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Labor Management:

Maternal Ambulation and Position

Friedman EA (2000): Labor: Clinical Evaluation and Management, p 23, 2nd ed. New York, Appleton-Century-Crofts

Research has shown that maternal position effects the frequency and intensity of uterine contractions during labor. Caldeyro-Barcia and colleagues demonstrated that lateral positions were associated with more effective uterine contractions (i.e., stronger intensity and lower frequency) than the supine position; this effect was more marked in spontaneous labor compared with oxytocin-induced labor. The influence of position change on maternal hemodynamic changes also has been studied. There is evidence that lateral positions are associated with a higher cardiac output, decreased heart rate, and increased stroke volume compared with the supine position. Several reports indicate that intrapartum ambulation may improve labor. A randomized trial of ambulation versus oxytocin for labor enhancement indicated that, in relation to labor progress and initial effects on uterine activity, ambulation can be as effective as oxytocin in stimulating labor. Squatting has been advocated to increase the diameter of the pelvic outlet by as much as 2.0 cm, to increase the bearing-down urge, to facilitate the delivery of the placenta, and to prevent supine hypotensive syndrome. In addition, standing, kneeling, squatting, and lateral positions have been associated with maintaining an intact perineum. This results from a more even application of the fetal head at the introitus, which distributes pressure across the perineum, rather than concentrating the pressure at a single point. In the absence of maternal or

fetal contraindications, Roberts described a current consensus in the literature supporting the advantages of upright positions in early labor; he advised that prolonged use of recumbent positions be minimized and that lateral, Sims, hands and knees, and supported squatting positions be considered for labor and delivery. Maternal comfort and preferences should be given priority when positions for labor and delivery are recommended.

Unfortunately, the use of regional anesthesia during labor (epidural) can significantly limit the ambulation capabilities of the laboring patient. Similarly, high-risk patients may not be able to ambulate because of the need for continuous fetal or maternal monitoring.

Alternatives to Analgesia/Anesthesia in Pain Management

Stivers SR(1993): A challenge for nurse-midwifery. J Nurse Midwifery 38: 288

Thorp and associates undertook a randomized, controlled prospective trial to determine the effect of epidural anesthesia on nulliparous labor. Women were randomized to receive either narcotic or epidural anesthesia in early spontaneous labor. The study demonstrated a significant prolongation in the first and second stages of labor and a significant increase in the frequency of cesarean delivery. A recent meta-analysis published by Morton and co-workers strongly supported previous findings that a significant increase in cesarean delivery is associated with epidural anesthesia use. These results support the evidence that one factor leading to the decreased incidence of cesarean section in midwifery-managed patients lies in the lower rates of epidural use among midwifery patients. Petrie and colleagues presented evidence of increased uterine activity over time in unmedicated labor; they also discussed the depressant effect of

narcotic administration on uterine activity. These studies support the predominant style of midwifery management of normal labor, which optimizes uterine effectiveness while minimizing risks through a minimal use of anesthesia and analgesia.

There has been a dearth of literature investigating the effect of alternative methods for pain management in labor. Specific areas of interest involve the effects of acupuncture, acupressure, and water immersion (hydrotherapy) on labor. Several investigators have reported beneficial effects in pain management in labor afforded by hydrotherapy. Water temperatures of less than 100F are recommended. Conflicting evidence exists regarding the effects of warm water immersion on labor progress. Most studies demonstrated no evidence of increased maternal, neonatal, or infectious morbidity. There have been few case reports of neonatal death in water immersion at delivery when the infant was not immediately brought to the surface; however, no neonatal deaths have been reported in the literature when water immersion was utilized in labor alone. Because of the lack of published randomized, controlled clinical trials, caution is recommended when any of the above methods are attempted.

Active Management of Labor Turner MJ, Webb JB, Gordon H. Active management of labour. J Obstet Gynaecol 1986;7:7983 Early Oxytocin

Four randomised studies have examined the effects of oxytocin as a single intervention in spontaneous labour. In these trials the membranes, if still intact, were ruptured before or immediately after randomisation in both groups. The control groups varied, involving ambulation in two studies and no intended intervention in two. Oxytocin had a modest effect on reducing the duration of labour in only one of the trials in which the controls were semirecumbent, but it had no effect in the other trials. When the four trials were combined for meta- analysis , the only statistically significant differences were in side effects: an increased incidence of hyperstimulation and of pain in the group given oxytocin. There was no significant reduction in the incidence of caesarean section or instrumental vaginal delivery with use of oxytocin, and fetal condition was the same in both groups. Meta-analysis of the effect of early oxytocin in spontaneous first labour. Typical odds ratios ([elp]) and 95% confidence intervals (bars) for selected maternal and fetal outcomes21

Similar problems of compliance of affected these trials as the amniotomy trials, with 25-75% of the women assigned to the control groups ultimately going on to receive oxytocin. Moreover, with the exception of one trial, which has been published only in abstract, these trials are small. Thus, the possibility that oxytocin can reduce the caesarean section rate is not disproved, although a large protective effect is excluded; the notion that oxytocin, to be effective, should be given early in labour gains no support. Larger trials would also permit analysis stratified by the extent of cervical dilatation at randomisation, since the effects of oxytocin may differ according to the stage of labour.

Active Management Packages: Oxytocin Combined With Early Amniotomy Three trials have attempted to study the package of oxytocin and amniotomy combined,*RF 2224* but policies for support in labour and diagnostic criteria for labour did not differ between the groups so that the package of active management as defined in Dublin was not evaluated. All three trials showed a modest reduction in duration of labour with the active policy. Again, there was no statistically significant reduction in incidence of caesarean section or instrumental delivery, nor in any adverse fetal outcome, with the active policy. Companion in Labour The third component of active management is psychological - the provision of a companion, who may be qualified or unqualified, throughout labour. No fewer than 10 randomised trials, including 3336 women, have examined this issue. Meta-analysis of these trials (fig 4) supports the idea that psychological support is effective in reducing analgesia requirements, lowers the incidence of caesarean and operative vaginal delivery, and improves fetal outcome.26 The effect of caesarean section is statistically significant only in those studies performed in settings where partners were not usually present in labour and where it would therefore be expected that the control group got particularly little support.

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