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Cochrane Systematic Review Supports Lamaze Healthy Birth Practice #2- Walk, Move Around And Change Positions Throughout Labor

December 19th, 2013 by avatar
Image Source: © Sharon Muza

Image Source: © Sharon Muza

Today, author Henci Goer takes a look at a new Cochrane Systematic Review; “Maternal positions and mobility during first stage labour” and finds that the results of this review support the 2nd Lamaze International Healthy Birth Practice: Walk, move around and change positions throughout labor. Families taking Lamaze childbirth classes learn how they can promote physiologic birth by using a variety of positions throughout their labor, but women don’t have to take a childbirth class to know that walking and trying different positions reduces pain and speeds up labor.  Intuitively, women respond to the needs of their baby and their body during labor.  Henci examines the review and shares some of the benefits that were found in the women who followed the 2nd Healthy Birth Practice to promote safe and healthy birth. – Sharon Muza, Community Manager.

Advocates for physiologic care in labor will be pleased, although not surprised, to know that a Cochrane systematic review supports mobility and upright positioning in first-stage labor (the cervical dilation phase) (Lawrence 2013.) The review includes 18 randomized controlled trials (RCTs) comprising 3337 women not having epidurals at trial entry and 7 trials comprising 1881 women in which all participants had epidurals or combined spinal-epidurals at trial entry.

The body of data poses challenges in analysis and interpretation. Trials were published between 1963 and 2012 and conducted in 13 countries. As reviewers note, this means that they took place in highly varied cultural and healthcare contexts, equally varied expectations on the part of staff and laboring women, and with evolving healthcare technologies, all of which could influence results. In addition, comparison “treatment” and “control” groups also varied widely and overlapped among them. So, for example, one trial compared walking with remaining in bed in whatever posture, including upright postures; another compared walking with recumbent postures; and still another combined sitting and walking as upright postures and compared them with recumbent postures. That being said, here is what the reviewers found:

Compared with recumbent postures and bed care, upright postures and walking in women without epidurals at trial entry:

• Shortened first-stage labor duration by a mean difference of 1 hour 22 minutes in women overall (15 trials, 2503 women) and by 1 hour 13 minutes in first-time mothers (12 trials, 1486 women). In women with prior births (4 trials, 662 women), duration differed by only 34 minutes, and the difference just missed achieving statistical significance, that is, statistical analysis shows that the difference is unlikely to be due to chance. By comparison, rupturing membranes, commonly used to “get the show on the road,” had no effect on first-stage duration in women overall (5 trials, 1127 women) (Smyth 2013), and too few women were reported according to first-time or prior births to draw meaningful conclusions.

• Decreased likelihood of cesarean delivery (14 trials, 2682 women) by 30%. Likelihood decreased by 20% in first-time mothers (8 trials, 1237 women) and 40% in women with prior births (4 trials, 775 women), but the differences didn’t achieve statistical significance probably because aggregated numbers were too small (underpowered) and cesarean rates too low to detect a difference. By contrast, rupturing membranes increases the likelihood of cesarean surgery by 30%, a risk that misses achieving statistical significance by a whisker and probably would have achieved significance had not so many women assigned to “conserve membranes” actually had their membranes ruptured (Smyth 2013).

• Reduced use of epidural analgesia (9 trials, 2107 women) by 20%.

• Didn’t increase satisfaction or decrease complaints of pain, but only one small study (107 women) measured satisfaction, and among the three trials (338 women) evaluating pain, women reported less pain in two of them, but in the third (201 women), which comprised 60% of the population overall, participants assigned to sit or walk were not allowed to lie down at any time during first stage. Bloom et al. (1998), by far the largest of any of the trials at 1067 participants, wasn’t included in the pain and satisfaction assessments probably because they took a different approach. They asked women who walked whether they would want to walk in a future labor. Ninety-nine percent said “Yes,” which would seem a ringing endorsement of ambulation.

• Showed no evidence of increasing maternal, fetal, or neonatal harm. In fact, one small trial (200 women) reported significantly fewer admissions to neonatal intensive care.

Benefits were maintained when subgroupings of upright postures were compared with subgroupings of recumbent postures, as for example, walking compared with recumbent/supine/lateral or sitting and standing, squatting, kneeling, or walking compared with recumbent/supine/lateral.

No benefits were found for walking or upright postures (7 trials, 1881 women) in women who had epidurals or combined spinal-epidurals at trial entry. This doesn’t really mean much, though, because in some trials, substantial percentages of women assigned to walk didn’t actually do so, and in others “ambulation” was defined to be as little as 5 minutes of walking per hour.

The review leaves some questions open: Can mobility be used to treat delayed progress? Should women with ruptured membranes be allowed to walk? What about women at risk for fetal compromise? To the first question, it makes sense to encourage walking and upright positioning as a first-line measure to treat progress delay. The alternatives, rupturing membranes and oxytocin augmentation, have potential harms while walking and position changes don’t. To the second, when upright, gravity would tend to bring the presenting part downward to block the cervical opening, thereby protecting against umbilical cord prolapse. A common sense approach might be to monitor fetal heart tones throughout a contraction upon the woman first assuming an upright position and repeat whenever she returns to an upright position after lying down. To the last question, studies would need to be done, but rupturing membranes increases risk of fetal compromise by releasing the fluid that prevents umbilical cord compression (you can’t compress a liquid), and augmentation increases contraction intensity, which also could increase risk of compromise in a vulnerable fetus.

The true benefits of mobility are almost certainly much greater than the review shows. This is because RCTs are analyzed according to “intent to treat,” that is, participants are kept with their assigned group regardless of their actual treatment. To do otherwise would negate the point of random assignment, which is to avoid bias; however, when substantial percentages of participants receive the treatment of the other group, as is the case with many of the mobility RCTs, it both diminishes differences between groups and makes it harder to detect a significant difference between them. This was a problem in all the mobility RCTs, not just the ones where women already had regional analgesia on board. Again, take Bloom et al. (1998): among women assigned to walk, 22%—approaching 1 in 4—never walked at all, and of the women who did, the mean time spent out of bed was an hour mostly because of policies that kept them in, or returned them to, bed.

The reviewers conclude:

[W]e believe wherever possible, women should be informed of the benefits of upright positions, encouraged and supported to take up whatever positions they choose, they should not have their freedom of movement options restricted unless clinically indicated, and they should avoid spending long periods supine (p. 23).

It isn’t enough, though, to advise women that it’s a good idea to stay mobile and stay off their backs unless staff follow through on not restricting freedom of movement. As matters currently stand, conventional hospital labor management couldn’t do a better job of restricting mobility if that were its intended goal. To turn that around, hospitals would need to:

• Provide an environment conducive to mobility, including ample space for moving around and props such as birth balls, rocking chairs, and cushions,

• Provide comfort measures such as hot and cold packs, private showers, and soaking tubs to reduce and delay use of epidural analgesia,

• Train staff in encouraging and providing physical assistance in changing positions, in the use of mobility props, and in how to provide emotionally supportive care,

• Welcome doulas who can share the burden of providing physical and emotional support,

• Use intermittent listening to fetal heart tones except when continuous monitoring is medically indicated,

• Reserve IVs for medical indications, which would mean allowing women oral intake of fluids and calories, and

• When mobility-inhibiting interventions are required or the woman desires an epidural, minimize their impact by such measures as telemetry monitoring, inserting IV catheters in the forearm rather than the hand or wrist or using saline locks instead of IVs, and encouraging women with epidurals to assume upright positions and change positions periodically.

In other words, promoting mobility in labor is the proverbial tip of the iceberg. Floating below is the vast bulk of providing physiologic care. That won’t be easy for a number of reasons.

For one thing, medical research principles require that investigators define the intervention under evaluation precisely and maximize compliance with its administration. But this is the direct opposite of women doing what instinctively feels best in an environment that encourages their experimentation and is free from elements that inhibit or restrict them. We have no trials that compare this style of care with conventional medical-model management, which means we don’t have data showing the true degree of harm arising from confining and circumscribing mobility in labor or the magnitude of the benefits to be gained with promoting it. Without that knowledge, there is little incentive to change.

For another, in the topsy-turvy world of medical-model research, maternal movements and physiologically normal behaviors are framed as “interventions.” This means that being up and around and having the freedom to labor in the positions of the woman’s choice has to prove itself, not confinement to bed and positioning restriction. What is more, to institute change, the “intervention” must prove itself superior according to medical model concepts of improved outcomes, or conventional management stands, however much that management lacks an evidence basis. This explains how Bloom and colleagues could entitle their trial “Lack of effect of walking on labor and delivery” despite walking having no harms and 99% of women who walked wanting to do so again in a future labor.

Finally, powerful forces line up against instituting the sweeping changes that would be required to convert to mobility-friendly care. Inertia is one. People will generally resist change even when it benefits them personally, which in this case it doesn’t. Economics is another. The costs of maintaining a 24/7 obstetric analgesia service demand that most women have epidurals while any renovation expenses, such as providing private showers, soaking tubs, or telemetry monitoring, would not be reimbursed. Hospital culture is perhaps the biggest obstacle of all. “This is the way we’ve always done it” and “what is must be right” are potent impediments to improvement. Specifically, so long as reducing cesarean rates isn’t a shared, strongly-held goal—and a cursory glance at hospital cesarean rates shows that it isn’t in most hospitals—motivation to change will be low.

All of this is to say that reform won’t be easy, not that it can’t be done, and, I would add, the wellbeing of mothers and babies obliges us to try. In that interest, can we crowd source strategies? Are any hospitals in your community mobility friendly? What are their practices and policies? Have any of you been involved in projects to increase mobility in labor, and if so, what went well and what would you do differently?

References

Bloom, S. L., McIntire, D. D., Kelly, M. A., Beimer, H. L., Burpo, R. H., Garcia, M. A., & Leveno, K. J. (1998). Lack of effect of walking on labor and delivery. N Engl J Med, 339(2), 76-79. http://www.ncbi.nlm.nih.gov/pubmed/9654537?dopt=Citation

Lawrence, A., Lewis, L., Hofmeyr, G. J., & Styles, C. (2013). Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev, 10, CD003934. doi: 10.1002/14651858.CD003934.pub4 http://www.ncbi.nlm.nih.gov/pubmed/24105444

Smyth, R. M., Markham, C., & Dowswell, T. (2013). Amniotomy for shortening spontaneous labour. Cochrane Database Syst Rev, 6, CD006167. doi: 10.1002/14651858.CD006167.pub4 http://www.ncbi.nlm.nih.gov/pubmed/23780653

 

Evidence Based Medicine, Guest Posts, Healthy Birth Practices, Healthy Care Practices, New Research, Push for Your Baby, Research , , , , , ,

Safe at Home? New Home Vs. Hospital Birth Study Reviewed by Henci Goer

November 26th, 2013 by avatar

 Regular contributor Henci Goer examines the most recent study on the safety of home birth in the United States.  When taking a closer look at the data analysis done by the authors, there are concerns not addressed in the study, that raise issues that cause the study’s conclusions to be questioned. Henci shares some other studies that do not reach the same results about the safety of home birth. Have you read this study?  If you had read this study too, did you find more questions than answers when you were done? – Sharon Muza, Community Manager, Science & Sensibility.

“Researchers have already cast much darkness on the subject, and if they continue their investigation, we shall soon know nothing at all.” – Mark Twain

flickr.com/photos/vestfamily/2591899412/

The latest contender in the long list of studies attempting to compare the safety of home and hospital birth, “Selected perinatal outcomes associated with planned home births in the United States,” was published last month (Cheng 2013). Let’s start by summarizing the study:

Using data compiled from the U.S. birth certificate, Cheng and colleagues compared outcomes between 12,039 women “planning” home births with 2,081,753 women having hospital births. All women were at term (between 37 and 43 weeks) and carrying one head-down baby. Women with prior cesarean were not excluded. After adjustment for numerous factors including number of prior births, medical conditions (hypertension, diabetes), risk factors (smoking), and social and demographic factors (race/ethnicity, age, marital status), women having home births were much less likely to have an instrumental vaginal delivery (0.1% vs. 6.2%; odds ratio 0.1), induced labor (1.4% vs. 25.7%; odds ratio 0.2), or labor augmentation (2.1% vs. 22.2%; odds ratio 0.3). They were also, however, twice as likely to have a baby with a 5-minute Apgar less than 4 (0.24% vs. 0.37%; odds ratio 1.9), three times as likely to have a baby experience neonatal seizure (0.06% vs. 0.02%; odds ratio 3.1), and more than twice as likely to have a baby with 5-minute Apgar less than 7 (2.42% vs. 1.17%; odds ratio 2.4). On the other hand, similar percentages of babies needed more than 6 hours of ventilator support, and babies born at home were much less likely to be admitted to intensive care (0.57% vs. 3.03%; odds ratio 0.2). In the discussion, the investigators note that removing the 489 women with previous cesareans who had planned home birth and women with medical or obstetric conditions did not alter that infants of women with prior births who planned home birth were more likely to have a low Apgar score. They don’t specify whether this was 5-minute Apgar less than 4 or less than 7 nor do they report the occurrence rate in this higher-risk subgroup.

There is more. To evaluate the effect of birth attendant qualifications, the investigators excluded births attended by doctors or unknown birth attendant and stratified the remaining home birth population into those attended by professional midwives and those attended by “other midwives.” (Confusingly, study authors state that Certified Professional Midwives [CPMs] were categorized as Certified Nurse-Midwives in the birth certificate data yet go on to refer solely to “CNMs” in the rest of the analysis.) In the subset attended by professional midwives, newborn outcomes were similar except that hospital-born infants were more likely to be admitted to intensive care (0.37% vs. 3.03%; odds ratio 0.1).

Cheng and colleagues conclude that while women planning home births are less likely to experience obstetric intervention, their babies are more likely to be born in poor condition. Do their data warrant that conclusion?

To begin with, the relevant question isn’t the tradeoffs between planned home birth per se and hospital birth. It is: “What are the excess risks for healthy women at low risk of urgent complications who plan home birth with qualified home birth attendants compared with similar women planning hospital birth?” This study can’t answer that question. Here’s why:

The study only includes women actually delivering at home, but you can’t make a meaningful comparison unless you have the outcomes of women transferred to hospital. “Planning” in this study meant only that birth at home wasn’t accidental, not the more usual meaning that birth may be planned at home but problems during labor may alter that plan. I discovered this when I wrote the lead author to request cesarean rates, which, oddly, to me, were not reported in the study. She responded that this was because cesareans aren’t performed at home. Puzzled by this explanation, I wrote back that neither are instrumental vaginal delivery, induction, nor labor augmentation, which were reported. She responded that birth certificate data don’t state how labor was induced or augmented but that perhaps at home births it was by rupturing membranes and that “apparently some midwives or birth attendants do perform vacuum extraction at home,” but it is rare since only 10 were reported.

Not all women planning home birth were low-risk. For one thing, women with prior cesareans were included. For another, the methods section states that the analysis adjusted for medical risk, and the discussion notes that women with prior children in the home birth group were more likely to have babies with low Apgar scores even after removing women with medical risk, which implies that some of them had medical problems.

Not all women in the home birth group had qualified home birth attendants. Outcome data on the overall population came from women recorded as being attended by MDs, DOs, “other midwife,” “others,” and “unknown/not stated” as well as by professional midwives.

Rates of neonatal seizure and 5-minute Apgar less than 4 were very low, and the study doesn’t report on perinatal death or permanent disability. As concerning as an excess in low Apgar scores and seizures may be, the real question is excess incidence of permanent harm. Even without limiting the population to low-risk women with qualified care providers, only 1 more baby per 1000 born at home experienced very low 5-minute Apgar, and only 4 more babies per 10,000 experienced neonatal seizure, and while babies born in poor condition are more likely to incur permanent neurologic damage or die, most will recover. Also, as we saw, differences in rates of these adverse outcomes disappeared with a qualified provider.

The proof of the pudding lies in studies free of these weaknesses. A study of 530,000 low-risk Dutch women found no difference in deaths during labor or newborn death rates between women planning, but not necessarily having, home birth and those planning hospital birth (de Jonge 2009). A Canadian study comparing outcomes of 2900 women eligible for home birth with women equally eligible but planning hospital birth reported worse newborn outcomes (more required resuscitation at birth or oxygen for more than 24 hrs and more birth injuries), worse maternal outcomes (more anal sphincter tears and postpartum hemorrhage), and more use of instrumental and cesarean delivery in the hospital population (Janssen 2009).

What can we take away from Cheng and colleagues analysis? First, care provider qualifications matter. Women desiring home birth should have access to professional midwifery care, which argues for making CPMs legal in all 50 states. Second, less than optimal candidates are birthing at home, and some women may be continuing labor at home who shouldn’t. Why might that be? Women may choose home birth because they want control over what happens to them, they have had a prior negative hospital experience, or they want to avoid unnecessary medical intervention (Boucher 2009), the last of which will include women denied hospital VBAC. Women may resist hospital transfer for the same reasons or because they know that at best, hospital transfer means losing the care and advice of the care provider they trust and at worst, they will be treated badly by disapproving hospital staff. If we want to reduce their numbers, hospital-based practitioners need to address the behaviors, practices, and policies that drive women away from hospital birth. This would have the added benefit of improving care for the 99% of American women who would never consider birthing at home.

References

Boucher, D., Bennett, C., McFarlin, B., & Freeze, R. (2009). Staying home to give birth: why women in the United States choose home birth. J Midwifery Womens Health, 54(2), 119-126. http://www.ncbi.nlm.nih.gov/pubmed/?term=boucher+2009+home+birth

Cheng, Y. W., Snowden, J. M., King, T. L., & Caughey, A. B. (2013). Selected perinatal outcomes associated with planned home births in the United States. Am J Obstet Gynecol, 209(4), 325 e321-328. doi: 10.1016/j.ajog.2013.06.022 http://www.ncbi.nlm.nih.gov/pubmed/23791564

de Jonge, A., van der Goes, B. Y., Ravelli, A. C., Amelink-Verburg, M. P., Mol, B. W., Nijhuis, J. G., . . . Buitendijk, S. E. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG 116(9), 1177-1184. http://www.ncbi.nlm.nih.gov/pubmed/?term=de+jonge+2009+planned+home

Janssen, P. A., Saxell, L., Page, L. A., Klein, M. C., Liston, R. M., & Lee, S. K. (2009). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ, 181(6-7), 377-383. http://www.ncbi.nlm.nih.gov/pubmed/19720688

 

Guest Posts, Home Birth, Maternity Care, Medical Interventions, New Research, Newborns, Research , , , , , , ,

Does the Hospital “Admission Strip” Conducted on Women in Labor Work as Hoped?

October 3rd, 2013 by avatar

The 20 minute electronic fetal monitoring strip is a “right of passage” for any woman being admitted to the hospital in labor.  But is this automatic 20 minute strip evidence based?  Regular Science & Sensibility contributor Henci Goer takes a look at a recent Cochrane systematic review and lets us know what the research says.  Do you discuss this with your students?  Do you share about this practice  in your classes and with your patients and students?  What do you tell them? Will it change after reading Henci’s review below? – Sharon Muza, Science & Sensibility Community Manager

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© http://www.flickr.com/photos/jcarter

Some weeks ago, I did a Science and Sensibility post summarizing the latest version of the Cochrane systematic review of continuous electronic fetal monitoring (EFM)—AKA cardiotocography (CTG)—in labor versus intermittent listening. A couple of commenters on that post asked if I would tackle the “admission strip,” the common practice of doing EFM for 20 minutes or so at hospital admission in labor to see whether ongoing continuous monitoring is warranted.

I was in luck because the Cochrane Library has a recent systematic review of randomized controlled trials of this practice versus intermittent listening in women at low risk for fetal hypoxia (Devane 2012). The rationale for the admission strip, as the reviewers explain, is that pregnancy risk factors don’t predict all babies who will experience morbidity or mortality in labor. The admission strip is an attempt to identify women free of risk factors whose babies nevertheless might benefit from closer monitoring. Let’s see whether the admission strip succeeds at identifying those babies and improving their outcomes.

As to whether the admission strip identifies babies believed to be in need of closer surveillance, the answer is “yes.” Pooled analysis (meta-analysis) of the trials found that 15 more women per 100 allocated to the admission strip group went on to have continuous EFM (3 trials, 10,753 women), and 3 more babies per 100 underwent fetal blood sampling (3 trials, 10,757 babies).

Furthermore, women almost certainly underwent more cesareans as well (4 trials, 11,338 women). All four trials reported more cesareans in the admission strip group. The pooled increased risk of 20% just missed achieving statistical significance, but this is probably because cesarean rates were so low, only 3 to 4% in by far the biggest trial, which contributed 8056 participants. Because of the lack of heterogeneity among trials, the reviewers think the difference is likely to be real. If it is, then using an admission strip in low-risk women results in 1 additional cesarean for every 136 women monitored continuously (number needed to harm). I would add that not separating out first-time mothers, who are at greater risk for cesarean delivery, probably masked a bigger effect in this subgroup. How big an effect might this be?  Let’s assume a 9% cesarean rate in low-risk first-time mothers, that being the rate found  in first-time mothers still eligible for home birth at labor onset in the Birthplace in England study (2011). At this cesarean rate, a 20% increase over baseline would calculate to 1 additional cesarean for every 55 first-time mothers monitored continuously.

The crucial question, though, is whether increased monitoring and surgical deliveries produced better perinatal outcomes. To that, the answer is “no.” Combined fetal and neonatal death rates in infants free of congenital anomalies were identical at 1 per 1000 in both groups (4 trials, 11,339 babies). The reviewers acknowledge that their meta-analysis of over 11,000 babies is still “underpowered,” i.e., too small to detect a difference in outcomes. However, they continue, the event is so rare in low-risk women that no trial or meta-analysis would likely be big enough to do so. Additionally, no differences were found for cases of hypoxic ischemic encephalopathy (1 trial, 2367 babies), admissions to neonatal intensive care (4 trials, 11,331 babies), neonatal seizure (1 trial, 8056 babies), evidence of multi-organ compromise within the first 24 hours (1 trial, 8056 babies), or even 5-minute Apgar scores less than 7 (4 trials, 11,324 babies).

The reviewers therefore conclude:

We found no evidence of benefit for the use of the admission CTG for low-risk women on admission in labour. Furthermore, the probability is that admission CTG increases the caesarean section rate by approximately 20%. . . . The findings of this review support recommendations that the admission CTG not be used for women who are low risk on admission in labour. Women should be informed that admission CTG is likely associated with an increase in the incidence of caesarean section without evidence of benefit (Devane 2012, p. 2). [Emphasis mine.]

Conclusion

According to the best evidence, the admission strip isn’t just ineffective, it’s harmful, and its use should be abandoned

References

Birthplace in England Collaborative Group. (2011). Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ, 343, d7400.  http://www.ncbi.nlm.nih.gov/pubmed/22117057?dopt=Citation

Devane, D., Lalor, J. G., Daly, S., McGuire, W., & Smith, V. (2012). Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing. Cochrane Database Syst Rev, 2, CD005122. doi: 10.1002/14651858.CD005122.pub4 http://www.ncbi.nlm.nih.gov/pubmed/22336808

Childbirth Education, Do No Harm, Evidence Based Medicine, Fetal Monitoring, Guest Posts, Maternity Care, Medical Interventions, Metaanalyses, New Research, Research, Uncategorized , , , , , , , ,

Continuous Electronic Fetal Monitoring (Cardiotocography) in Labor: Should It Be Routine?

September 3rd, 2013 by avatar

Regular Science & Sensibility contributor and author Henci Goer takes a look at the recent Cochrane review “Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour” to determine if the researchers found any new information on the benefits or risks of CTG for normal, low risk labors.  Read on to see if things might have changed and are the hospitals in your area conforming with recommendations of ACOG, SCOG and RCOG?  Are these recommendations based on the evidence?  - Sharon Muza, Community Manager, Science & Sensibility

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http://flic.kr/p/o43Lw

Almost all women laboring in U.S. hospitals undergo continuous electronic fetal monitoring (EFM) (Declercq 2006), but should they? A new iteration of the Cochrane systematic review of randomized controlled trials of EFM versus intermittent auscultation (listening) can answer that question (Alfirevic 2013).

The rationale behind continuous EFM was that insufficient oxygen (hypoxia) in labor was a major cause of intrapartum fetal death and permanent brain injury. It was thought that enhanced ability to pick up changes in fetal heart rate (FHR) patterns signaling distress would enable doctors to rescue the fetus in time to prevent perinatal death and cerebral palsy. Does that theory hold up in practice?

According to the Cochrane review, not so much—nor, I might add, is this news since all prior versions have reported the same results. Continuous EFM fails to decrease perinatal mortality, whether in women overall (11 trials, 33,513 participants) or in the subgroups of high-risk women (5 trials, 1974 participants), mixed-risk/risk not specified populations (3 trials, 15,490 participants), or low-risk women (3 trials, 16,049 participants). Neither does it reduce incidence of cerebral palsy whether in women overall (2 trials, 13,252 women) or in high-risk women (1 trial, 173 participants) or in a mixed-risk/risk not specified population (1 trial, 13,079). (No trial reported comparative cerebral palsy rates in low-risk women.) In fact, cerebral palsy rates were increased more than two-fold (risk ratio: 2.54) in the EFM group in the sole high-risk trial reporting this outcome, although with only 173 women and one trial, it is unclear what, if anything, should be made of this. The authors, noting that the delay between diagnosis and taking action was longer in the EFM group, speculated that EFM may have been providing a false sense of feeling in control of the situation (Shy 1990). So it turns out more information isn’t necessarily better information.

Continuous EFM isn’t a total washout. It reduces the incidence of neonatal seizure, which is of some benefit since neonatal seizure can indicate permanent brain injury, the likelihood of which depends on the severity of seizure and whether it is accompanied by other symptoms. Among women overall (9 trials, 32,386 participants), it halved seizure rates (risk ratio: 0.50). In high-risk populations (5 trials, 4805 participants), it reduced seizure rates (risk ratio: 0.67), but the difference failed to achieve statistical significance while in low-risk populations (3 trials, 25,175 participants), the reduction was by nearly two-thirds (risk ratio: 0.36), and in mixed-risk/risk not specified populations (2 trials, 2406 participants), the reduction approached 80% (risk ratio: 0.18). The reviewers calculate that with a baseline seizure risk of 3.0 per 1000 labors among women overall in the intermittent auscultation group, 667 women  would have to have continuous EFM in order to prevent 1 neonatal seizure. In low-risk women, in whom the baseline risk was 1.2 per 1000 labors with intermittent auscultation, my calculation raised that to 833 women.

Although continuous EFM fails in achieving its original goal of preventing perinatal death and cerebral palsy, the reduction in incidence of neonatal seizure would seem to argue for universal continuous EFM, were it not that this benefit comes at a price: continuous EFM increases the likelihood of cesarean surgery, and to a lesser degree, instrumental vaginal delivery, which increased among women overall by 15% (risk ratio: 1.15). Among women overall (11 trials, 18,861 participants), continuous EFM increased likelihood of cesarean by nearly two-thirds (risk ratio: 1.63); among high-risk women (6 trials, 2069 women), it doubled the risk (risk ratio: 1.91); it did the same (risk ratio: 2.06) among low-risk women (2 trials, 1431 participants) while among mixed-risk/risk not specified populations (3 trials, 15,361 participants), the rate was increased (risk ratio: 1.14), but the difference wasn’t statistically significant. The reviewers calculate that assuming a 15% cesarean rate with intermittent auscultation, one additional cesarean would be performed for every 11 women monitored, and 61 additional cesareans would be performed to prevent 1 seizure. In low-risk women, my calculation found that 1 additional cesarean would be performed for every 6 women monitored, and 76 additional cesareans would be performed to prevent 1 seizure.

The Cochrane reviewers conclude that women should be informed that EFM neither reduces perinatal mortality nor cerebral palsy and that while it reduces incidence of neonatal seizures, it does so at the cost of increased cesarean and instrumental vaginal deliveries. Cesarean and instrumental deliveries, I hardly need point out, have their own associated harms, some of them quite serious, and these must be set against the reduction in seizures (Childbirth Connection 2012; Goer 2012). The reviewers write:

Given the perceived conflict between the risk for the mother . . . and benefit for the baby . . . , it is difficult to make quality judgments as to which effect is more important. . . . The real challenge is how best to convey this uncertainty to women and help them to make an informed choice without compromising the normality of labour.

That gives us our marching orders, but how best might we carry them out? One reasonable course would be to see what obstetric guidelines advise.

http://flic.kr/p/98pfNc

The least decisive recommendation comes from the American Congress of Obstetricians and Gynecologists (2009), whose guidelines state: “Given that the available data do not show a clear benefit for the use of EFM over intermittent auscultation, either option is acceptable in a patient without complications” (p. 196). This suggests equivalency between the two, but, of course, they aren’t equivalent because continuous EFM increases likelihood of cesarean and instrumental vaginal delivery. ACOG further recommends that “the labor of women with high-risk conditions (eg, suspected fetal growth restriction, preeclampsia, and type 1 diabetes) should be monitored with continuous FHR monitoring” (p. 196), although they later acknowledge that this recommendation is based on “Level C” evidence, “expert opinion.”

The U.K. Royal College of Obstetricians and Gynaecologists takes a stronger stance: “Intermittent auscultation of the FHR is recommended for low-risk women in established labour in any birth setting” (p.155) (National Collaborating Center for Women’s and Children’s Health 2007). The Royal College advises switching to continuous EFM in low-risk women for these reasons:

  • significant meconium, with consideration for making the switch with light meconium
  • abnormal FHR is detected by intermittent auscultation
  • maternal fever
  • fresh bleeding developing in labor
  • oxytocin use for augmentation [I would assume this would also cover oxytocin induction.]
  • the woman’s request

The Canadian Society of Obstetricians and Gynaecologists provides the most detailed advice of all (Liston 2007). SOGC guidelines state: “Intermittent auscultation . . . is the recommended method of fetal surveillance [in healthy term women in spontaneous term labor who are free of risk factors for adverse perinatal outcome]” (p. S6). In women with risk factors for adverse perinatal outcome, the SOGC, like ACOG, recommends continuous EFM while acknowledging that “little scientific evidence” (p. S33) supports it. However, SOGC guidelines additionally state: “When a normal tracing is identified, it may be appropriate to interrupt the electronic fetal monitoring tracing for up to 30 minutes to facilitate periods of ambulation, bathing, or position change, providing that (1) the maternal-fetal condition is stable and (2) if oxytocin is being administered, the infusion rate is not increased” (p. S6).

The consistent recommendation that intermittent auscultation is preferable (in the case of RCOG and SOGC), or at least acceptable (in the case of ACOG), in low-risk women in spontaneous labor answers the question posed in the title. No, continuous EFM should not be routine, and we are on solid ground sharing this information and its sources with pregnant women.

Unfortunately, this doesn’t help most low-risk women laboring in U.S. hospitals because they will have either an epidural, be receiving oxytocin, or both. The SOGC guidelines can serve us here. With epidural analgesia, the guidelines state: “Intermittent auscultation may be used to monitor the fetus when epidural analgesia is used during labour, provided that a protocol is in place for frequent intermittent auscultation assessment (e.g., every 5 minutes for 30 minutes after epidural initiation and after bolus top-ups as long as maternal vital signs are normal)” (p. S6), and the SOGC guidelines treat induction and augmentation the same as women with risk factors, that is, with continuous EFM but permitting breaks if mother, baby, and oxytocin dose are stable. Suggesting that women in these categories request that their caregivers follow SOGC guidelines seems a pragmatic approach to achieving any benefits continuous EFM may provide while potentially reducing harms.

I could end here, but I can’t help asking: Why stop with search and rescue of hypoxic babies? Why not look at prevention? Among the 10,053 low-risk women at the Dublin Maternity Hospital, the neonatal seizure rates were 10 times (14 per 10,000 continuous EFM vs. 38 per 10,000 intermittent auscultation) those in the 14,618 women in the Dallas trial (1 per 10,000 continuous EFM vs. 4 per 10,000 intermittent auscultation) (Alfirevic 2013). I doubt that it’s coincidental that the Dublin Maternity Hospital is the home of Active Management of Labor, which prescribes routine early rupture of membranes and high doses of oxytocin with a short interval between dose increases for any woman not progressing at a minimum 1 cm dilation per hour. Early rupture of membranes, induction, and high-dose/short interval oxytocin regimens all increase stress on the fetus (Goer 2012). I think educators and doulas have a role to play here too. We can point women to Lamaze’s Healthy Birth Practices #1 and #4 to help them start a conversation with their care providers about labor induction and artificial rupture of membranes. And while women aren’t in a position to dictate oxytocin regimen, nurses and other hospital insiders can lobby for uniformly instituting the more physiologic oxytocin protocol found in Pitocin packaging if their hospital doesn’t mandate it already. An ounce of prevention is worth a pound of cure not the least because prevention has no adverse effects.

References

ACOG. (2009). Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. ACOG Practice Bulletin No. 106. http://www.ncbi.nlm.nih.gov/pubmed/19546798

Alfirevic, Z., Devane, D., & Gyte, G. M. (2013). Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev, 5, CD006066. doi: 10.1002/14651858.CD006066.pub2 http://www.ncbi.nlm.nih.gov/pubmed/23728657

Childbirth Connection. (2012). Vaginal or Cesarean Birth: What Is at Stake for Women and Babies? New York. http://transform.childbirthconnection.org/reports/cesarean/

Declercq, E., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to Mothers II:  Report of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection. http://childbirthconnection.org/pdfs/LTMII_report.pdf

Goer, H., & Romano, Amy. (2012). Optimal Care in Childbirth: The Case for a Physiologic Approach. Seattle: Classic Day Publishing.

Liston, R., Sawchuck, D., & Young, D. (2007). Fetal health surveillance: antepartum and intrapartum consensus guideline. J Obstet Gynaecol Can, 29(9 Suppl 4), S3-56. http://www.sogc.org/guidelines/documents/gui197CPG0709r.pdf

National Collaborating Centre for Women’s and Children’s Health. (2007). Intrapartum care. Care of healthy women and their babies during childbirth. London: NICE. http://www.nice.org.uk/nicemedia/live/11837/36275/36275.pdf

Shy, K. K., Luthy, D. A., Bennett, F. C., Whitfield, M., Larson, E. B., van Belle, G., . . . Stenchever, M. A. (1990). Effects of electronic fetal-heart-rate monitoring, as compared with periodic auscultation, on the neurologic development of premature infants. N Engl J Med, 322(9), 588-593. http://www.ncbi.nlm.nih.gov/pubmed/2406602?dopt=Citation

 

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Do Cesareans Cause Endometriosis? The Data Accumulate

July 30th, 2013 by avatar

 Today on Science & Sensibility, regular contributor Henci Goer takes a look at a new retrospective study looking at the potential relationship between cesarean birth and endometriosis development in the mother in the years after her surgery.  Did you know that research indicates an increase in endometriosis for those women who have undergone a cesarean delivery?  Henci shares this new study and asks us to continue to look further. – Sharon Muza, Community Manager, Science & Sensibility.

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© Patti Ramos Photography

My very first post in Science & Sensibility back in 2009 was a round-up of case studies and series reporting on the formation of endometriosis—also called “endometrioma” because the cells formed a solid mass—in the cesarean wound. I commented that case studies could serve to draw attention to possible serious complications worthy of further investigation and ended the post with the hope that researchers would take a closer look at this one. Now I have run across a study that does exactly that.  I wanted to share it with you today.

Swedish investigators, Andolf, Thorsell, and Kallen (2010), used a national in-patient data registry linked to a birth registry to identify all women giving birth to their first child between 1986 and 2004. After excluding women who had a diagnosis of endometriosis before their first birth, 709,090 women remained, of whom 3110 were diagnosed with endometriosis and treated in hospitals after their first birth. Investigators tracked women from the date they gave birth to their first child to either the date of the first diagnosis of endometriosis, the date of their 55th birthday, or December 31, 2004, the date on which investigators retrieved the dataset, whichever came first.

Investigators looked both at cesarean-scar endometrioma and general pelvic endometriosis. They postulated that since endometriosis results from uterine lining cells taking hold and growing outside of the uterus, cesarean surgery could disperse these cells throughout the pelvis, not just seed them into the uterine wound.

After accounting for factors that were associated both with endometriosis and cesarean delivery (maternal age at first delivery; BMI; smoking; and years of involuntary childlessness before first delivery), none of which had any appreciable effect, they found that having at least one cesarean nearly doubled the risk of developing endometriosis (hazard ratio: 1.8). This calculated to 1 additional case of endometriosis within 10 years for every 325 women undergoing cesarean surgery. Having multiple cesareans didn’t appear to further increase the risk. Both women with only vaginal births and women with cesareans had new diagnoses of endometriosis, but a graph of the cumulative incidence rates showed that the line angled upward much more steeply as time passed in women with cesareans compared with women with only vaginal births.

The incidence rate of cesarean-scar endometrioma specifically was 1 per 1000 among women having cesareans. This may be considered a minimum since the data registry would not capture women who had cesarean-scar endometrioma but who either never received the correct diagnosis or were never admitted to a hospital for treatment.

The Swedish analysis has added to our knowledge of the relationship between cesarean surgery and endometriosis. It gave us an incidence rate for cesarean-scar endometrioma and showed that cesarean surgery also is associated with increased likelihood of developing generalized pelvic endometriosis of sufficient severity to require in-hospital treatment.  Preventing that primary cesarean can play a critical role in reducing the number of women who will deal with the pain, complications and need for treatment of endometriosis that resulted from their cesarean surgery.  When considering cesarean surgery, women should be told of the excess risk of developing generalized pelvic endometriosis and cesarean-scar endometrioma and their consequent complications (pain, irregular bleeding, infertility) as part of the informed decision-making process.

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Did you know that an increase in endometriosis rates is a possible consequence of cesarean section? Are the women you are teaching and  working with aware of this potential development and what it might mean?  Do you consider this something that you would share in your role as Doula? Childbirth Educator? Midwife? OB?  Let us know in the comments. – SM

References

Andolf, E., Thorsell, M., & Kallen, K. (2010). Cesarean delivery and risk for postoperative adhesions and intestinal obstruction: a nested case-control study of the Swedish Medical Birth Registry. American Journal of Obstetrics & Gynecology, 203(4), 406 e401-406.

 

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