Evidence-based labor management: first stage of labor (part 3)

Evidence-based cesarean delivery: preoperative management (part 7)

Preoperative preparation for cesarean delivery is a multistep approach for which protocols should exist at each hospital system. These protocols should be guided by the findings of this review. The interventions reviewed and recommendations made for this review have a common goal of decreasing maternal and neonatal morbidity and mortality related to cesarean delivery. The preoperative period starts before the patient's arrival to the hospital and ends immediately before skin incision. The Centers for Disease Control and Prevention recommends showering with either soap or an antiseptic solution at least the night before a procedure. Skin cleansing in addition to this has not been shown to further decrease rates of infection. Hair removal at the cesarean skin incision site is not necessary, but if preferred by the surgical team then clipping or depilatory creams should be used rather than shaving. Preoperative enema is not recommended. A clear liquid diet may be ingested up to 2 hours before and a light meal up to 6 hours before cesarean delivery. Consider giving a preoperative carbohydrate drink to nondiabetic patients up to 2 hours before planned cesarean delivery. Weight-based intravenous cefazolin is recommended 60 minutes before skin incision: 1-2 g intravenous for patients without obesity and 2 g for patients with obesity or weight ≥80 kg. Adjunctive azithromycin 500 mg intravenous is recommended for patients with labor or rupture of membranes. Preoperative gabapentin can be considered as a way to decrease pain scores with movement in the postoperative period. Tranexamic acid (1 g in 10-20 mL of saline or 10 mg/kg intravenous) is recommended prophylactically for patients at high risk of postpartum hemorrhage and can be considered in all patients. Routine use of mechanical venous thromboembolism prophylaxis is recommended preoperatively and is to be continued until the patient is ambulatory. Music and active warming of the patient, and adequate operating room temperature improves outcomes for the patient and neonate, respectively. Noise levels should allow clear communication between teams; however, a specific decibel level has not been defined in the data. Patient positioning with left lateral tilt decreases hypotensive episodes compared with right lateral tilt, which is not recommended. Manual displacers result in fewer hypotensive episodes than left lateral tilt. Both vaginal and skin preparation should be performed with either chlorhexidine (preferred) or povidone iodine. Placement of an indwelling urinary catheter is not necessary. Nonadhesive drapes are recommended. Cell salvage, although effective for high-risk patients, is not recommended for routine use. Maternal supplemental oxygen does not improve outcomes. A surgical safety checklist (including a timeout) is recommended for all cesarean deliveries.

Evidence-based labor management: postpartum care after vaginal delivery (part 6)

In the setting of postpartum care after vaginal delivery, rooming-in is associated with a higher rate of exclusive breastfeeding rate at hospital discharge, but there is insufficient evidence to support or refute rooming-in to increase breastfeeding at 6 months. Education and support for breastfeeding are valuable interventions to promote initiation of breastfeeding whether it is offered by a healthcare professional, nonhealthcare professional, or peer. A combined intervention, a professional provider-led intervention, having a protocol available for the provider training program, and implementation during both the prenatal and postnatal periods increased the rate of exclusive breastfeeding for 6 months. There is no single effective treatment for breast engorgement. Breast massage, continuing breastfeeding, and pain relief are recommended by national guidelines. Nonsteroidal anti-inflammatory drugs and acetaminophen are better than placebo for relief of pain caused by uterine cramping and perineal trauma; acetaminophen is effective in breastfeeding individuals who underwent episiotomy; and local cooling pain relievers have been shown to reduce perineal pain for 24 to 72 hours, compared with no treatment. There is insufficient evidence to assess the safety and efficacy of postpartum routine universal thromboprophylaxis after vaginal delivery. Anti-D immune globulin administration is recommended in Rhesus-negative individuals who have given birth to a Rhesus-positive infant. There is very low-quality evidence that a universal complete blood count is useful in reducing the risk of receiving blood products. In the absence of any postpartum complication, there is insufficient evidence to recommend a routine postpartum ultrasound. Measles, mumps, and rubella combination; varicella; human papillomavirus; and tetanus, diphtheria, and pertussis vaccines should be administered in nonimmune individuals in the postpartum period. Smallpox and yellow fever vaccines should be avoided. Individuals undergoing postplacental placement are more likely to use an intrauterine device at 6 months than those advised to follow-up for placement during outpatient postpartum care. An implant is safe and effective for immediate postpartum contraception. There is insufficient evidence to support or refute the routine administration of micronutrient supplements in breastfeeding women. Placentophagia does not provide any benefits and exposes mothers and offspring to infectious risks. Therefore, it should be discouraged. Because of the low level of evidence, there is insufficient data to assess the efficacy of home visits in the postpartum period. There is insufficient evidence to recommend when to resume daily activities, and individuals should be counseled to return to prepregnancy level of activity or exercise when comfortable. Sexual activity, housework exercise, driving, climbing stairs, and lifting weights should be resumed as soon as postpartum individuals want. A behavioral educational intervention reduces depression symptoms and increases breastfeeding duration. Physical activity after delivery is protective against postpartum mood disorders. There is no strong evidence that supports early discharge after vaginal delivery compared with standard discharge (ie, ≥48 hours).

Changes in Salivary Oxytocin Level of Term Pregnant Women after Aromatherapy Footbath for Spontaneous Labor Onset: A Non-Randomized Experimental Study

BACKGROUND

Aromatherapy is usually used to stimulate labor. However, its specific physiological effects have been scarcely examined. We evaluated whether an aromatherapy footbath increases oxytocin levels in term pregnant women.

METHODS

In this quasi-experimental study, low-risk term pregnant women in Japan underwent aromatherapy using a footbath (1) infused with clary sage and lavender essential oils, (2) infused with jasmine oil, or (3) with no infused oils (control group). The primary outcome was the salivary oxytocin level. The secondary outcomes were uterine contractions and cortisol levels.

RESULTS

In the clary sage and lavender group (n = 28), the oxytocin level increased significantly after the footbath (p = 0.035). The jasmine group (n = 27) and control group (n = 27) exhibited trends toward a respective increase and decrease in the oxytocin level; however, the changes in the oxytocin levels between the clary sage and lavender group and the control group showed no significance difference. There were no significant differences in the changes in the uterine contractions and cortisol levels between the experiment and control groups.

CONCLUSIONS

The changes in the oxytocin levels in the clary sage and lavender group did not differ significantly with those in the control group, possibly because of the small sample size. Further studies are required to examine the effects of repeated aromatherapy footbaths to stimulate labor.

The Effect of Using Endorphin Massage for Decreasing Pain at First Stage in Normal Labor

Labor pain is a subjective experience of physical sensations associated with uterine contractions, dilation, thinning cervix and fetal descent during labor. To resolve the pain of labor, it has been implemented in a nonpharmacological method which is endorphin massage, in understanding endorphin massage for pressing pain in the first stage, in an active phase of normal multiparous mothers' deliveries. This research aims to research endorphin massage's influence on suppressing pain during the active phase of normal labor of multiparous mothers. This study is quasi-experimental with a cross-sectional approach. The study population of all women giving birth administered the purposive sampling data capture techniques, and it was obtained 132 multiparous mothers with normal labor in the observation sheet. Data were examined by administering a T-test. The majority of the pain intensity in the first stage of active phase multiparous mothers with normal labor, before the breath relaxation, is severe, with up to 49% experiencing severe pain. The majority of the percentage of moderate pain in the first stage of active phase multiparous mothers with normal labor, after breath relaxation, is as high as 42%. Meanwhile, the pain intensity of the first stage in active phase multiparous mothers with normal labor, prior to endorphin massage, is as high as 73.3%. Pain intensity of the first stage in active phase multiparous mothers normal labor after endorphin massage, the majority of the percentage is moderate pain up to 53.3%. Statistical test results obtained p-value is 0.004 endorphin massage. In conclusion, there is an effect of breath relaxation on the intensity of pain during normal labor in multiparous mothers. Furthermore, researchers can do a combination of endorpine massage with other treatments to treat pain during the I active phase of labor and pain intensity checks can be done by testing cortisol levels.

Quality of perinatal care for women with high-risk pregnancies during the COVID-19 pandemic in Iran

Background

COVID-19 has had a catastrophic effect on the healthcare system. Healthcare quality assessment measures the difference between expected and actual performances to identify gaps in the healthcare system. This study aimed to evaluate the quality of perinatal care for women with high-risk pregnancies (HPR) during the COVID-19 pandemic.

Materials and Methods

This cross-sectional study enrolled 450 women with HPR from health centers in Ahvaz, Iran, from December 2020 to May 2021, using a multi-stage sampling method. Quality of care was assessed using an observational checklist adapted from Ministry of Health guidelines. Data were analyzed using descriptive and statistical methods.

Results

The quality of the assessed aspect in comprehensive health centers and in peripartum, perinatal, and postpartum wards was moderate. The overall score for peripartum care was significantly positively correlated with the length of the retraining period, and the quality of perinatal care was significantly related to the proportion of elective cesarean sections and preterm delivery.

Conclusion

The development of care practices in health centers in Iran should focus on education and counseling. Practices in peripartum wards should emphasize the use of partographs, physical/mental support, and privacy for mothers, while perinatal wards should focus on timely counseling.

Evidence-based labor management: third stage of labor (part 5)

During the third stage of labor, oxytocin and tranexamic acid, oxytocin and misoprostol, oxytocin and methylergometrine, or carbetocin is recommended for the prevention of postpartum hemorrhage after vaginal delivery. Intravenous oxytocin (10 IU) immediately after delivery of the neonate (after either anterior shoulder or whole-body delivery) and before delivery of the placenta is recommended. If oxytocin and tranexamic acid combination is chosen, intravenous tranexamic acid (1 g) in addition to intravenous oxytocin (10 IU) immediately after delivery of the neonate and before placental delivery is recommended. If oxytocin and misoprostol combination is chosen, sublingual misoprostol (400 µg) in addition to intravenous oxytocin (10 IU) immediately after delivery of the neonate is recommended. If there is no intravenous access or if in low-resource settings, sublingual misoprostol (400 µg) and intramuscular oxytocin (10 IU) are recommended. If oxytocin and methylergometrine combination is chosen, intramuscular methylergometrine (0.2 mg) and intravenous oxytocin (10 IU) immediately after delivery of the neonate are recommended. Single-dose intravenous or intramuscular carbetocin (100 µg) immediately after delivery of the neonate is recommended. Controlled cord traction and delayed cord clamping for approximately 60 seconds is recommended. There is insufficient evidence to support or refute umbilical cord milking, uterine massage, or nipple stimulation for the prevention of postpartum hemorrhage. Repair of first- and second-degree lacerations with continuous synthetic suture technique is recommended. No repair of first-degree lacerations if hemostatic and normal cosmesis can be considered. Repair of third-degree lacerations with end-to-end or overlap continuous synthetic suture technique is recommended. Repair of fourth-degree lacerations with delayed absorbable 4-0 or 3-0 polyglactin or chromic suture in a running fashion is recommended. The use of single-dose second-generation cephalosporin at the time of third- or fourth-degree laceration repairs can be considered. Skin-to-skin contact after delivery is recommended. There is insufficient evidence to support or refute routine cord blood gas sampling after delivery. Public cord blood banking is recommended.

Induction within or after 12 hours of ≥36 weeks' prelabor rupture of membranes: a systematic review and meta-analysis

OBJECTIVE

This study aimed to evaluate the incidence of chorioamnionitis in women with singleton gestations with ≥36 weeks' prelabor rupture of membranes induced with oxytocin within or after 12 hours of prelabor rupture of membranes.

DATA SOURCES

The search was conducted using MEDLINE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID, and Cochrane Library as electronic databases from their inception to May 2020.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials of women with singleton cephalic gestations and prelabor rupture of membranes at ≥36 weeks comparing induction of labor with oxytocin either ≤12 hours after prelabor rupture of membranes or >12 hours after prelabor rupture of membranes (expectant management group).

STUDY APPRAISAL AND SYNTHESIS METHODS

The risk of bias in each included study was assessed using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. All analyses were done using an intention-to-treat approach, evaluating women according to the treatment group to which they were randomly allocated in the original trials. The primary outcome was the incidence of chorioamnionitis.

RESULTS

After exclusions, 9 randomized controlled trials including 3759 women were analyzed. Women with singleton cephalic gestations and prelabor rupture of membranes at ≥36 weeks who have induction of labor ≤12 hours after prelabor rupture of membranes have shorter time between prelabor rupture of membranes and delivery (-12.68 hours; 95% confidence interval, -16.15 to -9.21) and higher chance of delivering within 24 hours of prelabor rupture of membranes (91% vs 46%; relative risk, 1.93; 95% confidence interval, 1.59-2.35). Cesarean and operative vaginal deliveries were not significantly different between the groups. Induction of labor ≤12 hours after prelabor rupture of membranes was also associated with significantly fewer incidences of chorioamnionitis (5.3% vs 9.9%; relative risk, 0.62; 95% confidence interval, 0.40-0.97), endometritis (2.4% vs 4.2%; relative risk, 0.59; 95% confidence interval, 0.40-0.87), neonatal sepsis (6.1% vs 11.8%; relative risk, 0.46; 95% confidence interval, 0.27-0.79), and admission to neonatal intensive care unit (6.4% vs 12.0%; relative risk, 0.54; 95% confidence interval, 0.43-0.69) compared with women managed expectantly, usually at >24 hours. The subgroup analysis of 3323 women with induction of labor at ≤6 hours showed similar results, including similar significant reductions in chorioamnionitis, endometritis, neonatal sepsis, and admission to neonatal intensive care unit.

CONCLUSION

Women with symptoms of prelabor rupture of membranes at ≥36 weeks should be evaluated promptly, and if prelabor rupture of membranes is confirmed, they should have induction of labor within 12 hours and perhaps even within 6 hours since the first symptom of prelabor rupture of membranes. This management is associated with significantly less morbidity, especially in terms of infections, for both the mother and the baby, with no evidence of any harm.

Counseling in maternal-fetal medicine: SARS-CoV-2 infection in pregnancy

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a zoonotic coronavirus that crossed species to infect humans, causing coronavirus disease 2019 (COVID-19). Despite a potentially higher risk of pregnant women acquiring SARS-CoV-2 infection compared with the non-pregnant population (particularly in some ethnic minorities), no additional specific recommendations to avoid exposure are needed in pregnancy. The most common clinical symptoms and laboratory signs of SARS-CoV-2 infection in pregnancy are fever, cough, lymphopenia and elevated C-reactive protein levels. Pregnancy is associated with a higher risk of severe SARS-CoV-2 infection compared with the non-pregnant population, including pneumonia, admission to the intensive care unit and death, even after adjusting for potential risk factors for severe outcomes. The risk of miscarriage does not appear to be increased in women with SARS-CoV-2 infection. Evidence with regards to preterm birth and perinatal mortality is conflicting, but these risks are generally higher only in symptomatic, hospitalized women. The risk of vertical transmission, defined as the transmission of SARS-CoV-2 from the mother to the fetus or the newborn, is generally low. Fetal invasive procedures are considered to be generally safe in pregnant women with SARS-CoV-2 infection, although the evidence is still limited. In pregnant women with COVID-19, use of steroids should not be avoided if clinically indicated; the preferred regimen is a 2-day course of dexamethasone followed by an 8-day course of methylprednisolone. Non-steroidal anti-inflammatory drugs may be used if there are no contraindications. Hospitalized pregnant women with severe COVID-19 should undergo thromboprophylaxis throughout the duration of hospitalization and at least until discharge, preferably with low molecular weight heparin. Hospitalized women who have recovered from a period of serious or critical illness with COVID-19 should be offered a fetal growth scan about 14 days after recovery from their illness. In asymptomatic or mildly symptomatic women who have tested positive for SARS-CoV-2 infection at full term (i.e. ≥ 39 weeks of gestation), induction of labor might be reasonable. To date, there is no clear consensus on the optimal timing of delivery for critically ill women. In women with no or few symptoms, management of labor should follow routine evidence-based guidelines. Regardless of COVID-19 status, mothers and their infants should remain together and breastfeeding, skin-to-skin contact, kangaroo mother care and rooming-in throughout the day and night should be practiced, while applying necessary infection prevention and control measures. Many pregnant women have already undergone vaccination, mostly in the USA where the first reports show no significant difference in pregnancy outcomes in pregnant women receiving SARS-CoV-2 vaccination during pregnancy compared with the background risk. Vaccine-generated antibodies were present in the umbilical cord blood and breast milk samples of pregnant and lactating women who received the mRNA COVID-19 vaccine. Based on the available limited data on the safety of the COVID-19 vaccine in pregnancy, it seems reasonable to offer the option of vaccination to pregnant women after accurate counseling on the potential risk of a severe course of the disease and the unknown risk of fetal exposure to the vaccine. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Novel device vs manual examinations for the measurement of cervical dilation in labor: a randomized controlled trial

BACKGROUND

Cervical dilation and changes in cervical dilation inform the management of labor, including decisions to admit a patient to the hospital, augment labor, or perform a cesarean delivery. Practitioners routinely measure cervical dilation subjectively using 2 fingers on manual examination; however, agreement of ≤1 cm between 2 observers has been reported as 60% to 91% previously in laboring women.

OBJECTIVE

To evaluate the agreement among different providers' examinations using DilaCheck (interexaminer agreement) compared with interexaminer agreement between 2 manual examinations for cervical dilation of women in labor.

STUDY DESIGN

Women admitted in labor to a labor and delivery service were randomized to receive 2 cervical examinations from trained providers, using either a novel device (DilaCheck) or the standard manual examination. This randomized controlled trial compares a novel device with the standard method of manual examination for the measurement of cervical dilation. The novel device consisted of a string measuring tape suspended between 2 soft plastic rings worn on the index and middle fingertips. Interobserver agreement, defined as the agreement (exact, ≤1 cm [primary outcome], or ≤2 cm) in the numeric cervical dilation measurement obtained by 2 different examiners, was compared between the 2 groups.

RESULTS

A total of 42 women in labor were randomized, 21 to the novel device and 21 to the standard manual examination groups. The 2 device examinations agreed in 19% of cases, whereas manual examinations agreed exactly in 42.9% of cases (P=.10). Interobserver agreement of ≤1 cm was 61.9% vs 95.2%, respectively (P=.008). Interobserver agreement of ≤2 cm was 90.5% vs 100%, respectively (P=.15). Most interobserver disagreement was seen at 5 to 7 cm of cervical dilation.

CONCLUSION

A novel device, DilaCheck, intended for a more objective cervical assessment of women in labor did not improve interobserver agreement; in fact, it decreased it. Standard cervical dilation examinations result in poor interexaminer exact agreement, usually at best 50% or less. Clinical management should be based on clinical differences of >1 cm because, in general, 90% of cervical examinations will agree within 1 cm of each other. Given the importance of dilation measurements in the management of labor, continued innovation in this field would benefit women in labor and the providers caring for them; however, the puzzle remains unsolved.