (< 40 mg/dL). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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[Intervention Review]
Intravenous uids for reducing the duration of labour in low risk nulliparous women
Feroza Dawood1 , Therese Dowswell2 , Siobhan Quenby3 Womens NHS Foundation Trust, Liverpool, UK. 2 Cochrane Pregnancy and Childbirth Group, Department of Womens and Childrens Health, The University of Liverpool, Liverpool, UK. 3 Clinical Sciences Research Institute, University of Warwick, Coventry, UK Contact address: Feroza Dawood, Liverpool Womens NHS Foundation Trust, Crown Street, Liverpool, L8 7SS, UK. feroza.dawood@lwh.nhs.uk. fdawood@liv.ac.uk. Editorial group: Cochrane Pregnancy and Childbirth Group. Publication status and date: New, published in Issue 6, 2013. Review content assessed as up-to-date: 17 June 2013. Citation: Dawood F, Dowswell T, Quenby S. Intravenous uids for reducing the duration of labour in low risk nulliparous women. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD007715. DOI: 10.1002/14651858.CD007715.pub2. Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
1 Liverpool
ABSTRACT Background Several factors may inuence the progression of normal labour. It has been postulated that the routine administration of intravenous uids to keep women adequately hydrated during labour may reduce the period of contraction and relaxation of the uterine muscle, and may ultimately reduce the duration of the labour. It has also been suggested that intravenous uids may reduce caesarean sections (CS) for prolonged labour. However, the routine administration of intravenous uids to labouring women has not been adequately elucidated although it is a widely-adopted policy, and there is no consensus on the type or volume of uids that are required, or indeed, whether intravenous uids are at all necessary. Women may be able to adequately hydrate themselves if they were allowed oral uids during labour. Furthermore, excessive volumes of intravenous uids may pose risks to both the mother and her newborn and different uids are associated with different risks. Objectives To evaluate whether the routine administration of intravenous uids to low-risk nulliparous labouring women reduces the duration of labour and to evaluate the safety of intravenous uids on maternal and neonatal health. Search methods We searched the Cochrane Pregnancy and Childbirth Groups Trials Register (13 February 2013). Selection criteria Randomised controlled trials of intravenous uid administration to spontaneously labouring low-risk nulliparous women. Data collection and analysis The review authors independently assessed trials for inclusion, trial quality and extracted data.
Intravenous uids for reducing the duration of labour in low risk nulliparous women (Review) Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 1
Main results We included nine randomised trials with 1781 women. Three trials had more than two treatment arms and were included in more than one comparison. Two trials compared women randomised to receive up to 250 mL/hour of Ringers lactate solution as well as oral intake versus oral intake only. For women delivering vaginally, there was a reduction in the duration of labour in the Ringers lactate group (mean difference (MD) -28.86 minutes, 95% condence interval (CI) -47.41 to -10.30). There was no statistical reduction in the number of CS in the Ringers lactate group (risk ratio (RR), 0.73 95% CI 0.49 to 1.08). Three trials compared women who received 125 mL/hour versus 250 mL/hour of intravenous uids with free oral uids in both groups. Women receiving a greater hourly volume of intravenous uids (250 mL) had shorter labours than those receiving 125 mL (MD 23.87 minutes, 95% CI 3.72 to 44.02, 256 women). There was no statistically signicant reduction in the number of CS in the 250 mL intravenous uid group (average RR 1.00, 95% CI 0.54 to1.87, three studies, 334 women). In one study the number of assisted vaginal deliveries was lower in the group receiving 125 mL/hour (RR 0.47, 95% CI 0.27 to 0.81). Four trials compared rates of intravenous uids in women where oral intake was restricted (125 mL/hour versus 250 mL/hour). There was a reduction in the duration of labour in women who received the higher infusion rate (MD 105.61 minutes, 95% CI 53.19 to 158.02); P < 0.0001, however, ndings must be interpreted with caution as there was high heterogeneity amongst trials (I2 = 53%). There was a signicant reduction in CS in women receiving the higher rate of intravenous uid infusion (RR 1.56, 95% CI 1.10 to 2.21; P = 0.01). There was no difference identied in the assisted delivery rate (RR 0.78, 95% CI 0.44 to 1.40). There was no clear difference between groups in the number of babies admitted to the NICU (RR 0.48, 95% CI 0.07 to 3.17). Two trials compared normal saline versus 5% dextrose. Only one reported the mean duration of labour, and there was no strong evidence of a difference between groups (MD -12.00, 95% CI -30.09 to 6.09). A trial reporting the median suggested that the duration was reduced in the dextrose group. There was no signicant difference in CS or assisted deliveries (RR 0.77, 95% CI 0.41 to 1.43, two studies, 284 women) and (RR 0.59, 95% CI 0.21 to 1.63, one study, 93 women) respectively. Only one trial reported on maternal hyponatraemia (serum sodium levels < 135 mmol/L ). For neonatal complications, there was no difference in the admission to NICU) or in low Apgar scores, however 33.3% of babies developed hyponatraemia in the dextrose group compared to 13.3 % in the normal saline group (RR 0.40, 95% CI 0.17 to 0.93) (P = 0.03). One trial reported a higher incidence of neonatal hyperbilirubinaemia in the dextrose group of babies. There was no difference in neonatal hypoglycaemic episodes between groups. Authors conclusions Although the administration of intravenous uids compared with oral intake alone demonstrated a reduction in the duration of labour, this nding emerged from only two trials. The ndings of other trials suggest that if a policy of no oral intake is applied, then the duration of labour in nulliparous women may be shortened by the administration of intravenous uids at a rate of 250 mL/hour rather than 125 mL/hour. However, it may be possible for women to simply increase their oral intake rather than being attached to a drip and we have to consider whether it is justiable to persist with a policy of nil by mouth. One trial raised concerns about the safety of dextrose and this needs further exploration. None of the trials reported on the evaluation of maternal views of being attached to a drip during their entire labour. Furthermore, there was no objective assessment of dehydration. The evidence from this review does not provide robust evidence to recommend routine administration of intravenous uids. Interpreting the results from trials was hampered by the low number of trials contributing data and by variation between trials. In trials where oral uids were not restricted there was considerable variation in the amount of oral uid consumed by women in different arms of the same trial, and between different trials. In addition, results from trials were not consistent and risk of bias varied. Some important research questions were addressed by single trials only, and important outcomes relating to maternal and infant morbidity were frequently not reported.
PLAIN LANGUAGE SUMMARY Intravenous uids for preventing prolonged labour in women giving birth to their rst baby Labour may be considered to be a period of prolonged exercise. Labouring women may become dehydrated as a result of the physical exertion caused by the muscles of the womb contracting. In many institutions women are subjected to a questionable policy of restricted oral intake. Only sips of water or ice chips are allowed. In institutions where this is employed, women are given routine intravenous
Intravenous uids for reducing the duration of labour in low risk nulliparous women (Review) Copyright 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 2
uids (through a drip).The aim of this review was to evaluate the impact of the routine administration of intravenous uids (using a drip) on the duration of labour in women who were in their rst pregnancy. We also wanted to determine any side-effects of intravenous uids on the mother and the newborn. We included nine randomised controlled trials.The review demonstrated that in women who are not freely drinking uids during the course of their labour, additional uids through a drip (intravenously) reduces the duration of their labour. The number of caesarean sections was also reduced when women received normal saline or Ringers lactate at a rate of 250 mL/hour compared to 125 mL/hour. Dextrose-containing uids reduced the sodium levels (hyponatraemia) of both the labouring mother and their newborns. However, the differences in the methodology and quality of several of the trials do not provide sufcient evidence to recommend routinely attaching labouring women to a drip. Further research needs to be undertaken as to whether or not women who are freely drinking, even need to have a drip, and the policy of restricted oral intake needs to be urgently reviewed.
BACKGROUND
Description of the condition

Human labour is physically demanding and there are several factors that may inuence the normal progression of labour. One of the rationales for administering intravenous uids during labour is the need to provide an adequate metabolic environment to support the demands of labour. While the physiological caloric requirement for a labouring uterus has been reported to be approximately ten grams of carbohydrates per hour (Morton 1985), the actual amount of hydration that a labouring uterus requires for efcient contraction, has not been quantied. It does seem logical that adequate hydration and perhaps supplemental glucose is required to maintain endurance and muscle efciency during the process of labour and parturition, but is the routine administration of intravenous uids entirely necessary? The labouring uterine smooth muscle may be compared to periods of prolonged exertion as is seen with prolonged exercise, for example, in distance runners. Several prospective randomised trials in the eld of sports medicine have demonstrated that regular uid replacement during exercise improved performance and prevented dehydration in long-distance runners (Barr 1991; Maughan 1996; Montain 1992). Some researchers believe that extrapolating data from exercise physiology to uterine smooth muscle, may provide some insight as to why some women who may be inadequately hydrated undergo prolonged labours (Saltin 1998). During exercise, uid loss is poorly regulated and moreover, the rate of uid loss by sweating and respiration is not reduced in a state of dehydration (Garite 2000). More specically, uterine blood ow is not autoregulated and in the presence of decreased intravascular volume (which may occur secondary to dehydration), uid may be redistributed away from the uterus potentially aggravating the problem (Eslamian 2006). Optimal uterine perfusion is not only
required for adequate fetal oxygenation, but also for the delivery of nutrients and the elimination of waste products from the contracting myometrium. Furthermore, labouring women who are not adequately hydrated may have alterations in the acid-base balance of the uid surrounding the myometrial bres resulting in a decrease in the pH. Changes in the pH have been shown to affect calcium signalling and the force of myometrial contractility, prolonging the course of labour (Pierce 2003). Some studies have therefore postulated that dysfunctional or prolonged labour, a leading indication for primary caesarean section delivery, could, at least in part, be caused by inadequate uterine forces or inappropriately co-ordinated contractions because of inadequate hydration. The hypothesis that was developed was that women who are adequately hydrated with routine administration of intravenous uids, have a reduced duration of labour and a reduced need for caesarean section delivery for prolonged labour (Eslamian 2006; Garite 2000). This theory raises several questions: can intravenous uids be proven to reduce the duration of labour and caesarean section delivery for prolonged labour? If so, what is the optimal rate and optimal type of intravenous uid to be administered to labouring women? Are there any associated risk factors with routine intravenous uid administration? Indeed the benets of routine administration of intravenous uids to low-risk labouring women have not been properly evaluated. Despite the lack of evidence, many institutions have adopted the policy of restricting women from food and drink in labour and replacing oral intake with intravenous uids instead. Another purported reason for enforcing a policy of nil by mouth is that it is a protective measure against aspiration of gastric contents in the event of general anaesthesia. However, the advent of epidural anaesthesia and antacids has greatly reduced the risk of pulmonary complications and the attendant morbidity from the aspiration of pulmonary contents has virtually disappeared (OSullivan 2003). The likelihood of mortality from aspiration during caesarean sec3
tion has been quoted as 1.8 per 100,000 (Schuitemaker 1997), and adjusted for the vastly reduced number of general anaesthetics, the actual risk is even lower at 1 in 1.2 million. (Romano 2009). Despite a revision of guidelines from the American Society of Anesthesiologists (ASA 2007) to encourage the oral intake of clear uids in labour, almost 83% of women in America are routinely given intravenous uids instead, even if they were deemed low risk (Romano 2009). Practices vary amongst different countries. Many midwifery-led units in the UK at least, do not routinely administer intravenous uids for low-risk women and neither is it a common practice in home births and some birth centres (Michael 1991). A survey that was conducted in around 350 units in England and Wales revealed that a third allowed some food or drink and well over 90% allowed some oral intake (Michael 1991). In the Netherlands too, women have been allowed unrestricted oral intake (Scheepers 1998). While it is acknowledged that labour is a demanding event, and in some cases may be prolonged, should women be routinely supplemented with intravenous uids or could this be simply avoided by allowing women to eat and drink according to their own feelings of hunger or thirst? Whether or not restricting oral food intake is justiable is the subject of another review (Singata 2010). Besides medicalising a normal labour, women may nd intravenous uids uncomfortable and being attached to an intravenous line limits mobility. Furthermore, intravenous infusions can lead to elevated central venous pressure after the administration of only one to two litres of uid. Fluid overload has also been associated with increased cardiovascular work and pulmonary oedema (Carvalho 1994).There are also concerns that excessive uids administered to the mother, may affect the newborn as well. More recent studies found that if mothers received more than 200 mL/ hour of uids, their babies were 3.2 times more likely to experience excess weight loss at three days compared to mothers who had less than 100 mL/hour of uids (Chantry 2011; Noel-Weiss 2011). The aim of this review was to evaluate the impact of routine administration of intravenous uids to low-risk nulliparous labouring women. We also aimed to explore the safety of the mother and the baby.
consider the use of intravenous uids for women with a febrile illness or pyrexia during labour. There are different types of intravenous uids that may be employed and there are side-effects that are associated with some. For example, although high-dose glucose solutions may correct maternal ketosis, the administration thereof may be associated with an increased incidence of neonatal hyponatraemia (Tarnow-Mordi 1981). Dextrose-only solutions may also cause maternal hyponatraemia and affect serum osmolality (Keppler 1988). Different volumes of uids may also be used. Excessive amounts of uids may lead to uid overload (Montain 2008) in the mother. There are also concerns over newborn weight loss during the rst three days following birth that occurs when mothers have received large volumes of intravenous uids (Chantry 2011; Noel-Weiss 2011). While intravenous uids may seem a simple and benign intervention to healthcare professionals, routine intravenous uids may adversely affect the perception of labour for women and negatively impact on the normality of labour. We therefore also planned to evaluate the qualitative disadvantages of routine intravenous uids which include women being less mobile in labour, maternal discomfort, fear and pain and overall negative feelings.
How the intervention might work

As already discussed above, some women may become very dehydrated during labour as the uterine muscle has to contract and relax continuously and this may be required for a prolonged period of time. The intense exertion that may be required may lead to dehydration. Adequate uid replacement enhances muscle performance in long-distance runners. The administration of intravenous uids to keep women adequately hydrated during labour may reduce the period of contraction and relaxation of the uterine muscle and may ultimately reduce the duration of the labour. It has been postulated that dehydration may contribute to prolonged and inefcient labour and it can be hypothesised that adequate maternal hydration will be important for optimum oxygenation, delivery of nutrients and elimination of waste products from the contracting myometrium. It has also been suggested that adequate intravenous uid replacement regimens may even obviate the need for caesarean sections that are performed solely for failure to progress in labour, or prolonged labour (Eslamian 2006) that may result from inadequate hydration. Some types of intravenous uids (dextrose-containing solutions), may also provide a caloric supplementation for labouring women. However, the notion that the administration of routine intravenous uids may prevent operative deliveries by preventing dehydration is largely theoretical as operative deliveries may result from various factors. However, even if there is a partial benet of intravenous uids in the reduction of unnecessary caesarean sections then it is important to evaluate this as there are wider cost implications as well as the impact on future pregnancies.
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Description of the intervention

The intervention that we reviewed is the routine administration of uids through an intravenous line (drip) to low-risk nulliparous women in labour. This review focuses specically on the routine use of intravenous administration of uids during labour for the purpose of uid and nutritional support/management and not for clinical conditions where intravenous uids are medically indicated, for example, as preload prior to epidural analgesia, or for any other medical interventions such as cardio-respiratory conditions, diabetes, haematological or renal disease. Neither did we
Why it is important to do this review

As outlined above, in many centres, the use of routine intravenous uids administration is widespread and pervasive without a cogent body of evidence. Furthermore, little cognisance has been noted regarding the safety and efcacy of routine intravenous uids, and indeed the potential dangers of some types of uids. Although oral uids are the simplest and easiest way of replenishing lost uids, it is thought that amounts of more than 500 mL/hour are required in prolonged exertion (Noakes 1993) such as labour. Thus, there may be some justication for the routine use of intravenous uids for labouring women, however, the volumes and types of uids need further clarication. The main aim of this review is to determine the impact (if any) on the use of routine intravenous uid administration on the duration of labour. Different types of intravenous uid regimens may produce different results for women in labour. The type and volume of intravenous uid that is administered during labour need to be elucidated. Moreover, this review is important as it may assist in providing evidence that routine intravenous uid administration is not superior to unrestricted oral intake in low-risk women.
Randomised and quasi-randomised studies comparing the administration of different volumes of the same intravenous uids Randomised and quasi-randomised studies comparing the administration of different intravenous uids Since this review aims to determine whether the routine use of intravenous uids shortens the duration of labour or minimises the need for augmentation of labour, women who subsequently require oxytocin augmentation have not been excluded. However, women who require oxytocin primarily for induction of labour were excluded. Therefore, we included caesarean sections, other operative deliveries and the need for augmentation as outcome measures. We have not included cross-over trials; this research design is not suitable for this intervention during labour.
Types of participants Nulliparous women We intentionally restricted the review to nulliparous women as we felt that the inclusion of multiparous women would introduce a considerable bias as this would include women in their second, third or fourth labours. The main aim of the review is to determine whether intravenous uids reduce the duration of labour. It is generally accepted that women tend to labour quicker in subsequent labours and this would have introduced a bias. It would have been difcult to determine the inuence that a womans parity had on the duration of labour. Therefore, to exclude this bias and for the sake of uniformity, we only included low-risk nulliparous women. Spontaneous active labour Singleton presentations Cephalic presentation Term pregnancies (greater than 36 weeks) Low-risk pregnancies (i.e. no medical conditions such as diabetes, pre-eclampsia etc and no obstetric problems such as antepartum haemorrhage or chorioamnionitis)
OBJECTIVES
To assess the impact of early or routine intravenous uid administration on the duration and course of labour. To determine the risks and benets of early or routine intravenous uid administration during labour. To determine the risks and benets of different uid regimens (i.e. different volumes or different types of uids, or both) used in labour. To compare the course of labour when intravenous uids are compared with oral intake. To compare the course of labour when oral intake is supplemented by routine intravenous uids versus oral intake only.
METHODS
Types of interventions Intravenous uid versus no intravenous uids (restricted oral intake) Intravenous uids versus no intravenous uids (oral intake not restricted) Intravenous uids + oral intake versus intravenous uids alone Intravenous uids + oral intake versus oral intake alone Comparison of different rates of intravenous uids Comparison of different types of intravenous uids
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Criteria for considering studies for this review
Types of studies Randomised and quasi-randomised studies comparing the administration of routine intravenous uids compared with nonadministration of intravenous uids
Types of outcome measures The outcomes were divided into maternal and fetal outcomes.
Primary outcomes
Maternal 1. 2. 3. 4. Duration of labour (in minutes) Fluid overload Caesarean section Assisted delivery
Fetal 1. Admission to neonatal intensive care unit (NICU)/special care baby unit 2. Low Apgar scores (less than seven at ve minutes) 3. Cord pH < 7.0 4. Newborn weight loss (rst three days)
4. handsearches of 30 journals and the proceedings of major conferences; 5. weekly current awareness alerts for a further 44 journals plus monthly BioMed Central email alerts. Details of the search strategies for CENTRAL, MEDLINE and EMBASE, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the Specialized Register section within the editorial information about the Cochrane Pregnancy and Childbirth Group. Trials identied through the searching activities described above are each assigned to a review topic (or topics). The Trials Search Co-ordinator searches the register for each review using the topic list rather than keywords. We will not apply any language restrictions.
Data collection and analysis
Selection of studies
Secondary outcomes
All review authors (Feroza Dawood (FD), Therese Dowsell (TD) and Siobhan Quenby (SQ)) independently assessed for inclusion all the potential studies identied as a result of the search strategy. Disagreement was resolved through discussion. Data extraction and management We designed a data extraction form to capture data. For eligible studies, FD ,TD and SQ extracted the data using the agreed form. We resolved discrepancies through discussion. We entered data into Review Manager software (RevMan 2011) and checked for accuracy.
Maternal 1. 2. 3. 4. Maternal comfort Maternal satisfaction Subjective feelings of thirst Ketoacidosis
Fetal and neonatal 1. Hyponatraemia 2. Hyperbilirubinaemia
Assessment of risk of bias in included studies Two review authors independently assessed risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We resolved any disagreement by discussion.
Search methods for identication of studies
Electronic searches We contacted the Trials Search Co-ordinator to search the Cochrane Pregnancy and Childbirth Groups Trials Register (13 February 2013). The Cochrane Pregnancy and Childbirth Groups Trials Register is maintained by the Trials Search Co-ordinator and contains trials identied from: 1. monthly searches of the Cochrane Central Register of Controlled Trials (CENTRAL); 2. weekly searches of MEDLINE; 3. weekly searches of EMBASE;
(1) Random sequence generation (checking for possible selection bias)
We have described for each included study the method used to generate the allocation sequence in sufcient detail to allow an assessment of whether it should produce comparable groups. We assessed the method as: low risk of bias (any truly random process, e.g. random number table; computer random number generator); high risk of bias (any non-random process, e.g. odd or even date of birth; hospital or clinic record number);
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unclear risk of bias.

(2) Allocation concealment (checking for possible selection bias)
We have described for each included study the method used to conceal allocation to interventions prior to assignment and assess whether intervention allocation could have been foreseen in advance of, or during recruitment, or changed after assignment. We assessed the methods as: low risk of bias (e.g. telephone or central randomisation; consecutively numbered sealed opaque envelopes); high risk of bias (open random allocation; unsealed or nonopaque envelopes, alternation; date of birth); unclear risk of bias.
(3.1) Blinding of participants and personnel (checking for possible performance bias)
We assessed methods as: low risk of bias (e.g. no missing outcome data; missing outcome data balanced across groups); high risk of bias (e.g. numbers or reasons for missing data imbalanced across groups; as treated analysis done with substantial departure of intervention received from that assigned at randomisation); unclear risk of bias.
(5) Selective reporting (checking for reporting bias)
We have described for each included study the methods used, if any, to blind study participants and personnel from knowledge of which intervention a participant received. We considered studies to be at low risk of bias if they were blinded, or if we judged that the lack of blinding would be unlikely to affect results. We assessed blinding separately for different outcomes or classes of outcomes. We assessed the methods as: low, high or unclear risk of bias for participants; low, high or unclear risk of bias for personnel;
(3.2) Blinding of outcome assessment (checking for possible detection bias)
We have described for each included study how we investigated the possibility of selective outcome reporting bias and what we found. We assessed the methods as: low risk of bias (where it is clear that all of the studys prespecied outcomes and all expected outcomes of interest to the review have been reported); high risk of bias (where not all the studys pre-specied outcomes have been reported; one or more reported primary outcomes were not pre-specied; outcomes of interest are reported incompletely and so cannot be used; study fails to include results of a key outcome that would have been expected to have been reported); unclear risk of bias.
(6) Other bias (checking for bias due to problems not covered by (1) to (5) above)
We have described for each included study the methods used, if any, to blind outcome assessors from knowledge of which intervention a participant received. We assessed blinding separately for different outcomes or classes of outcomes. We assessed the methods used to blind outcome assessment as: low, high or unclear risk of bias.
(4) Incomplete outcome data (checking for possible attrition bias due to the amount, nature and handling of incomplete outcome data)
We have described for each included study any important concerns we had about other possible sources of bias. We assessed whether each study was free of other problems that could put it at risk of bias: low risk of other bias; high risk of other bias; unclear whether there is risk of other bias.
(7) Overall risk of bias
We have described for each included study, and for each outcome or class of outcomes, the completeness of data including attrition and exclusions from the analysis. We have stated whether attrition and exclusions were reported and the numbers included in the analysis at each stage (compared with the total randomised participants), reasons for attrition or exclusion where reported, and whether missing data were balanced across groups or were related to outcomes. Where sufcient information was reported, or was supplied by the trial authors, we re-included missing data in the analyses which we undertook.
We made explicit judgements about whether studies are at high risk of bias, according to the criteria given in the Handbook (Higgins 2011). With reference to (1) to (6) above, we assessed the likely magnitude and direction of the bias and whether we considered it was likely to impact on the ndings. We explored the impact of the level of bias through undertaking sensitivity analyses - see Sensitivity analysis.
Measures of treatment effect
Dichotomous data
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For dichotomous data, we have presented results as summary risk ratio with 95% condence intervals.
Continuous data
For continuous data, we used the mean difference if outcomes were measured in the same way between trials. We planned to use the standardised mean difference to combine trials that measured the same outcome, but used different methods. Unit of analysis issues
We analysed data on all participants with available data in the group to which they were allocated, regardless of whether or not they received the allocated intervention. If in the original reports participants were not analysed in the group to which they were randomised, and there was sufcient information in the trial report, we would have attempted to restore them to the correct group. Assessment of heterogeneity We examined statistical heterogeneity in each meta-analysis using the T, I and Chi statistics. We regarded heterogeneity as substantial if the T was greater than zero and either an I was greater than 30% or there was a low P value (less than 0.10) in the Chi test for heterogeneity. In the presence of heterogeneity, we have used a random-effects meta-analysis as an overall summary if calculating an average treatment effect was considered appropriate. Assessment of reporting biases In future updates of this review, if there are 10 or more studies in the meta-analysis we will investigate reporting biases (such as publication bias) using funnel plots. We will assess funnel plot asymmetry visually, and use formal tests for funnel plot asymmetry. For continuous outcomes we will use the test proposed by Egger 1997, and for dichotomous outcomes we will use the test proposed by Harbord 2006. If asymmetry is detected in any of these tests or is suggested by a visual assessment, we will perform exploratory analyses to investigate it. Data synthesis We carried out statistical analysis using the Review Manager software (RevMan 2011). We used xed-effect meta-analysis for combining data where trials examined the same intervention, and the trials populations and methods were judged sufciently similar. Where we suspected clinical or methodological heterogeneity between studies sufcient to suggest that treatment effects may differ among trials, we used random-effects meta-analysis. If we identied substantial heterogeneity in a xed-effect metaanalysis we noted this and repeated the analysis using a randomeffects method, when appropriate. Where we used random-effects analyses, the results are presented as the average treatment effect with its 95% condence interval, along with the estimates of I. Subgroup analysis and investigation of heterogeneity If we had identied substantial heterogeneity, we planned to investigate it using subgroup analyses and sensitivity analyses. We planned to assess differences between subgroups by interaction tests. In this version of the review too few studies contributed data to allow this additional analysis.
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Cluster-randomised trials
We did not anticipate any cluster-randomised trials on this topic. However, if we identify any cluster-randomised trials in future updates of this review they will be included in the analyses along with individually-randomised trials. We will adjust their sample sizes using the methods described in the Handbook (Higgins 2011) using an estimate of the intracluster correlation co-efcient (ICC) derived from the trial (if possible), from a similar trial or from a study of a similar population. If we use ICCs from other sources, we will report this and conduct sensitivity analyses to investigate the effect of variation in the ICC. If we identify both clusterrandomised trials and individually-randomised trials, we plan to synthesise the relevant information. We will consider it reasonable to combine the results from both if there is little heterogeneity between the study designs and the interaction between the effect of intervention and the choice of randomisation unit is considered to be unlikely. We will also acknowledge heterogeneity in the randomisation unit and perform a subgroup analysis to investigate the effects of the randomisation unit.
Cross-over trials
We did not include cross-over trials. Dealing with missing data For included studies, we noted levels of attrition. We planned to explore the impact of including studies with high levels of missing data in the overall assessment of treatment effect by using sensitivity analysis; however, in this version of the review most of the trials had low levels of attrition and we did not carry out this planned analysis. For all outcomes, we carried out analyses, as far as possible, on an intention-to-treat basis, i.e. we attempted to include all participants randomised to each group in the analyses. The denominator for each outcome in each trial was the number randomised minus any participants whose outcomes were known to be missing (available case analysis).
Sensitivity analysis We planned to carry out sensitivity analyses to explore the effect of trial quality for important outcomes in the review. Where there was risk of bias associated with a particular aspect of study quality (e.g. quasi-randomisation or high risk of bias for allocation concealment), we planned to explore this by sensitivity analyses using the primary outcomes. However, in this version of the review only a very limited number of studies contributed data for each outcome and so we did not carry out this planned analysis. In future updates, as more data become available, we will carry out these additional analyses.
Shrivastava 2009; Stratton 1995) were included in this review. Collectively, a total of 1781 women were initially recruited, however due to attrition and exclusion, the nal analysis is based on 1617 women. For full details, see Characteristics of included studies.
Participants
All women were spontaneously labouring low-risk nulliparous women with a singleton pregnancy at term, i.e. at least 36 weeks completed gestation. We excluded trials that solely studied women whose labours were induced.
RESULTS
Interventions
Various different intravenous uids in different volumes (see Effects of interventions below).
Description of studies
We included nine trials that collectively recruited 1781 women. However, due to attrition and various exclusion factors, the nal analysis in this review is based on 1617 women. Results of the search We included nine trials and excluded 26 trials. Included studies Nine trials (Alavi 2005; Coco 2010; Direkvand-Moghadam 2012; Eslamian 2006; Garite 2000; Kavitha 2012; Maderia 2007; Excluded studies We excluded 26 trials. For details, see Characteristics of excluded studies. In addition, we identied one trial that is still ongoing (Salim 2011) and two that are awaiting assessment (Amir 2004; Rad 2012).
Risk of bias in included studies

Summaries of risk of bias assessments have been set out in Figure 1 and Figure 2.
Figure 1. Risk of bias graph: review authors judgements about each risk of bias item presented as percentages across all included studies.
Figure 2. Risk of bias summary: review authors judgements about each risk of bias item for each included study.
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Allocation Adequate and secure concealment of allocation was described in seven trials (Coco 2010; Direkvand-Moghadam 2012; Eslamian 2006; Garite 2000; Kavitha 2012; Shrivastava 2009; Stratton 1995). We classied as unclear allocation risk in the Alavi 2005 trial, as although sealed envelopes were used there was unclear information on the method of randomisation. There was also an unclear risk of allocation concealment in the study by Maderia 2007 as it was published as an abstract with limited information.
Comparison 1: Intravenous uid alone versus no intravenous uids (restricted oral intake) None of the included studies analysed this comparison. Comparison 2: Intravenous uids alone versus no intravenous uids (unrestricted oral intake) None of the included trials analysed this comparison. Comparison 3: Intravenous uids alone versus intravenous uids and oral intake None of the included studies studied this comparison Comparison 4: Intravenous uids (up to 250 mL/hour) + oral intake versus oral intake alone Two trials were included in this comparison (DirekvandMoghadam 2012; Kavitha 2012). In the study by Direkvand-Moghadam 2012, 120 women were divided into four groups; the control group was allowed free oral intake of water and/or, soft drinks, in three intervention arms women received intravenous Ringer lactate solution at rates of 60 mL, 120 mL or 250 mL per hour throughout active labour and were also allowed free oral uids. To allow a single pair-wise comparison for this study, in the data and analysis tables for this comparison, we combined the results for the three groups receiving intravenous uids. The mean total amount of oral or intravenous intake for the four groups was not stated. In Kavitha 2012, 96 women were randomised to receive 250 mL/ hour of Ringers lactate solution as well as oral intake, and 99 women received oral intake only. The mean amount of oral uid intake was 1325 mL in the intravenous uid group and 896 mL in the oral intake group. Oral intake included both plain water and coconut water.
Primary outcomes
Blinding Where intravenous uids were compared with no intravenous uids, masking women and staff would not be feasible, and staff would also be likely to be aware of treatment group when women were randomised to have different rates of infusion. Lack of blinding may have had an effect on outcomes in ve of the included studies (Alavi 2005; Coco 2010; Direkvand-Moghadam 2012; Garite 2000; Kavitha 2012). In one study it was stated that infusion rates were masked (Eslamian 2006), and in one study reported in a brief abstract, it was not clear whether there had been any attempt at blinding women and staff. Where different intravenous uids were compared women and staff were blinded in Shrivastava 2009, but it was not clear whether there was blinding or not in Stratton 1995.
Incomplete outcome data In most of our included studies all women were accounted for in the analysis, or rates of attrition were low, reasons for loss to follow-up were explained, and were balanced across groups. In the Coco 2010 study, women were recruited during pregnancy and there was a high rate of loss to follow- up, putting this study at high risk of bias for this domain.
Effects of interventions
For the sake of clarity we have used the following comparisons. Intravenous uid versus no intravenous uids (restricted oral intake) Intravenous uids versus no intravenous uids (unrestricted oral intake) Intravenous uids + oral intake versus intravenous uids alone Intravenous uids + oral intake versus oral intake alone Different rates of intravenous uids + oral intake Comparison of different rates of intravenous uids Comparison of different types of intravenous uids Three trials with more than two arms are included in more than one comparison (Direkvand-Moghadam 2012; Kavitha 2012; Shrivastava 2009).
Maternal outcomes Duration of labour in minutes (vaginal deliveries): Both studies reported on the duration of labour although Direkvand-Moghadam 2012 reported separate results for each stage of labour and in the analysis we used the duration of the active rst stage of labour. There was a reduction in the duration of labour in the intravenous uids + oral intake group of 29 minutes (mean difference (MD) 28.86, 95% condence interval (CI) -47.41 to -10.30, two studies, 241 women) (Analysis 4.1). Direkvand-Moghadam 2012 reported that the duration of the 2nd and the 3rd stages of labour were reduced for women receiving intravenous uids, although the difference between groups for the third stage was not statistically signicant (data not shown).
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Mode of delivery: There was no statistically signicant reduction in the number of caesarean sections (CS) in the intravenous uid group (risk ratio (RR) 0.73, 95% CI 0.49 to1.08, two studies, 315 women) (Analysis 4.2). Neither study reported the number of assisted vaginal deliveries. Fluid overload: There were no cases of uid overload in either group in the Kavitha 2012 trial. Neonatal outcomes NICU admission: There was no evidence of a statistically signicant difference in admission to the neonatal unit in the Kavitha 2012 trial (RR 0.52, 95% CI 0.05 to 5.59) (Analysis 4.5). Apgar score > seven at ve minutes: This was reported by DirekvandMoghadam 2012; there were no infants with a low Apgar score at ve minutes in either group (Analysis 4.6). Other primary outcomes: Neither of the two studies included in this comparison reported on cord pH or newborn weight loss.
Secondary outcomes
deliveries in both groups in this study (RR 0.47, 95% CI 0.27 to 0.81) (Analysis 5.3). Fluid overload: There were no cases of uid overload in either group in the two studies reporting this outcome. Neonatal outcomes NICU admission: There was no strong evidence of a difference between groups in admission to the neonatal unit in the two trials reporting this outcome; overall, there were a total of eight admissions from the pooled sample of 274 (RR 0.56, 95% CI 0.15 to 2.06) (Analysis 5.5). Apgar score > seven at ve minutes: This was reported by Coco 2010 and Direkvand-Moghadam 2012; there were no infants with a low Apgar score at ve minutes in either study (Analysis 5.6). Other primary outcomes: None of the studies included in this comparison reported on cord pH or newborn weight loss.
Secondary outcomes
There were no data reported for any of our maternal or infant secondary outcomes (maternal hyponatraemia, maternal comfort/ discomfort, maternal feelings of thirst, neonatal hyponatraemia, neonatal hypoglycaemia or hyperbilirubinaemia). Comparison 5: Intravenous uids 125 mL/hour + oral intake versus intravenous uids 250 mL/hour + oral intake Three studies were included in this comparison (Coco 2010; Direkvand-Moghadam 2012; Kavitha 2012).
Primary outcomes
There were no data reported for any of our maternal or infant secondary outcomes (maternal hyponatraemia, maternal comfort/ discomfort, maternal feelings of thirst, neonatal hyponatraemia, neonatal hypoglycaemia or hyperbilirubinaemia). Comparison 6: Comparison of different rates of intravenous uids (125 mL/hour versus 250 mL/hour) with restricted oral intake Four trials (Alavi 2005; Eslamian 2006; Garite 2000; Maderia 2007 ) were included in this comparison with a total number of 808 women. Two trials (Eslamian 2006; Garite 2000 ) compared different rates of Ringers lactate solution. The Alavi 2005 trial compared different rates of normal saline in dextrose water, while there was no further information on the type of uid used in the Maderia 2007 trial.
Primary outcomes
Maternal outcomes Duration of labour in minutes (vaginal deliveries): All three studies included in this comparison reported on the duration of labour. (Direkvand-Moghadam 2012 reported separate results for each stage of labour and in the analysis we have used the length of the active rst stage of labour). Women receiving a greater hourly volume of intravenous uids (250 mL) plus free oral uids had shorter labours than those receiving 125 mL (MD 23.87, 95% CI 3.72 to 44.02, three studies, 256 women) (Analysis 5.1). Mode of delivery: There was no statistically signicant reduction in the number of caesarean sections (CS) in the 250 mL hourly intravenous uid group (average RR 1.00, 95% CI 0.54 to1.87, three studies, 334 women (random-effects analysis)) (Analysis 5.2). One study reported results for 80 women and the number of assisted vaginal deliveries was lower in the group receiving 125 mL hourly plus free oral uids compared with the group receiving 250 mL although there were relatively high numbers of assisted
Maternal outcomes Duration of labour in minutes (vaginal deliveries): There was a signicant reduction in the duration of labour in women who received a higher infusion rate of intravenous uids (MD 105.61, 95% CI 53.19 to 158.02 (P < 0.0001) four studies, 632 women. However, ndings must be interpreted with caution as results in the four trials were not consistent. There was fairly high statistical heterogeneity amongst trials and results have been pooled using a random-effects model (heterogeneity within this comparison I2 = 53%) (Analysis 6.1). Mode of delivery: There was a signicant reduction in the caesarean section rate in women receiving a higher rate of intravenous uid infusion without any signicant heterogeneity between trials (RR
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1.56, 95% CI 1.10 to 2.21; (P = 0.01) four trials, 748 women, I2 = 0%) (Analysis 6.2). Only two trials reported on assisted delivery (Eslamian 2006; Garite 2000). There was no evidence of any difference between groups in the assisted delivery rate (RR 0.78, 95% CI 0.44 to 1.40 (Analysis 6.3). Fluid overload: Only one trial reported on uid overload (Garite 2000). Only one woman in the 125 mL/hour group was reported to have developed uid overload, while no women suffered this in the 250 mL/hour group (RR 3.22 and wide 95% CI of 0.13 to 78.11) (Analysis 6.4). Neonatal outcomes NICU admission: There was no strong evidence that the rate of infusion affected admission to NICU in 3 studies with data for 689 babies, overall the number of admissions was relatively low and results in different studies were not consistent. We used a randomeffects model for this analyses and the 95% condence intervals for this outcome are wide (average RR 0.48, 95% CI 0.07 to 3.17, I2 47%). (Analysis 6.5). Apgar score < seven at ve minutes: More babies had low Apgar scores in the 125 mL/hour group compared to the 250 mL/hour group although the difference between groups was not statistically signicant (RR 4.35, 95% CI 0.97 to 19.51, three studies, 689 babies) (Analysis 6.6). Other primary outcomes: Neither of the studies included in this comparison reported on cord pH or newborn weight loss.
Secondary outcomes
Primary outcomes
Maternal outcomes Duration of labour in minutes: Both studies included in this comparison reported duration of labour. Stratton 1995 reported the mean duration of labour and there was no strong evidence of a difference in the duration of labour for women receiving normal saline versus a 5% dextrose solution (MD of -12.00, 95% CI 30.09 to 6.09) (Analysis 8.1). Shrivastava 2009 reported the median time from uid initiation to delivery and reported shorter duration in the 5% dextrose group (median 392 minutes) versus the normal saline group (median 464 minutes) and this difference between groups was reported to be statistically signicant (P = 0.02) (data not shown in the data and analysis tables). Mode of delivery: There was no signicant difference in the need for caesarean section or assisted delivery (RR 0.77, 95% CI 0.41 to 1.43, two studies, 284 women) and (RR 0.59, 95% CI 0.21 to 1.63, one study, 93 women) respectively. (Analysis 8.2; Analysis 8.3). Fluid overload: There were no cases of uid overload in either group in the single study reporting this outcome (Analysis 8.4.) Neonatal outcomes NICU admission: There was no evidence of a difference between groups in admissions to the neonatal unit (RR 1.11, 95% CI 0.42 to 2.93, two studies, 284 babies) (Analysis 8.5). Apgar score < seven at ve minutes: There was no difference in the number of babies with low Apgar scores (RR 0.48, 95% CI 0.04, 5.25, two studies, 284 babies) (Analysis 8.6). Other primary outcomes: Neither of the two studies included in this comparison reported on cord pH or newborn weight loss.
Secondary outcomes
None of the trials reported on maternal feelings of thirst, maternal comfort or satisfaction/dissatisfaction of being attached to intravenous uids. None of the trials reported on low cord pH, neonatal hyponatraemia, hypoglycaemia, fetal hyperbilirubinaemia or newborn weight loss. Comparison 7: 125 mL/hour Ringers lactate versus 125 mL/hour 5% dextrose None of the trials included in this version of the review analysed this comparison. Comparison 8: 125 mL/hour normal saline versus 125 mL/hour 5% dextrose Two trials ( Shrivastava 2009) and Stratton 1995 analysed this comparison involving 284 women. In the Shrivastava 2009 trial, a total of 191 women were randomised to two groups: 97 women were randomised to receive 125 mL/hour normal saline and 94 women were randomised to receive 125 mL/hour of 5% dextrose solution. In the Stratton 1995 trial, 45 women received normal saline and 48 women received 5% dextrose solution.
As far as maternal complications are concerned, only the Stratton 1995 trial reported on maternal hyponatraemia (serum sodium levels < 135 mmol/L ). While none of the women in the normal saline group developed hyponatraemia, nine women in the dextrose groups did (RR 0.06, 95% CI 0.00, 0.94) (Analysis 8.9). The Shrivastava 2009 trial did not conduct any assessment of maternal hyponatraemia. (This was not a pre-specied review outcome.) In the Stratton 1995 trial, one-third of babies (33.3%) developed hyponatraemia in the dextrose group compared to 13.3 % in the normal saline group (RR 0.40, 95% CI 0.17 to 0.93; P = 0.03) (Analysis 8.12). It is noteworthy that the Shrivastava 2009 trial did not conduct any testing for neonatal hyponatraemia. The Shrivastava 2009 trial did report neonatal hyperbilirubinaemia, and although there were more babies in the dextrose group of babies with hyperbilirubinaemia the difference between groups was not statistically signicant (RR 0.39, 95% CI 0.08 to 1.95) ( Analysis 8.13). There was no difference in neonatal hypoglycaemic
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episodes between the two groups with a RR of 0.97, (95% CI 0.20 to 4.68) (Analysis 8.14). Comparison 9: 125 mL/hour normal saline versus 125 mL/hour Ringers lactate None of the included trials so far have analysed this comparison.
excluded from the nal analysis, which was based on only 80 participants. The main drive for routine intravenous uid administration, was as a consequence of the pervasive nil by mouth policy for labouring women. The justication and arguments against this has been addressed above. As such, intravenous uids are administered to women in labour without robust scientic evidence that they are required, or if they are required, what volumes or which types of uids are to be used. An arbitrary rate of 125 mL/hour seems to be employed by many centres. Hence, our next question was to determine whether when women are restricted in their oral intake, and intravenous uids are administered, is the rate of 125 mL/ hour sufcient? Four trials (Alavi 2005; Eslamian 2006; Garite 2000; Maderia 2007), in which women were restricted in their oral intake, compared 125 mL/hour versus 250 mL/hour of intravenous uids.The type of uid in the Alavi 2005 trial was normal saline in dextrose water. Both the Eslamian 2006 and Garite 2000 trials administered Ringers lactate solution. There was insufcient information on the type of uid that was used in the Maderia 2007 trial as it was published as an abstract only. The meta-analysis of the four trials revealed that the mean duration of labour was signicantly reduced (by approximately one and half hours) in the group that received the increased rate of 250 mL/hour of uid, however there was considerable heterogeneity between trials which makes this result more difcult to interpret. In addition, there was a statistically signicant reduction in the number of caesarean sections in the 250 mL/hour group. There was insufcient information about the indication for CS in the Maderia 2007 trial, however, the remaining three trials (Alavi 2005; Eslamian 2006; Garite 2000) describe the indication for CS, and the majority of CS were for failure to progress in the rst stage. What was not standardised however, is how failure to progress was diagnosed in each of the trials. None of the trials was able to demonstrate conclusively that increased hydration directly prevented caesarean sections for failure to progress.There was no signicant difference in the rates of assisted delivery between the two groups. As far as neonatal complications were concerned, more babies were admitted to the neonatal unit in the 250 mL/hour group, although the difference between groups was not statistically signicant. However, there was a statistically higher risk of low Apgar scores in the 250 mL/hour group. None of the trials reported on neonatal hyponatraemia, hypoglycaemia or newborn weight loss in the rst three days of life. The impact on maternal and neonatal safety of different types of intravenous uids has not been rigorously evaluated. The three most common solutions that are used are normal saline, Ringers lactate and dextrose solutions. None of the trials directly compared normal saline versus Ringers lactate, or Ringers lactate versus dextrose solutions. Two trials Shrivastava 2009; Stratton 1995 compared normal saline versus 5% dextrose solution. The Shrivastava
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DISCUSSION
We reviewed nine trials that collectively recruited 1781 women. However, due to attrition and various exclusion factors, the nal analysis is based on 1617 women. One of the underlining objectives of this review was to determine, in the rst instance whether or not, the routine administration of intravenous uids conferred any benet to nulliparous labouring women, particularly in reducing the duration of labour. Therefore, we searched for trials that compared usual care of unrestricted oral uids with intravenous uid administration. Only two trials analysed this comparison (Direkvand-Moghadam 2012; Kavitha 2012). Pooled results from these trials showed a reduction in mean duration of labour for women receiving intravenous uids compared with oral intake only. However, it is worth noting that in one of the trials (Kavitha 2012), the mean oral intake in the women in the intravenous uids + oral intake group was much higher than in the oral intake group only (1325 versus 896 mL). There were no signicant maternal or neonatal complications in the intravenous uids group. As these ndings are based on just two trials, they need to be interpreted with caution. In the Coco 2010 trial, women were divided into two groups, i.e. intravenous uids and oral intake versus usual care, the usual care that was referred to was not conned solely to oral intake. In fact, women in the usual care group had received a mean volume of 1627 mL of intravenous uid (approximating to a rate of 125 mL/hour). The intravenous uid that was administered in both groups was Ringers lactate. The ndings of the Coco 2010 trial were therefore grouped with the comparison of 125 mL/hour of intravenous uid and oral intake versus 250 mL/hour intravenous uid and oral intake. Two groups from the Kavitha 2012 and Direkvand-Moghadam 2012 trials also compared these different rates. The ndings from these trials showed a reduction in the duration of labour in the 250 mL/hour intravenous uid + oral intake group.There was a difference in the types of oral uids that were consumed in two of these trials. In the Kavitha 2012 trial the oral uid intake consisted of plain water and coconut water, while in the Coco 2010 trial, oral intake included water, juices and carbonated drinks, and these may have inuenced caloric content. The quality of the Coco 2010 trial needs to be taken into account as although the trial initially recruited 220 women, there was a very high attrition rate with more than 60% of women
2009 trial administered the same rate of 125 mL/hour for both solutions. Although the Stratton 1995 trial also administered the same rate of uids in their two groups, the rate was not the same as the Shrivastava 2009 trial. The results of these two trials were not consistent in Stratton 1995 there were no clear differences in the mean duration of labour, whereas Shrivastava 2009 reported shorter duration in the 5% dextrose group (reported as median). There was no difference in the rates of caesarean section or assisted delivery between the two groups. Regarding maternal complications, the Shrivastava 2009 trial did not assess for maternal hyponatraemia. Based on just the Stratton 1995 trial, there was a statistically signicant increased risk of maternal hyponatraemia noted in the dextrose group. There was no assessment of uid overload in the Shrivastava 2009 trial, and there were no cases of uid overload in either group in the Stratton 1995 trial. Regarding neonatal welfare, there was no difference in the admission to SCBU or low Apgar scores between the groups. While the Shrivastava 2009 trial did not report on neonatal hyponatraemia, the Stratton 1995 trial found a statistically higher incidence of neonatal hyponatraemia in the dextrose arm of the trial. In summary, the routine administration of intravenous uids compared with oral intake alone demonstrated that intravenous uids conferred a reduction in the duration of labour, however, this was based on limited evidence. The ndings of the other trials in this review suggest that if a policy of strictly no oral intake is to be employed, then the duration of labour in nulliparous women may be shortened by the administration of intravenous uids at a rate of 250 mL/hour rather than 125 mL/hour. The caesarean section rate may also be reduced. However, is it justiable to subject women to routine intravenous uids for a reduction in the labour when it is not clear that this would have a positive effect on other maternal and neonatal outcomes? There are inconsistencies across the trials with regard to maternal and neonatal adverse outcome and several trials have simply not reported on the safety of increased intravenous uids. Of concern too, is the increased attendant maternal and neonatal morbidity that is associated with intravenous 5% dextrose solutions. Both maternal and neonatal hyponatraemia are increased, and although these results are based on just one trial, perhaps 5% dextrose should be avoided until a larger trial can demonstrate better safety. None of the trials that were included in this review reported on the evaluation of maternal views of comfort, satisfaction or dissatisfaction of being attached to a drip during their entire labour. Furthermore, there was no subjective or objective evaluation of maternal thirst. There was no objective assessment of dehydration either (no measurements of ketosis). None of the trials elicited whether or not there is any associated newborn weight loss with intravenous uids.
Quality of the evidence

Overall, the quality of evidence in this review is limited: rstly, for any one outcome few studies contributed results, and for many outcomes evidence was derived from only one or two relatively small trials. Furthermore, for our primary outcome results were not simple to interpret. Duration of labour was not measured in a consistent way between trials; in some studies duration was from the initiation of study uids to delivery, while in others it was for a specic stage of labour and the total duration was not stated. One study reported the median (Shrivastava 2009), and for studies reporting the mean the standard deviation (SD) was frequently not reported. For these studies, to allow us to include the data, we calculated the SD from other information in the paper. As the mean was reported in most studies, we assumed that the distribution was normal and that the SD was similar in both arms of the trials, but this was not always clear. In addition, not all studies made it clear that the duration of labour related only to those women having vaginal deliveries; in the studies by Alavi 2005 and Kavitha 2012 for example, this was not explicitly stated. In the data and analysis we have used the number of women having vaginal deliveries as the denominators. The ndings of the review also need to be interpreted in the light of our assessments of risk of bias; overall, the methodological quality of studies was assessed as moderate or good, but for some bias domains we were unable to make judgements about bias due to unclear descriptions, or limited descriptions of the methods used.
AUTHORS CONCLUSIONS Implications for practice

In the rst instance, taking into account the potential maternal and neonatal morbidity that may arise from the unnecessary administration of intravenous uids, we need to justify why the policy of nil by mouth still permeates current practice. This is especially so since the dangers of gastric aspiration have been shown to be virtually eliminated and a concern of the past. Therefore, given that there is no clear evidence of harm associated with unrestricted oral intake perhaps it is time to abandon this policy altogether and to allow women to self-regulate their oral intake during labour. Rather than routine administration of intravenous uids, it may be more appropriate for intravenous uids to be administered for clinical reasons, or if a labouring women becomes ketotic. The evidence gleaned from this review does not provide evidence that is robust enough to recommend routine administration of intravenous uids. Interpreting ndings relating to duration of labour was not straightforward as there was considerable heterogeneity in terms of the mean length of labour and in the variability in length of labour (SDs) in different trials. It is unclear why duration of labour was so different in the various settings but this may
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partly be explained by different denitions of the start of active labour. There was also variation in the rates of CS and assisted deliveries in different settings. In addition, interpreting the results from trials was hampered by the low number of trials contributing data to each comparison and in variation between trials. In trials where oral uids were not restricted there was considerable variation in the amount of oral uid women consumed in different arms of the same trial as well as between different trials. In addition, results from trials were not consistent and the risk of bias in trials varied. Some of the important research questions were addressed by single trials only and important outcomes relating to maternal and infant morbidity were frequently not reported.
may cause newborn weight loss in the rst 72 hours, future trials should attempt to elicit this. More high quality trials need to be conducted that address whether there is even a need for intravenous uids at all.
ACKNOWLEDGEMENTS
Sincere gratitude to Lynn Hampson and Frances Kellie for their guidance and assistance in trial searches and methodology. As part of the pre-publication editorial process, this review has been commented on by three peers (an editor and two referees who are external to the editorial team) and the Groups Statistical Adviser. The National Institute for Health Research (NIHR) is the largest single funder of the Cochrane Pregnancy and Childbirth Group. The views and opinions expressed therein are those of the authors and do not necessarily reect those of the NIHR, NHS or the Department of Health. The nal version of this systematic review was nancially supported by the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) and the Department of Reproductive Health and Research (RHR), World Health Organization. The named authors alone are responsible for the views expressed in this publication.
Implications for research

The ndings of these trials do have clinical implications for labour management, however, more studies are needed to validate these ndings and to elicit a scientic evaluation to quantify levels of hydration in labouring women. Perhaps an objective assessment of maternal dehydration may improve the quality of future studies. Further trials are also required to evaluate whether additional intravenous uids in women with unlimited access to oral uids confers any reduction in the length of labour, without potentially harming the neonate. Future trials should denitely also include an evaluation of maternal perceptions, comfort and mobility during labour. Since there is emerging evidence that excessive intravenous uids
REFERENCES
References to studies included in this review

Alavi 2005 {published data only} Alavi MH, Talaei Rad Z, Dadgar SR. Assessment of the effects of increased intravenous hydration on the course of labor in nulliparous term pregnancies. Medical Journal of the Islamic Republic of Iran 2005;18(4):28992. Coco 2010 {published data only} Coco A, Derksen-Schrock A, Coco K, Raff T, Horst M, Hussar E. A randomized trial of increased intravenous hydration in labor when oral uid is unrestricted. Family Medicine 2010;42(1):526. Direkvand-Moghadam 2012 {published data only} Direkvand-Moghadam A, Rezaeian M. Increased intravenous hydration of nulliparas in labor. International Journal of Gynecology and Obstetrics 2012;118(3):2135. Eslamian 2006 {published data only} Eslamian L, Marsoosi V, Pakneeyat Y. Increased intravenous uid intake and the course of labor in nulliparous women. International Journal of Gynecology & Obstetrics 2006;93(2): 1025.
Garite 2000 {published data only} Garite TJ, Weeks J, Peters-Phair K. A randomized trial on the inuence of increased intravenous hydration on the course of nulliparous labor. American Journal of Obstetrics and Gynecology 2000;182(1 Pt 2):S37. Garite TJ, Weeks J, Peters-Phair K, Pattilo C, Brewster WR. A randomized controlled trial of the effect of increased intravenous hydration on the course of labor in nulliparous women. American Journal of Obstetrics and Gynecology 2000; 183:15448. Hausman N, Garite T, Rumney P. The inuence of increased intravenous hydration on the incidence of nonreassuring fetal heart rate patterns in nulliparous labor [abstract]. American Journal of Obstetrics and Gynecology 2001;184(1):S6. Kavitha 2012 {published data only} Kavitha A, Chacko KP, Thomas E, Rathore S, Christoper S, Biswas B, et al.A randomized controlled trial to study the effect of IV hydration on the duration of labor in nulliparous women. Archives of Gynecology and Obstetrics 2012;285(2):3436.
16
Maderia 2007 {published data only} Maderia LM, Hoffman MK, Wilson S, Chichester ML. Effect of intravenous hydration on labor length and delivery mode [abstract]. Obstetrics & Gynecology 2007;109(4 Suppl):90S. Shrivastava 2009 {published data only} Shrivastava V, Garite T, Jenkins S, Saul L, Rumney P, Preslicka C, et al.A double-blinded randomized controlled trial comparing normal saline with and without dextrose on the course of labor in nulliparas. American Journal of Obstetrics and Gynecology 2007;197(6 Suppl 1):S18, Abstract no: 36. Shrivastava VK, Garite TJ, Jenkins SM, Saul L, Rumney P, Preslicka C, et al.A randomized, double-blinded, controlled trial comparing parenteral normal saline with and without dextrose on the course of labor in nulliparas. American Journal of Obstetrics and Gynecology 2009;200(4):379.e16. Stratton 1995 {published data only} Stratton JF, Stronge J, Boylan P. Non-electrolyte solutions in labouring primigravida. 27th British Congress of Obstetrics and Gynaecology; 1995 July 4-7; Dublin, Ireland. 1995: Abstract no: 490. Stratton JF, Stronge J, Boylan PC. Hyponatraemia and non-electrolyte solutions in labouring primigravida. European Journal of Obstetrics & Gynecology and Reproductive Biology 1995;59:14951.
Haesslein 1975 {published data only} Haesslein HC, Goodlin RC. Intrapartum hypertension and intravenous saline. Journal of Reproductive Medicine 1975; 14:89. Higgins 1996 {published data only} Higgins J, Gleeson R, Holohan M, Cooney C, Darling M. Maternal and neonatal hyponatraemia: a comparison of Hartmanns solution with 5% dextrose for the delivery of oxytocin in labour. European Journal of Obstetrics & Gynecology and Reproductive Biology 1996;68:478. Hofmann 2001 {published data only} Hofmann J, Schrod L, Schleelein O, Springer S, Steck T. Effects of prepartum infusion solutions on glucose and bilirubin metabolism of mother and child in the prepartum and postpartum period [Auswirkungen von prapartal verabreichten Infusionslosungen auf den Zucker und Bilirubinstoffwechsel von Mutter und Kind peri und postpartal]. Zeitschrift fur Geburtshilfe und Neonatologie 2001;205(2):604. Jamal 2007 {published data only} Jamal A, Choobak N, Tabassomi F. Intrapartum maternal glucose infusion and fetal acid-base status. International Journal of Gynecology & Obstetrics 2007;97(3):1879. Kenepp 1985 {published data only} Kenepp NB, Cheek TC, Gabbe SG, Gutsche BB. Intrapartum maternal intravenous dextrose administration. Anesthesiology 1985;63:436. Loong 1987 {published data only} Loong EPL, Lao TTH, Chin RKH. Effects of intrapartum intravenous infusion of 5% dextrose or Hartmanns solution on maternal and cord blood glucose. Acta Obstetricia et Gynecologica Scandinavica 1987;66(3):2413. Menigaux 1993 {published data only} Menigaux C, Hamza J, Bougnieres P, Saint-Maurice C. Neonatal glycemia: does the maternal iv uid regimen during labor make a difference?. Regional Anesthesia 1993; 18:91. Navarette,1982 {published data only} Navarrete L, Ratinoff I, Clavero P, Sabatel R, Herrera R. Maternal metabolic control in the intrapartum management [Control metablico materno intraparto]. Acta Obsttrica y Ginecolgica Hispano-Lusitana 1982;30(2):12130. Nordstrom 1995 {published data only} Nordstrom L, Arulkumaran S, Chua S, Ratnam S, Ingemarsson I, Kublickas M, et al.Continuous maternal glucose infusion during labor: effects on maternal and fetal glucose and lactate levels. American Journal of Perinatology 1995;12:35762. Omigbodun 1989 {published data only} Omigbodun AO. Choice of intravenous uid infusion in labour and maternal postpartum blood pressure. Tropical and Geographical Medicine 1989;41:2279. Omigbodun 1991 {published data only} Omigbodun AO, Fajimi JL, Adeleye JA. Effects of using either saline or glucose as a vehicle for infusion in labour. East African Medical Journal 1991;68:8892.
17
References to studies excluded from this review

Boylan 1980 {published data only} Boylan P, Lewis PJ. Fetal breathing in labor. Obstetrics & Gynecology 1980;56:358. Caspi 1979 {published data only} Caspi E, Ron-El R, Modai D. Controlled intravenous bicarbonate and fetal-maternal acid-base balance. I. The primipara. Obstetrics & Gynecology 1979;54:61523. Cerri 2000 {published data only} Cerri V, Tarantini M, Zuliani G, Schena V, Redaelli C, Nicolini U. Intravenous glucose infusion in labor does not affect maternal and fetal acid-base balance. Journal of Maternal-Fetal Medicine 2000;9:2048. Cheek 1996 {published data only} Cheek TG, Samuels P, Miller F, Tobin M, Gutsche BB. Normal saline i.v. uid load decreases uterine activity in active labour. British Journal of Anaesthesia 1996;77:6325. Cheek TG, Samuels P, Tobin M, Gutsche BB. Rapid intravenous saline infusion decreases uterine activity in labor, epidural analgesia does not. Anesthesiology 1989;71: A884. Fisher 1997 {published data only} Fisher AJ, Huddleston JF. Intrapartum maternal d-glucose infusion reduces the risk of umbilical cord acidemia. American Journal of Obstetrics and Gynecology 1997;176(1 Pt 2):S20.
Omigbodun 1993 {published data only} Omigbodun AO, Akindele JA, Osotimehin BO, Fatinikun T, Fajimi JL, Adeleye JA. Effect of saline and glucose infusions of oxytocin on neonatal bilirubin levels. International Journal of Gynecology & Obstetrics 1993;40: 2359. Oral 2003 {published data only} Oral E, Gezer A, Cagdas A, Pakkal N. Oxytocin infusion in labor: the effect different indications and the use of different diluents on neonatal bilirubin levels. Archives of Gynecology & Obstetrics 2003;267:11720. Rooth 1967 {published data only} Rooth G, Jacobson L. Interrelationship between maternal and foetal acid-base and electrolyte balance during labour. 5th World Congress of Gynecology and Obstetrics; 1967; Sydney, Australia. 1967:187. Rosenberg 2006 {published data only} Rosenberg V, Rauch E, Eglinton G, Skupski D. Intrapartum maternal glycemic control in women with insulin requiring diabetes: a randomized clinical trial of rotating uids vs. insulin drip [abstract]. American Journal of Obstetrics and Gynecology 2005;193(6 Suppl):S93. Rosenberg VA, Eglinton GS, Rauch ER, Skupski DW. Intrapartum maternal glycemic control in women with insulin requiring diabetes: a randomized clinical trial of rotating uids versus insulin drip. American Journal of Obstetrics and Gynecology 2006;195(4):10959. Simpson 2005 {published data only} Simpson KR, James DC. Efcacy of intrauterine resuscitation techniques in improving fetal oxygen status during labor. Obstetrics & Gynecology 2005;105:13628. Singhi 1982 {published data only} Singhi S, Choo Kang E, Hall JS. Hazards of maternal hydration with 5% dextrose. Lancet 1982;2:3356. Thaler 2007 {published data only} Thaler I. Maternal glucose infusion during labor increases fetal lactate production and modies fetal acid-base balance. American Journal of Obstetrics and Gynecology 2007;197(6 Suppl 1):S182, Abstract no: 629. Watson 2012 {published data only} Watson J. The effect of intrapartum intravenous uid management on breastfed newborn weight loss. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing 2011; 40:S97. Watson J, Hodnett E, Armson BA, Davies B, WattWatson J. A randomized controlled trial of the effect of intrapartum intravenous uid management on breastfed newborn weight loss. Journal of Obstetric, Gynecologic, & Neonatal Nursing 2012;41(1):2432. Wells-Brooks 2001 {published data only} Wells-Brooks NY. Uterine contraction frequency changes following crystalloid infusion [thesis]. Tennessee: University of Tennessee, 2001.
Wright 2000 {published data only} Wright TE, Martin D, Qualls C, Curet LB. Effects of intrapartum administration of invert sugar and D5LR on neonatal blood glucose levels. Journal of Perinatology 2000; 20:2178.
References to studies awaiting assessment

Amir 2004 {published data only} Amir AliAkbari S, Dabiri F, Bakhshori Z, Alavii Majd H. Effects of increased intravenous hydration on the outcome of labor in nulliparous women at Shariati hospital in Bandar Abbas, 2003. Journal of Faculty of Nursing & Midwifery of Shaheed Beheshti University of Medical Sciences And Health Services 2004;14(46):49. Rad 2012 {published data only} Rad RH, Najar S, Hekmat K. Effects of intravenous normal saline with and without dextrose on labour duration and delivery outcomes in nulliparous women. Koomesh 2012;13 (4):4349.
References to ongoing studies

Salim 2011 {unpublished data only} Salim R. Intrapartum hydration. http://www.controlledtrials.com/mrct/trial/1276843/nct01242293 (accessed 2011).
Additional references
ASA 2007 American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anesthesia: An updated report by the American Society of Anesthesiologists. Anesthesiology 2007;106(4):84363. Barr 1991 Barr SI, Costill DL, Fink WJ. Fluid replacement during prolonged exercise: effects of water, saline, or no uid. Medicine and Science in Sports and Exercise 1991;23(7): 8117. Carvalho 1994 Carvalho JC, Mathias RS. Intravenous hydration in obstetrics. International Anesthesiology Clinics 1994;32(2): 1015. Chantry 2011 Chantry CJ, Nommsen-Rivers LA. Excess weight loss in rst-born breastfed newborns relates to maternal intrapartum uid balance. Pediatrics 2011;127(1):1719. Egger 1997 Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997;315(7109):62934. Harbord 2006 Harbord RM, Egger M, Sterne JA. A modied test for small-study effects in meta-analyses of controlled trials with binary endpoints. Statistics in Medicine 2006;25(20): 344357.
18
Higgins 2011 Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org. Keppler 1988 Keppler AB. The use of intravenous uids during labour. Birth 1988;15(2):759. Maughan 1996 Maughan RJ, Bethell LR, Leiper JB. Effects of ingested uids on exercise capacity and on cardiovascular and metabolic responses to prolonged exercise in man. Experimental Physiology 1996;81(5):84759. Michael 1991 Michael S, Reilly C, Caunt J. Policies for oral intake during labour. A survey of maternity units in England and Wales. Anaesthesia 1991;46(12):10713. Montain 1992 Montain SJ, Coyle EF. The effect of graded dehydration on hyperthermia and cardiovascular drift during exercise. Journal of Applied Physiology 1992;73:134050. Montain 2008 Montain SJ. Hydration recommendations for sport 2008. Current Sports Medical Reports 2008;7(4):18792. Morton 1985 Morton KE, Jackson MC, Gillmer MD. A comparison of the effects of four intravenous solutions for the treatment of ketonuria during labour. British Journal of Obstetrics and Gynaecology 1985;92(5):4739. Noakes 1993 Noakes TD. Fluid replacement during exercise. Exercise and Sport Sciences Reviews 1993;21:297330. Noel-Weiss 2011 Noel-Weiss J, Woodend AK, Peterson WE, Gibb W, Groll D. An observational study of associations among maternal uids during parturition,neonatal output,and breastfed newborn weight loss. International Breatsfeeding Journal 2011;6(9):110. OSullivan 2003 OSullivan G, Scrutton M. NPO during labor. Is there any scientic validation?. Anesthesiology Clinics of North America 2003;21(1):8798.
Pierce 2003 Pierce SJ, Kupittayanant S, Shmigol A, Wray S. The effects of pH change on calcium signalling and force in pregnant human myometrium. American Journal of Obstetrics and Gynecology 2003;188:10318. RevMan 2011 The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). 5.1. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2011. Romano 2009 Romano AM. First, do no harm: How routine interventions, common restrictions, and the organisation of our healthcare system affect the health of mothers and newborns. J perinatal Educ 2009;18(3):5862. Saltin 1998 Saltin S, Costill DL. Fluid and electrolyte balance during prolonged exercise. In: Horton ES, Terjung RL editor(s). Exercise, Nutrition and Metabolism. New York: MacMillan, 1988:1508. Scheepers 1998 Scheepers H, Essed G, Brouns F. Aspects of fodd and uid intake during labour. Policies of midwives and obstetricians in the Netherlands. European Journal of Obstetrics & Gynecology and Reproductive Biology 1998;78(1):3740. Schuitemaker 1997 Schuitemaker N, van Roosmalen J, Dekker G, van Dongen P, van Geijn H, Gravenhorst JB. Maternal mortality after cesarean scetion in the Netherlands. Acta Obstetricia et Gynecologica Scandinavia 1997;76(4):3324. Singata 2010 Singata M, Tranmer J, Gyte GML. Restricting oral uid and food intake during labour. Cochrane Database of Systematic Reviews 2010, Issue 1. [DOI: 10.1002/ 14651858.CD003930.pub2] Tarnow-Mordi 1981 Tarnow-Mordi WO, Shaw JC, Liu D, Gardner DA, Flynn FV. Iatrogenic hyponatraemia of the newborn due to maternal uid overload: a prospective study. British Medical Journal 1981;283(6292):63942. Indicates the major publication for the study
19
CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]

Alavi 2005 Methods Participants Prospective randomised clinical trial. 194 nulliparous women in term spontaneous labours with a singleton pregnancy, cephalic presentation 112 women received 125 mL/hour; 82 women received 250 mL/hour 125 mL/hour vs 250 mL/hour of normal saline in dextrose water Duration of labour in minutes; CS due to failure to progress No other oral intake; no food. No epidurals.
Interventions Outcomes Notes
Risk of bias Bias Authors judgement Support for judgement Women were randomised but the study does not specify method of randomisation Possible selection bias. Unclear details. No attrition reported.
Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias Unclear risk Low risk
Low risk Unclear risk
Fairly transparent results. No details about duration of study. Not mentioned.
Blinding of participants and personnel High risk (performance bias) All outcomes Blinding of outcome assessment (detection Low risk bias) All outcomes
Detailed reporting of outcome assessment.
20
Coco 2010 Methods Participants Prospective randomised trial. Nulliparous women in spontaneous active labour with a singleton, vertex presentation 37 weeks gestation were included. Women were eligible for inclusion if dilatation was between 2 and 5 cm, with or without ruptured membranes 220 women were recruited. 116 women excluded due to preterm delivery, pre-eclampsia or scheduled CS 11 women excluded as uids were delayed. 4 women did not have consent forms. 9 women delivered elsewhere so were lost to follow-up. 80 women fullled criteria for inclusion and were analysed. 37 women received 250 mL of lactated Ringers solution IV per hour (IV uid group) and 43 women received usual care Usual care consisted of lactated Ringers solution IV for medical indications at the discretion of the provider. The women in this group received a mean volume of 1627 mL of uid Both groups were allowed unrestricted oral intake of uids. Duration of labour; rst, second stage and total duration. Unrestricted oral uids (water, juice, carbonated drinks) amounts recorded in both groups
Interventions
Outcomes Notes Risk of bias Bias
Authors judgement
Support for judgement Random number chart.
Random sequence generation (selection Low risk bias) Allocation concealment (selection bias) Incomplete outcome data (attrition bias) All outcomes Low risk High risk
Consecutively numbered opaque sealed envelopes. Large attrition due to recruitment taking place antenatally rather than at the onset of labour Clear explanatory notes when attrition occurred. 220 women were recruited. 116 women excluded due to preterm delivery, preeclampsia or scheduled CS 11 women excluded as uids were delayed. 4 women did not have consent forms. 9 women delivered elsewhere so were lost to follow-up. 80 women fullled criteria for inclusion and were analysed. Prospective data capture. No restriction on oral uid intake may have inuenced results; inherent bias of women drinking as much as possible, although similar mean oral intake in both groups
21
Selective reporting (reporting bias) Other bias
Coco 2010
(Continued)
Women recruited from 4 hospitals including 3 private practices Blinding of participants and personnel High risk (performance bias) All outcomes Unclear as to whether measures were taken to blind personnel Participants: potential bias in that they were informed about increased uids in labour and allowed to drink Potential bias as participants recruited antenatally and could have inuenced the amount of uids ingested orally Prospective analysis by nursing staff.
Blinding of outcome assessment (detection Low risk bias) All outcomes Direkvand-Moghadam 2012 Methods Participants
Prospective randomised controlled trial. 4 arms with individual randomisation 120 women in labour at a hospital in Ilam, Iran in 2010. Inclusion criteria: nulliparity, aged between 18-35 years, singleton pregnancy, spontaneous active labour (dened as cervical dilatation of 4 to 5 cm), gestational age 38-40 weeks, normal fetal heart tracings, intact membranes and vertex presentation. Labour analgesia was not used Exclusion criteria: elective labour induction, emergency CS, known cephalopelvic disproportion, diagnosed pre-eclampsia, chorioamnionitis, pyelonephritis, maternal cardiac or renal disease, IUGR, cervix dilated > 5 cm 4 groups: 30 women in each group 1. Control. Free oral uids (no IV uids). 2. Free oral uids + IV Ringer lactate solution at infusion rate of 60 mL/hour. 3. Free oral uids + IV Ringer lactate solution at infusion rate of 120 mL/hour. 4. Free oral uids + IV Ringer lactate solution at infusion rate of 60 mL/hour. In all groups partograms were used to monitor progress in labour. Amniotomy was performed by a midwife when cervical dilatation reached 5 cm if membranes had not ruptured spontaneously. At one hour after amniotomy, if uterine contractions were less than 3 in ten minutes, or dilation was less than 1.2 cm per hour, oxytocin was used for labour augmentation Duration of active phase of rst stage of labour, duration of 2nd and 3rd stages of labour, need for oxytocin augmentation, mode of delivery, Apgar scores at 1 and 5 minutes In the data and analyses in this review for comparison 4 (IV uids plus oral intake vs oral intake alone) we have combined results for the three groups receiving IV uids to allow a single pair-wise comparison between women receiving IV uids plus oral uids vs oral uids alone. This study is also included in comparison 5 where different hourly rates of infusion are compared
Interventions
Outcomes
Notes
22
Direkvand-Moghadam 2012
(Continued)
Risk of bias Bias Authors judgement Support for judgement Random number tables.
Random sequence generation (selection Low risk bias) Allocation concealment (selection bias) Low risk
Opaque, sealed, consecutively numbered envelopes. 120 women were randomised and all seemed to be accounted for in the analysis. There was no mention of missing data for any outcome Assessment from published study report. In the methods section it was stated that the 4 groups were matched for inclusion criteria. It was not clear what this meant Blinding women or staff to this intervention was not mentioned. Lack of blinding may have affected staff behaviour and outcome assessment It was not mentioned whether any outcome data were collected by blind outcome assessors. Lack of blinding may have affected staff behaviour and outcome assessment
Incomplete outcome data (attrition bias) All outcomes
Low risk
Selective reporting (reporting bias) Other bias
Unclear risk Unclear risk
Blinding of participants and personnel High risk (performance bias) All outcomes
Blinding of outcome assessment (detection High risk bias) All outcomes
Eslamian 2006 Methods Participants Prospective double-blind randomised trial. 300 nulliparous women enrolled; all women went in to spontaneous labour at term; singleton pregnancies; cephalic presentation 153 randomised to 125 mL/hour; 147 women randomised to 250 mL/hour 2 different volumes of Ringers lactate solution (125 mL/hour vs 250 mL/hour) Duration of labour in minutes; CS due to failure to progress; assisted delivery Nil by mouth; no epidurals.
Interventions Outcomes Notes Risk of bias
23
Eslamian 2006
(Continued)
Bias
Authors judgement
Support for judgement Random computer-generated numbers.
Consecutively numbered opaque sealed envelopes. Detailed outcome data available for all 300 recruited women. No evidence of selective reporting. Authors acknowledge the following: no measurements of inherent maternal dehydration; no measurements of skin turgor, osmolality Double-blinded study with clear evidence of double-blinding measures
Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias
Low risk
Blinding of participants and personnel Low risk (performance bias) All outcomes Blinding of outcome assessment (detection Low risk bias) All outcomes Garite 2000 Methods Participants Prospective randomised trial.
None apparent.
195 nulliparous women in term spontaneous labour with a singleton pregnancy, cephalic presentation 125 mL/hour vs 250 mL/hour of Ringers lactate solution. 94 women received 125 mL/hour while 101 women received the higher volume of 250 mL/hour Maternal: duration of labour in minutes Maternal/fetal: need for CS or assisted delivery/Apgar < 7; admission to SCBU No food; no oral uid intake; sips of water only; ice chips allowed
Interventions
Outcomes
Notes Risk of bias Bias
Authors judgement
Support for judgement Random computer-generated sequence.

24
Random sequence generation (selection Low risk bias)
Garite 2000
(Continued)
Allocation concealment (selection bias) Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias
Low risk Low risk
Consecutively numbered opaque sealed envelopes. None of the women randomised needed to be excluded.
None apparent. No measurement of inherent maternal dehydration; no assessment of serum/urine osmolality No masking of interventions.
Blinding of participants and personnel High risk (performance bias) All outcomes Blinding of outcome assessment (detection Low risk bias) All outcomes Kavitha 2012 Methods Participants Randomised controlled trial.
None apparent.
293 nulliparous women with term spontaneous labours between 3- 6 cm dilatation, singleton pregnancy, cephalic presentation 99 women received oral hydration. 98 women were randomised to receive 125 mL/hour of Ringers lactate and oral uids 96 women were randomised to receiving 250 mL/hour of Ringers lactate and oral uids Maternal: duration of labour, mode of delivery, CS delivery for failure to progress, vomiting Fetal: admission to NICU. Oral uids was allowed in all study groups (no quantication of volumes required)
Interventions
Outcomes
Authors judgement
Support for judgement Computerised block randomisation.
Random sequence generation (selection Low risk bias) Allocation concealment (selection bias) Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Low risk Low risk
Sequential opaque envelopes. Complete outcomes for all participants; no attrition.
Low risk
None apparent.
25
Kavitha 2012
(Continued)
Other bias
High risk
Women in control group (oral uids) were allowed either plain uids or coconut water (no clear discussion about possible bias with coconut water) In IV uid groups, maximum quantity of IV uids was restricted to 3 litres to prevent uid overload No masking of interventions.
Blinding of participants and personnel High risk (performance bias) All outcomes Blinding of outcome assessment (detection Low risk bias) All outcomes Maderia 2007 Methods Participants Prospective randomised trial.
None apparent.
59 nulliparous women in term spontaneous labours with a singleton pregnancy, cephalic presentation 30 women received 125 mL/hour; 29 women received 250 mL/hour 125 mL/hour vs 250 mL/hour of unspecied IV uid. Duration of labour in minutes; CS due to failure to progress Nil by mouth; only ice-chips.
Interventions Outcomes Notes Risk of bias Bias
Authors judgement
Support for judgement No information (abstract only).
Random sequence generation (selection Unclear risk bias) Allocation concealment (selection bias) High risk
No information (abstract only); does not specify what type of IV uid administered No information (abstract only).
Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias
Unclear risk
Unclear risk Unclear risk
No information (abstract only). No information (abstract only). No information (abstract only).
Blinding of participants and personnel Unclear risk (performance bias) All outcomes
26
Maderia 2007
(Continued)
Blinding of outcome assessment (detection Unclear risk bias) All outcomes Shrivastava 2009 Methods Participants
No information (abstract only).
Prospective double-blinded randomised controlled trial. 300 nulliparous women in term spontaneous labour with a singleton pregnancy, cephalic presentation enrolled 5 women were withdrawn by their physician. 3 women did not meet inclusion criteria. 3 women had incomplete data collection. 11 women were not included in data analysis. 2 women were excluded (1 with diabetes mellitus 1 who developed pre-eclampsia) 289 women completed the study. 3 different groups: 97 women randomised to receive normal saline 125 mL/hour. 94 women randomised to receive 5% dextrose 125 mL/hour. 98 women randomised to receive 10% dextrose 125 mL/hour. Maternal: duration of rst, second stages of labour and total duration of labour, CS Fetal/neonatal: admission to neonatal unit, Apgar scores < 7 at 5 minutes, hyperbilirubinaemia requiring therapy, cord pH < 7.20, arterial cord glucose, hypoglycaemia at 1 and 2 hours Nil by mouth; ice chips only.
Interventions
Outcomes
Authors judgement
Support for judgement Computer-generated randomisation.
Consecutively numbered opaque sealed envelopes by pharmacy staff Clear documentation of excluded women when incomplete data collection and clear documentation of reasons for attrition: 300 nulliparous women in term spontaneous labours with a singleton pregnancy, cephalic presentation enrolled 5 women were withdrawn by their physician. 3 women did not meet inclusion criteria
27
Incomplete outcome data (attrition bias) All outcomes
Low risk
Shrivastava 2009
(Continued)
(1 with diabetes mellitus, 1 who developed pre-eclampsia and 1 woman < 18 years) 3 women had incomplete data collection. 11 women were not included in data analysis. 289 women completed the study. Selective reporting (reporting bias) Low risk Clear ow-diagrams and different tables for maternal and neonatal outcomes Insufciently powered for neonatal outcomes. Double-blinded study; blinding by pharmacy personnel; each group assigned A, B, C and changed after every 80 women to minimise observer bias; IV bags were covered with non-transparent adhesive tapes to ensure double-blinding Adequate measures as above to ensure double-blinding.
Other bias
Unclear risk
Blinding of participants and personnel Low risk (performance bias) All outcomes
Blinding of outcome assessment (detection Low risk bias) All outcomes Stratton 1995 Methods Participants Prospective randomised trial.
100 primigravid women in spontaneous labour. 7 women randomised but no blood taken so excluded from analysis 4 other women declined consent. 2 other women excluded as no consent obtained by medical staff 5% dextrose vs normal saline for oxytocin augmentation. Maternal : delivery outcomes, mean duration of labour, CS, maternal hyponatraemia, uid overload Fetal: neonatal hyponatraemia. admission to NICU. Subgroup of women with epidurals.
Interventions Outcomes
Authors judgement
Support for judgement Random allocation.
Random sequence generation (selection Low risk bias)
28
Stratton 1995
(Continued)
Allocation concealment (selection bias) Incomplete outcome data (attrition bias) All outcomes Selective reporting (reporting bias) Other bias
Low risk Low risk
Sealed envelopes. Clear explanations for attrition due to omission of obtaining blood samples; failure to obtain consent Detailed explanations for all outcomes. A subgroup of women were given additional uids as part of their epidurals Not clearly apparent that study was double-blind.
Low risk High risk
Blinding of participants and personnel Unclear risk (performance bias) All outcomes Blinding of outcome assessment (detection Unclear risk bias) All outcomes CS: caesarean section IUGR: intrauterine growth restriction IV: intravenous NICU: neonatal intensive care unit SCBU: special care baby unit vs: versus
Outcomes not blinded.
Characteristics of excluded studies [ordered by study ID]
Study Boylan 1980
Reason for exclusion Open and double-blind study. Participants: unclear whether nullips or multips; also in a subgroup, labour was induced Interventions: intravenous bolus of glucose versus Hartmanns Outcome: fetal breathing; no maternal outcomes. Method: appears to be a case-controlled study. There is no evidence that women were randomly assigned to the 2 groups Participants: 22 primips. Intervention: sodium bicarbonate infusion. Participants: 81 women but no distinction between nullips and multips Intervention: 43 women received 5% glucose and 38 women did not receive any uids Prospective randomised controlled trial. Participants: 34 labouring women (no clear distinction in outcomes between nullips and multips)
29
Caspi 1979
Cerri 2000
Cheek 1996
(Continued)
Interventions: extradural normal saline and glucose. Fisher 1997 Abstract only, so limited information. Participants: multips and nullips. Participants: all low-risk labouring women (nullips and multips) Interventions: 5% dextrose in water versus 5% dextrose in saline Outcome: maternal hypertension. Randomised controlled trial. Interventions; oxytocin in Hartmanns solution compared with the standard 5% dextrose regimen for induction or augmentation in labour. Outcomes: maternal serum sodium. Good study with clear randomisation method; reason for exclusion was non-spontaneous labour Participants: labouring women in their rst or second pregnancy (no distinction between nullips and multips) Interventions: glucose was compared with a glucose substitute treatment (Xylit) and an electrolyte treatment (Sterofundin) Randomised controlled trial. Participants: 178 women but all were multiparous (at least para 1) Intervention: 120 mL/hour of 5% dextrose was compared with the same volume of Ringers lactate Outcomes: primary outcome was fetal acid-base status. Randomised trial. Participants: 31 term labourers; unclear whether nullips or multips or both Intervention: different concentrations of dextrose solutions Outcomes; ketoacidosis. Limited information about duration of labour and other outcomes as published as abstract only Prospective randomised trial. Participants: 48 women (nullips and multips). Interventions: 5% dextrose solution or Hartmanns solution. Outcomes: maternal and cord blood glucose. Reason for exclusion: although there was a distinction between nullips and multips in the demographics, there was no distinction in the outcomes in terms of parity Randomised controlled trial. Participants: 20 labouring women having epidurals (study does not specify whether nullips or multips) Interventions: 50% dextrose versus Ringers lactate in women who were given a basal infusion of 100 mL/hour Ringers lactate before an epidural Outcome: maternal and neonatal hypoglycaemia. Abstract only. Randomised controlled trial. Participants: insufcient information on parity. Outcome: intrapartum metabolic control.
Haesslein 1975
Higgins 1996
Hofmann 2001
Jamal 2007
Kenepp 1985
Loong 1987
Menigaux 1993
Navarette,1982
30
(Continued)
Nordstrom 1995 Omigbodun 1989
All participants were on average para 1 therefore excluded. Participants: all women who required oxytocin for induction of labour or augmentation (so non-spontaneous labours). Furthermore, no distinction regarding parity Intervention: normal saline or 5% glucose with oxytocin. Outcomes: maternal postpartum blood pressure. Participants: all women who required oxytocin for induction of labour or augmentation (so non-spontaneous labours). Furthermore, no distinction regarding parity Intervention: normal saline or 5% glucose with oxytocin. Outcomes: maternal postpartum sodium levels; cord sodium levels Interventions: all women received oxytocin. Participants: nullips and multips included; control group comprised entirely of multiparous women Interventions: oxytocin for augmentation. Outcomes: neonatal bilirubin levels. Limited information available, published as abstract only. Participants: 60 labouring women; unclear whether nulliparous or not; no details of randomisation Interventions: sodium bicarbonate given to half the participants Participants: all women in this study were insulin requiring gestational diabetics therefore excluded Participants: 42 women were randomised to either a 500 mL or 1000 mL intravenous uid bolus over 20 minutes. All women were either being induced or having this bolus as a preload for epidurals. 51 women were randomised to 1 of 6 position sequences including supine with the head elevated 30, left lateral and right lateral for 15 minutes each in succession Study published as part of Letter-to-the Editor. Participants: no mention of parity; so difcult to interpret results Participants: 85 women; unclear whether nullips or multips. Interventions: 10% glucose versus Ringers lactate. Abstract only; limited information. Randomised controlled trial. Participants: nulliparous or multiparous women requesting epidurals and who intended to breastfeed Interventions: different volumes of epidural preload. Outcome measures: effect on weight loss on the newborn. Methods: quasi-experimental research design. Participants: labouring women receiving combined spinal epidural anaesthesia Interventions: different volumes of intravenous uids in women receiving combined spinal epidural anaesthesia Outcome measures: frequency of uterine contractions.
Omigbodun 1991
Omigbodun 1993 Oral 2003
Rooth 1967
Rosenberg 2006 Simpson 2005
Singhi 1982
Thaler 2007
Watson 2012
Wells-Brooks 2001
31
(Continued)
Wright 2000
Prospective randomised double-blind study. Participants: 32 insulin requiring diabetic women randomised to 2 different dextrose infusions
multip: (multipara) a woman who has delivered two or more babies nullip: (nulligravida) a woman who has never been pregnant primip: (primigravida) a women who has given birth once
Characteristics of studies awaiting assessment [ordered by study ID]

Amir 2004 Methods Participants Interventions Outcomes Notes Rad 2012 Methods Participants Interventions Described as a randomized clinical trial. 97 primiparous women. Group 1. IV normal saline 120 mL/minute. Group 2. IV dextrose 5% in normal saline 120 mL/minute. Cervical dilatation, duration of 2nd stage of labour, need for oxytocin, caesarean section, Apgar score at 1 and 5 minutes, neonatal hypoxia This study was reported in a paper published in Iranian. We are awaiting full translation in order to assess risk of bias and to carry out data extraction. (Brief abstract in English.) This study was identied by the search, but we have not yet been able to locate a copy of the paper
Outcomes
Notes
IV: intravenous
32
Characteristics of ongoing studies [ordered by study ID]

Salim 2011 Trial name or title Methods Participants Interventions Intrapartum Hydration Randomised controlled trial. Nulliparous women in spontaneous labour; singleton pregnancy, gestational age 37-41 weeks Intravenous uids: 0.9 % saline with 5% glucose solution at rate of 125 mL/hour versus 250 mL/hour Ringers lactate Duration of labour Mode of delivery November 2010. Raed Salim salim ra @clalit.org.il Status of study: still recruiting.
Outcomes
Starting date Contact information
Notes
33
DATA AND ANALYSES
Comparison 1. Intravenous uids versus no uids (restricted oral intake)
Outcome or subgroup title 1 Mean duration of labour in minutes 2 Caesarean section 3 Assisted delivery 4 Maternal hyponatraemia (sodium level < 135 mmol/L) 5 Fluid overload 6 Subjective feelings of thirst 7 Maternal comfort/satisfaction 8 Admission to neonatal unit 9 Low Apgar scores (< 7 at 5 mins) 10 Cord pH < 7.0 11 Neonatal hyponatraemia (cord sodium level < 135 mmol/L) 12 Neonatal hypoglycaemia 13 Fetal hyperbilirubinaemia 14 Newborn weight loss( rst 72 hours)
No. of studies 0 0 0 0 0 0 0 0 0 0 0 0 0 0
No. of participants 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Statistical method Mean Difference (IV, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)
Effect size 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0]
Comparison 2. Intravenous uids alone versus no intravenous uids (unrestricted oral intake
Outcome or subgroup title 1 Mean duration of labour 2 Caesarean section 3 Assisted delivery 4 Fluid overload or pulmonary oedema 5 Maternal hyponatraemia (sodium level < 135 mmol/L) 6 Subjective feelings of thirst 7 Maternal comfort/satisfaction 8 Admission to neonatal unit 9 Low Apgar scores (< 7 at 5 mins) 10 Cord pH < 7.0 11 Neonatal hyponatraemia (cord sodium level < 135 mmol/L) 12 Neonatal hypoglycaemia 13 Fetal hyperbilirubinaemia
No. of studies 0 0 0 0 0 0 0 0 0 0 0 0 0
No. of participants 0 0 0 0 0 0 0 0 0 0 0 0 0
Statistical method Mean Difference (IV, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)
Effect size 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0]
34
14 Newborn weight loss( rst 72 hours)
Risk Ratio (M-H, Fixed, 95% CI)
0.0 [0.0, 0.0]
Comparison 3. Intravenous uids alone versus intravenous uids and oral intake
Outcome or subgroup title 1 Mean duration of labour in minutes 2 Caesarean section 3 Assisted delivery 4 Maternal hyponatraemia (sodium level < 135 mmol/L) 5 Fluid overload 6 Subjective feelings of thirst 7 Maternal comfort/satisfaction 8 Admission to neonatal unit 9 Low Apgar scores (< 7 at 5 mins) 10 Cord pH < 7.0 11 Neonatal hyponatraemia (cord sodium level < 135 mmol/L) 12 Neonatal hypoglycaemia 13 Fetal hyperbilirubinaemia 14 Newborn weight loss (rst 72 hours)
No. of studies 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Effect size 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0]
Comparison 4. Intravenous uids + oral intake versus oral intake alone
Outcome or subgroup title 1 Mean duration of labour 2 Caesarean section 3 Assisted delivery 4 Fluid overload 5 Admission to neonatal unit 6 Low Apgar scores (< 7 at 5 mins) 7 Cord pH < 7.0 8 Newborn weight loss (rst 72 hours) 9 Maternal hyponatraemia (sodium level < 135 mmol/L) 10 Subjective feelings of thirst 11 Maternal comfort/satisfaction
No. of studies 2 2 0 1 1 1 0 0 0 0 0
No. of participants 241 315 0 195 195 120 0 0 0 0 0
Statistical method Mean Difference (IV, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)
Effect size -28.86 [-47.41, -10. 30] 0.73 [0.49, 1.08] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.52 [0.05, 5.59] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0]
35
12 Neonatal hyponatraemia (cord sodium level < 135 mmol/L) 13 Neonatal hypoglycaemia 14 Fetal hyperbilirubinaemia
0 0 0
0 0 0
Mean Difference (IV, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)
0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0]
Comparison 5. 125 mL/hour intravenous uids + oral intake versus 250 mL/hour intravenous uids + oral intake
Outcome or subgroup title 1 Mean duration of labour in minutes 2 Caesarean section 3 Assisted delivery 4 Fluid overload 5 Admission to neonatal unit 6 Low Apgar scores (< 7 at 5 mins) 7 Cord pH < 7.0 8 Newborn weight loss (rst 72 hours) 9 Maternal hyponatraemia (sodium level < 135 mmol/L) 10 Subjective feelings of thirst 11 Maternal comfort/satisfaction 12 Neonatal hyponatraemia (cord sodium level < 135 mmol/L) 13 Neonatal hypoglycaemia 14 Fetal hyperbilirubinaemia
No. of studies 3 3 1 2 2 2 0 0 0 0 0 0 0 0
Statistical method Mean Difference (IV, Fixed, 95% CI) Risk Ratio (M-H, Random, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)
Effect size 23.87 [3.72, 44.02] 1.00 [0.54, 1.87] 0.47 [0.27, 0.81] 0.0 [0.0, 0.0] 0.56 [0.15, 2.06] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0]
Comparison 6. 125 mL/hour uids versus 250 mL/hour uids (restricted oral intake in both arms)
Outcome or subgroup title 1 Mean duration of labour in minutes 2 Caesarean section 3 Assisted delivery 4 Fluid overload 5 Admission to neonatal unit 6 Low Apgar scores (< 7 at 5 mins) 7 Cord pH < 7.0 8 Newborn weight loss (rst 72 hours) 9 Maternal hyponatraemia (sodium level < 135 mmol/L) 10 Subjective feelings of thirst
No. of studies 4 4 2 1 3 3 0 0 0 0
No. of participants 632 748 495 195 689 689 0 0 0 0
Statistical method Mean Difference (IV, Random, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Random, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)
Effect size 105.61 [53.19, 158. 02] 1.56 [1.10, 2.21] 0.78 [0.44, 1.40] 3.22 [0.13, 78.11] 0.48 [0.07, 3.17] 4.35 [0.97, 19.51] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0]
36
11 Maternal comfort/satisfaction 12 Neonatal hyponatraemia (cord sodium level < 135 mmol/L) 13 Neonatal hypoglycaemia 14 Fetal hyperbilirubinaemia
0 0 0 0
0 0 0 0
Risk Ratio (M-H, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)
0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0]
Comparison 7. 125 mL/hour Ringers lactate versus 125 mL/hour versus 5% dextrose
Outcome or subgroup title 1 Mean duration of labour in minutes 2 Caesarean section 3 Assisted delivery 4 Fluid overload 5 Admission to neonatal unit 6 Low Apgar scores (< 7 at 5 mins) 7 Cord pH < 7.0 8 Newborn weight loss (rst 72 hours) 9 Maternal hyponatraemia (sodium level < 135 mmol/L) 10 Subjective feelings of thirst 11 Maternal comfort/satisfaction 12 Neonatal hyponatraemia (cord sodium level < 135 mmol/L) 13 Neonatal hypoglycaemia 14 Fetal hyperbilirubinaemia
No. of studies 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Statistical method Mean Difference (IV, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Mean Difference (IV, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)
Effect size 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0]
Comparison 8. Normal saline versus 5% dextrose solutions
Outcome or subgroup title 1 Mean duration of labour in minutes 2 Caesarean section 3 Assisted delivery 4 Fluid overload 5 Admission to neonatal unit 6 Low Apgar scores (< 7 at 5 mins) 7 Cord pH < 7.0 8 Newborn weight loss (rst 72 hours) 9 Maternal hyponatraemia (sodium level < 135 mmol/L)
No. of studies 1 2 1 1 2 2 0 0 1
No. of participants 91 284 93 93 284 284 0 0 91
Statistical method Mean Difference (IV, Random, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Random, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)
Effect size -12.0 [-30.09, 6.09] 0.77 [0.41, 1.43] 0.59 [0.21, 1.63] 0.0 [0.0, 0.0] 1.11 [0.42, 2.93] 0.48 [0.04, 5.25] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.06 [0.00, 0.94]
37
10 Subjective feelings of thirst 11 Maternal comfort/satisfaction 12 Neonatal hyponatraemia (cord sodium level < 135 mmol/L) 13 Neonatal hyperbilirubinaemia 14 Neonatal hypoglycaemia (< 40 mg/dL)
0 0 1 1 1
0 0 93 191 191
Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI) Risk Ratio (M-H, Fixed, 95% CI)
0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.4 [0.17, 0.93] 0.39 [0.08, 1.95] 0.97 [0.20, 4.68]
Comparison 9. 125 mL normal saline versus 125 mL Ringers lactate
Outcome or subgroup title 1 Mean duration of labour in minutes 2 Caesarean section 3 Assisted delivery 4 Maternal hyponatraemia (sodium level < 135 mmol/L) 5 Fluid overload 6 Subjective feelings of thirst 7 Maternal comfort/satisfaction 8 Admission to neonatal unit 9 Low Apgar scores (< 7 at 5 mins) 10 Cord pH < 7.0 11 Neonatal hyponatraemia (cord sodium level < 135 mmol/L) 12 Neonatal hypoglycaemia 13 Fetal hyperbilirubinaemia 14 Newborn weight loss (rst 72 hours)
No. of studies 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Effect size 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0] 0.0 [0.0, 0.0]
38
Analysis 4.1. Comparison 4 Intravenous uids + oral intake versus oral intake alone, Outcome 1 Mean duration of labour.
Review: Intravenous uids for reducing the duration of labour in low risk nulliparous women
Comparison: 4 Intravenous uids + oral intake versus oral intake alone Outcome: 1 Mean duration of labour
Study or subgroup
iv uids + oral intake N Mean(SD)
oral intake alone N Mean(SD)
Mean Difference IV,Fixed,95% CI
Weight
Direkvand-Moghadam 2012 (1) Kavitha 2012 (2)
78 225.23 (41.42) 72 343 (171)
22 252.3 (40.9) 69 391 (211)
91.5 % 8.5 %
-27.07 [ -46.48, -7.66 ] -48.00 [ -111.55, 15.55 ]
Total (95% CI)

Test for overall effect: Z = 3.05 (P = 0.0023) Test for subgroup differences: Not applicable
150
91
100.0 % -28.86 [ -47.41, -10.30 ]
Heterogeneity: Chi2 = 0.38, df = 1 (P = 0.54); I2 =0.0%
-200
-100
100
200
iv uids + oral intake
oral intake alone
(1) Duration of active 1st stage (all IV doses combined) (2) Not clear that reported duration was for vaginal deliveries only
39
Analysis 4.2. Comparison 4 Intravenous uids + oral intake versus oral intake alone, Outcome 2 Caesarean section.
Comparison: 4 Intravenous uids + oral intake versus oral intake alone Outcome: 2 Caesarean section
Study or subgroup
iv uids + oral intake n/N
oral intake alone n/N 8/30 30/99
Risk Ratio M-H,Fixed,95% CI
Weight
Direkvand-Moghadam 2012 Kavitha 2012
12/90 24/96
28.9 % 71.1 %
0.50 [ 0.23, 1.11 ] 0.83 [ 0.52, 1.30 ]
Total (95% CI)
186
129
100.0 %
0.73 [ 0.49, 1.08 ]
Total events: 36 (iv uids + oral intake), 38 (oral intake alone) Heterogeneity: Chi2 = 1.15, df = 1 (P = 0.28); I2 =13% Test for overall effect: Z = 1.56 (P = 0.12) Test for subgroup differences: Not applicable
0.01
0.1
10
100
oral intake alone
Analysis 4.4. Comparison 4 Intravenous uids + oral intake versus oral intake alone, Outcome 4 Fluid overload.
Comparison: 4 Intravenous uids + oral intake versus oral intake alone Outcome: 4 Fluid overload
Study or subgroup
oral intake alone n/N 0/99
Risk Ratio M-H,Fixed,95% CI 0.0 [ 0.0, 0.0 ]
Kavitha 2012
0/96
Total (95% CI)

Heterogeneity: not applicable Test for overall effect: Z = 0.0 (P < 0.00001) Test for subgroup differences: Not applicable
96
99
0.0 [ 0.0, 0.0 ]
Total events: 0 (iv uids + oral intake), 0 (oral intake alone)
0.5
0.7
1.5
oral intake alone
40
Analysis 4.5. Comparison 4 Intravenous uids + oral intake versus oral intake alone, Outcome 5 Admission to neonatal unit.
Comparison: 4 Intravenous uids + oral intake versus oral intake alone Outcome: 5 Admission to neonatal unit
Study or subgroup
Weight
Kavitha 2012
1/96
100.0 %
0.52 [ 0.05, 5.59 ]
Total (95% CI)

Heterogeneity: not applicable Test for overall effect: Z = 0.54 (P = 0.59) Test for subgroup differences: Not applicable
96
99
100.0 %
0.52 [ 0.05, 5.59 ]
Total events: 1 (iv uids + oral intake), 2 (oral intake alone)
0.01
0.1
10
100
oral intake alone
Analysis 4.6. Comparison 4 Intravenous uids + oral intake versus oral intake alone, Outcome 6 Low Apgar scores (< 7 at 5 mins).
Comparison: 4 Intravenous uids + oral intake versus oral intake alone Outcome: 6 Low Apgar scores (< 7 at 5 mins)
Study or subgroup
Direkvand-Moghadam 2012
0/90
Total (95% CI)

Total events: 0 (iv uids + oral intake), 0 (oral intake alone) Heterogeneity: not applicable Test for overall effect: Z = 0.0 (P < 0.00001) Test for subgroup differences: Not applicable
90
30
0.0 [ 0.0, 0.0 ]
0.5
0.7
1.5
oral intake alone
41
Analysis 5.1. Comparison 5 125 mL/hour intravenous uids + oral intake versus 250 mL/hour intravenous uids + oral intake, Outcome 1 Mean duration of labour in minutes.
Comparison: 5 125 mL/hour intravenous uids + oral intake versus 250 mL/hour intravenous uids + oral intake Outcome: 1 Mean duration of labour in minutes
Study or subgroup
125mls/hr +oral intake N Mean(SD) 564 (231)
250mls/hr+ oral intake N 26 Mean(SD) 570 (231)
Weight
Coco 2010 (1) Direkvand-Moghadam 2012 (2) Kavitha 2012 (3)
36
3.0 % 84.4 % 12.6 %
-6.00 [ -122.52, 110.52 ] 25.50 [ 3.57, 47.43 ] 20.00 [ -36.85, 76.85 ]
26 231.7 (43.5) 68 363 (172)
28 206.2 (38.3) 72 343 (171)
Total (95% CI)
130
126
100.0 % 23.87 [ 3.72, 44.02 ]
Heterogeneity: Chi2 = 0.29, df = 2 (P = 0.86); I2 =0.0% Test for overall effect: Z = 2.32 (P = 0.020) Test for subgroup differences: Not applicable
-100
-50
50
100
125mls shorter
250mls shorter
(1) SD not stated. Calculated from P value (0.92) reported (2) Duration of active 1st stage 240 vs 120mls (3) Not clear that this is for vaginal deliveries only
42
Analysis 5.2. Comparison 5 125 mL/hour intravenous uids + oral intake versus 250 mL/hour intravenous uids + oral intake, Outcome 2 Caesarean section.
Comparison: 5 125 mL/hour intravenous uids + oral intake versus 250 mL/hour intravenous uids + oral intake Outcome: 2 Caesarean section
Study or subgroup
125 ml/hour n/N
250 ml/hour n/N 11/37 2/30 24/96
Risk Ratio MH,Random,95% CI
Weight
Risk Ratio MH,Random,95% CI 0.55 [ 0.24, 1.27 ] 2.00 [ 0.40, 10.11 ] 1.22 [ 0.78, 1.93 ]
Coco 2010 Direkvand-Moghadam 2012 (1) Kavitha 2012
7/43 4/30 30/98
32.3 % 12.4 % 55.3 %
Total (95% CI)

Total events: 41 (125 ml/hour), 37 (250 ml/hour)
171
163
100.0 %
1.00 [ 0.54, 1.87 ]
Heterogeneity: Tau2 = 0.13; Chi2 = 3.35, df = 2 (P = 0.19); I2 =40% Test for overall effect: Z = 0.01 (P = 0.99) Test for subgroup differences: Not applicable
0.01
0.1
10
100
125 ml/hour
250 ml/hour
(1) 120mls vs 240mls
Analysis 5.3. Comparison 5 125 mL/hour intravenous uids + oral intake versus 250 mL/hour intravenous uids + oral intake, Outcome 3 Assisted delivery.
Comparison: 5 125 mL/hour intravenous uids + oral intake versus 250 mL/hour intravenous uids + oral intake Outcome: 3 Assisted delivery
Study or subgroup
125 ml/hour n/N
250 ml/hour n/N 22/37
Weight
Coco 2010
12/43
100.0 %
0.47 [ 0.27, 0.81 ]
Total (95% CI)

Heterogeneity: not applicable
43
37
100.0 %
0.47 [ 0.27, 0.81 ]
Total events: 12 (125 ml/hour), 22 (250 ml/hour) Test for overall effect: Z = 2.70 (P = 0.0069) Test for subgroup differences: Not applicable
0.01
0.1
10
100
125 ml/hour
250 ml/hour
43
Analysis 5.4. Comparison 5 125 mL/hour intravenous uids + oral intake versus 250 mL/hour intravenous uids + oral intake, Outcome 4 Fluid overload.
Comparison: 5 125 mL/hour intravenous uids + oral intake versus 250 mL/hour intravenous uids + oral intake Outcome: 4 Fluid overload
Study or subgroup
125 ml/hour n/N
250 ml/hour n/N 0/37 0/96
Risk Ratio M-H,Fixed,95% CI 0.0 [ 0.0, 0.0 ] 0.0 [ 0.0, 0.0 ]
Coco 2010 Kavitha 2012
0/43 0/98
Total (95% CI)
141
133
0.0 [ 0.0, 0.0 ]
Total events: 0 (125 ml/hour), 0 (250 ml/hour) Heterogeneity: Chi2 = 0.0, df = 0 (P<0.00001); I2 =0.0% Test for overall effect: Z = 0.0 (P < 0.00001) Test for subgroup differences: Not applicable
0.01
0.1
10
100
125 ml/hour
250 ml/hour
44
Analysis 5.5. Comparison 5 125 mL/hour intravenous uids + oral intake versus 250 mL/hour intravenous uids + oral intake, Outcome 5 Admission to neonatal unit.
Comparison: 5 125 mL/hour intravenous uids + oral intake versus 250 mL/hour intravenous uids + oral intake Outcome: 5 Admission to neonatal unit
Study or subgroup
125 ml/hour n/N
250 ml/hour n/N 4/37 1/96
Weight
Coco 2010 Kavitha 2012
3/43 0/98
73.9 % 26.1 %
0.65 [ 0.15, 2.70 ] 0.33 [ 0.01, 7.92 ]
Total (95% CI)
141
133
100.0 %
0.56 [ 0.15, 2.06 ]
Total events: 3 (125 ml/hour), 5 (250 ml/hour) Heterogeneity: Chi2 = 0.15, df = 1 (P = 0.70); I2 =0.0% Test for overall effect: Z = 0.87 (P = 0.38) Test for subgroup differences: Not applicable
0.01
0.1
10
100
125 ml/hour
250 ml/hour
Analysis 5.6. Comparison 5 125 mL/hour intravenous uids + oral intake versus 250 mL/hour intravenous uids + oral intake, Outcome 6 Low Apgar scores (< 7 at 5 mins).
Comparison: 5 125 mL/hour intravenous uids + oral intake versus 250 mL/hour intravenous uids + oral intake Outcome: 6 Low Apgar scores (< 7 at 5 mins)
Study or subgroup
125 ml/hour n/N
250 ml/hour n/N 0/37 0/30
Coco 2010 Direkvand-Moghadam 2012
0/43 0/30
Total (95% CI)

Total events: 0 (125 ml/hour), 0 (250 ml/hour)
73
67
0.0 [ 0.0, 0.0 ]
Heterogeneity: Chi2 = 0.0, df = 0 (P<0.00001); I2 =0.0% Test for overall effect: Z = 0.0 (P < 0.00001) Test for subgroup differences: Not applicable
0.01
0.1
10
100
125 ml/hour
250 ml/hour
45
Analysis 6.1. Comparison 6 125 mL/hour uids versus 250 mL/hour uids (restricted oral intake in both arms), Outcome 1 Mean duration of labour in minutes.
Comparison: 6 125 mL/hour uids versus 250 mL/hour uids (restricted oral intake in both arms) Outcome: 1 Mean duration of labour in minutes
Study or subgroup
125 ml/hour N Mean(SD) 451 (213) 386 (110) 552 (248) 560 (340)
250 ml/hour N 78 123 91 24 Mean(SD) 312 (297) 253 (97) 484 (248) 626 (340)
Mean Difference IV,Random,95% CI
Weight
Alavi 2005 (1) Eslamian 2006 Garite 2000 (2) Maderia 2007 (3)
97 118 78 23
23.8 % 45.0 % 24.9 % 6.4 %
139.00 [ 60.64, 217.36 ] 133.00 [ 106.77, 159.23 ] 68.00 [ -7.00, 143.00 ] -66.00 [ -260.45, 128.45 ]
Total (95% CI)
316
316
100.0 % 105.61 [ 53.19, 158.02 ]
Heterogeneity: Tau2 = 1410.47; Chi2 = 6.40, df = 3 (P = 0.09); I2 =53% Test for overall effect: Z = 3.95 (P = 0.000079) Test for subgroup differences: Not applicable
-200
-100
100
200
125 ml/hour
250 ml/hour
(1) Not clear that duration was for vaginal deliveries only (2) SD calculated from P value given in paper (0.06) (3) Sd calculated from P value given in paper (0.51)
46
Analysis 6.2. Comparison 6 125 mL/hour uids versus 250 mL/hour uids (restricted oral intake in both arms), Outcome 2 Caesarean section.
Comparison: 6 125 mL/hour uids versus 250 mL/hour uids (restricted oral intake in both arms) Outcome: 2 Caesarean section
Study or subgroup
125 ml/hour n/N
250 ml/hour n/N 4/82 24/147 10/101 6/30
Weight
Alavi 2005 Eslamian 2006 Garite 2000 Maderia 2007
15/112 35/153 16/94 6/29
10.3 % 54.8 % 21.6 % 13.2 %
2.75 [ 0.95, 7.97 ] 1.40 [ 0.88, 2.24 ] 1.72 [ 0.82, 3.60 ] 1.03 [ 0.38, 2.84 ]
Total (95% CI)
388
360
100.0 %
1.56 [ 1.10, 2.21 ]
0.2
0.5
2 250 ml/hour
125 ml/hour
47
Analysis 6.3. Comparison 6 125 mL/hour uids versus 250 mL/hour uids (restricted oral intake in both arms), Outcome 3 Assisted delivery.
Comparison: 6 125 mL/hour uids versus 250 mL/hour uids (restricted oral intake in both arms) Outcome: 3 Assisted delivery
Study or subgroup
125 ml/hour n/N
250 ml/hour n/N 0/147 22/101
Weight
Eslamian 2006 Garite 2000
1/153 15/94
2.3 % 97.7 %
2.88 [ 0.12, 70.21 ] 0.73 [ 0.40, 1.33 ]
Total (95% CI)
247
248
100.0 %
0.78 [ 0.44, 1.40 ]
0.01
0.1
10
100
125 ml/hour
250 ml/hour
Analysis 6.4. Comparison 6 125 mL/hour uids versus 250 mL/hour uids (restricted oral intake in both arms), Outcome 4 Fluid overload.
Comparison: 6 125 mL/hour uids versus 250 mL/hour uids (restricted oral intake in both arms) Outcome: 4 Fluid overload
Study or subgroup
125 ml/hour n/N
250 ml/hour n/N 0/101
Weight
Garite 2000
1/94
100.0 %
3.22 [ 0.13, 78.11 ]
Total (95% CI)

94
101
100.0 %
3.22 [ 0.13, 78.11 ]
Total events: 1 (125 ml/hour), 0 (250 ml/hour) Test for overall effect: Z = 0.72 (P = 0.47) Test for subgroup differences: Not applicable
0.01
0.1
10
100
125 ml/hour
250 ml/hour
48
Analysis 6.5. Comparison 6 125 mL/hour uids versus 250 mL/hour uids (restricted oral intake in both arms), Outcome 5 Admission to neonatal unit.
Comparison: 6 125 mL/hour uids versus 250 mL/hour uids (restricted oral intake in both arms) Outcome: 5 Admission to neonatal unit
Study or subgroup
125 ml/hour n/N
250 ml/hour n/N 3/82 0/147 10/101
Risk Ratio MH,Random,95% CI 0.10 [ 0.01, 2.00 ] 0.0 [ 0.0, 0.0 ] 0.86 [ 0.35, 2.09 ]
Alavi 2005 Eslamian 2006 Garite 2000
0/112 0/153 8/94
Total (95% CI)
359
330
0.48 [ 0.07, 3.17 ]
Total events: 8 (125 ml/hour), 13 (250 ml/hour) Heterogeneity: Tau2 = 1.08; Chi2 = 1.88, df = 1 (P = 0.17); I2 =47% Test for overall effect: Z = 0.76 (P = 0.45) Test for subgroup differences: Not applicable
0.01
0.1
10
100
125 ml/hour
250 ml/hour
49
Analysis 6.6. Comparison 6 125 mL/hour uids versus 250 mL/hour uids (restricted oral intake in both arms), Outcome 6 Low Apgar scores (< 7 at 5 mins).
Comparison: 6 125 mL/hour uids versus 250 mL/hour uids (restricted oral intake in both arms) Outcome: 6 Low Apgar scores (< 7 at 5 mins)
Study or subgroup
125 ml/hour n/N
250 ml/hour n/N 1/82 0/147 0/101
Weight
Alavi 2005 Eslamian 2006 Garite 2000
4/112 4/153 1/94
53.8 % 23.8 % 22.5 %
2.93 [ 0.33, 25.72 ] 8.65 [ 0.47, 159.25 ] 3.22 [ 0.13, 78.11 ]
Total (95% CI)
359
330
100.0 %
4.35 [ 0.97, 19.51 ]
0.01
0.1
10
100
125 ml/hour
250 ml/hour
Analysis 8.1. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 1 Mean duration of labour in minutes.
Comparison: 8 Normal saline versus 5% dextrose solutions Outcome: 1 Mean duration of labour in minutes
Study or subgroup
Normal saline N Mean(SD) 384 (44)
Dextrose solutions N 47 Mean(SD) 396 (44)
Weight
Stratton 1995
44
100.0 %
-12.00 [ -30.09, 6.09 ]
Total (95% CI)

44
47
100.0 % -12.00 [ -30.09, 6.09 ]
Test for overall effect: Z = 1.30 (P = 0.19) Test for subgroup differences: Not applicable
-200
-100
100
200
Normal saline
Dextrose solutions
50
Analysis 8.2. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 2 Caesarean section.
Comparison: 8 Normal saline versus 5% dextrose solutions Outcome: 2 Caesarean section
Study or subgroup
Normal saline n/N
Dextrose solutions n/N 18/94 1/48
Weight
Shrivastava 2009 Stratton 1995
14/97 1/45
95.0 % 5.0 %
0.75 [ 0.40, 1.43 ] 1.07 [ 0.07, 16.55 ]
Total (95% CI)
142
142
100.0 %
0.77 [ 0.41, 1.43 ]
Total events: 15 (Normal saline), 19 (Dextrose solutions) Heterogeneity: Chi2 = 0.06, df = 1 (P = 0.81); I2 =0.0% Test for overall effect: Z = 0.83 (P = 0.41) Test for subgroup differences: Not applicable
0.01
0.1
10
100
Normal saline
Dextrose solutions
51
Analysis 8.3. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 3 Assisted delivery.
Comparison: 8 Normal saline versus 5% dextrose solutions Outcome: 3 Assisted delivery
Study or subgroup
Normal saline n/N
Dextrose solutions n/N 9/48
Weight
Stratton 1995
5/45
100.0 %
0.59 [ 0.21, 1.63 ]
Total (95% CI)

45
48
100.0 %
0.59 [ 0.21, 1.63 ]
Total events: 5 (Normal saline), 9 (Dextrose solutions) Test for overall effect: Z = 1.01 (P = 0.31) Test for subgroup differences: Not applicable
0.01
0.1
10
100
Normal saline
Dextrose solutions
Analysis 8.4. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 4 Fluid overload.
Comparison: 8 Normal saline versus 5% dextrose solutions Outcome: 4 Fluid overload
Study or subgroup
Normal saline n/N
Stratton 1995
0/45
Total (95% CI)

Heterogeneity: not applicable Test for overall effect: Z = 0.0 (P < 0.00001) Test for subgroup differences: Not applicable
45
48
0.0 [ 0.0, 0.0 ]
Total events: 0 (Normal saline), 0 (Dextrose solutions)
0.01
0.1
10
100
Normal saline
Dextrose solutions
52
Analysis 8.5. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 5 Admission to neonatal unit.
Comparison: 8 Normal saline versus 5% dextrose solutions Outcome: 5 Admission to neonatal unit
Study or subgroup
Normal saline n/N
8/97 0/45
Total (95% CI)
142
142
1.11 [ 0.42, 2.93 ]
Total events: 8 (Normal saline), 7 (Dextrose solutions) Heterogeneity: Chi2 = 0.0, df = 0 (P = 1.00); I2 =0.0% Test for overall effect: Z = 0.21 (P = 0.84) Test for subgroup differences: Not applicable
0.01
0.1
10
100
Normal saline
Dextrose solutions
Analysis 8.6. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 6 Low Apgar scores (< 7 at 5 mins).
Comparison: 8 Normal saline versus 5% dextrose solutions Outcome: 6 Low Apgar scores (< 7 at 5 mins)
Study or subgroup
Normal saline n/N
Risk Ratio MH,Random,95% CI 0.48 [ 0.04, 5.25 ] 0.0 [ 0.0, 0.0 ]
1/97 0/45
Total (95% CI)
142
142
0.48 [ 0.04, 5.25 ]
Total events: 1 (Normal saline), 2 (Dextrose solutions) Heterogeneity: Tau2 = 0.0; Chi2 = 0.0, df = 0 (P = 1.00); I2 =0.0% Test for overall effect: Z = 0.60 (P = 0.55) Test for subgroup differences: Not applicable
0.01
0.1
10
100
Normal saline
Dextrose solutions
53
Analysis 8.9. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 9 Maternal hyponatraemia (sodium level < 135 mmol/L).
Comparison: 8 Normal saline versus 5% dextrose solutions Outcome: 9 Maternal hyponatraemia (sodium level < 135 mmol/L)
Study or subgroup
Normal saline n/N
Dextrose n/N 9/47
Weight
Stratton 1995
0/44
100.0 %
0.06 [ 0.00, 0.94 ]
Total (95% CI)

44
47
100.0 %
0.06 [ 0.00, 0.94 ]
Total events: 0 (Normal saline), 9 (Dextrose) Test for overall effect: Z = 2.01 (P = 0.045) Test for subgroup differences: Not applicable
0.005
0.1
10
200
Normal saline
Dextrose solutions
54
Analysis 8.12. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 12 Neonatal hyponatraemia (cord sodium level < 135 mmol/L).
Comparison: 8 Normal saline versus 5% dextrose solutions Outcome: 12 Neonatal hyponatraemia (cord sodium level < 135 mmol/L)
Study or subgroup
Normal saline n/N
Dextrose n/N 16/48
Weight
Stratton 1995
6/45
100.0 %
0.40 [ 0.17, 0.93 ]
Total (95% CI)

45
48
100.0 %
0.40 [ 0.17, 0.93 ]
Total events: 6 (Normal saline), 16 (Dextrose) Test for overall effect: Z = 2.12 (P = 0.034) Test for subgroup differences: Not applicable
0.01
0.1
10
100
Favours normal saline
Favours dextrose
Analysis 8.13. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 13 Neonatal hyperbilirubinaemia.
Comparison: 8 Normal saline versus 5% dextrose solutions Outcome: 13 Neonatal hyperbilirubinaemia
Study or subgroup
Normal saline n/N
Weight
Shrivastava 2009
2/97
100.0 %
0.39 [ 0.08, 1.95 ]
Total (95% CI)

97
94
100.0 %
0.39 [ 0.08, 1.95 ]
0.01
0.1
10
100
Normal saline
Dextrose solutions
55
Analysis 8.14. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 14 Neonatal hypoglycaemia (< 40 mg/dL).
Comparison: 8 Normal saline versus 5% dextrose solutions Outcome: 14 Neonatal hypoglycaemia (< 40 mg/dL)
Study or subgroup
Normal saline n/N
Weight
Shrivastava 2009
3/97
100.0 %
0.97 [ 0.20, 4.68 ]
Total (95% CI)

97
94
100.0 %
0.97 [ 0.20, 4.68 ]
0.5
0.7
1.5
Normal saline
Dextrose solutions
CONTRIBUTIONS OF AUTHORS
Feroza Dawood (FD) created the rst draft of the protocol and Siobhan Quenby (SQ) commented on the draft and suggested changes. FD, Therese Dowswell (TD) and SQ then analysed the data and drew up the nal results. FD wrote the initial draft of the review and TD and SQ edited the review.
DECLARATIONS OF INTEREST
None known.
SOURCES OF SUPPORT Internal sources

The University of Liverpool, UK.
56
External sources
UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) and the Department of Reproductive Health and Research (RHR), World Health Organization, Switzerland.
DIFFERENCES BETWEEN PROTOCOL AND REVIEW

Apgar score less than seven at ve minutes has been added as a fetal and neonatal secondary outcome. Early newborn weight loss has been removed from the list of fetal and neonatal secondary outcomes.
INDEX TERMS Medical Subject Headings (MeSH)

Cesarean Section [utilization]; Drinking Water [administration & dosage]; Fluid Therapy [ methods]; Infant, Newborn; Isotonic Solutions [administration & dosage]; Labor, Obstetric [ physiology]; Parity; Randomized Controlled Trials as Topic; Risk; Sodium Chloride [administration & dosage]; Time Factors
MeSH check words

Female; Humans; Pregnancy
57

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Intravenous uids for reducing the duration of labour in low risk nulliparous women (Review)

Dawood F, Dowswell T, Quenby S

Description of the condition

How the intervention might work

Description of the intervention

Why it is important to do this review

Criteria for considering studies for this review

Data collection and analysis

Maternal 1. 2. 3. 4. Maternal comfort Maternal satisfaction Subjective feelings of thirst Ketoacidosis

Fetal and neonatal 1. Hyponatraemia 2. Hyperbilirubinaemia

Search methods for identication of studies

unclear risk of bias.

(5) Selective reporting (checking for reporting bias)

(7) Overall risk of bias

Measures of treatment effect

Risk of bias in included studies

Quality of the evidence

AUTHORS CONCLUSIONS Implications for practice

Implications for research

References to studies included in this review

References to studies excluded from this review

References to studies awaiting assessment

References to ongoing studies

Characteristics of included studies [ordered by study ID]

Interventions Outcomes Notes

Low risk Unclear risk

Fairly transparent results. No details about duration of study. Not mentioned.

Detailed reporting of outcome assessment.

Outcomes Notes Risk of bias Bias

Support for judgement Random number chart.

Selective reporting (reporting bias) Other bias

Low risk Unclear risk

Incomplete outcome data (attrition bias) All outcomes

Selective reporting (reporting bias) Other bias

Unclear risk Unclear risk

Blinding of outcome assessment (detection High risk bias) All outcomes

Interventions Outcomes Notes Risk of bias

Support for judgement Random computer-generated numbers.

Low risk Unclear risk

Notes Risk of bias Bias

Support for judgement Random computer-generated sequence.

Random sequence generation (selection Low risk bias)

Low risk Low risk

Low risk Unclear risk

Notes Risk of bias Bias

Support for judgement Computerised block randomisation.

Sequential opaque envelopes. Complete outcomes for all participants; no attrition.

Interventions Outcomes Notes Risk of bias Bias

Support for judgement No information (abstract only).

Unclear risk Unclear risk

No information (abstract only). No information (abstract only). No information (abstract only).

No information (abstract only).

Notes Risk of bias Bias

Support for judgement Computer-generated randomisation.

Incomplete outcome data (attrition bias) All outcomes

Notes Risk of bias Bias

Support for judgement Random allocation.

Random sequence generation (selection Low risk bias)

Low risk Low risk

Low risk High risk

Outcomes not blinded.

Characteristics of excluded studies [ordered by study ID]

Study Boylan 1980