Increased intravenous hydration of nulliparas in labor

Intravenous fluid rate of 250 mL/h versus 125 mL/h in nulliparous women: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Evidence regarding the type and rate of intravenous (IV) fluid administration during labor is still inconclusive and the studies assessing the impact of IV fluids had mixed results.

OBJECTIVES

To evaluate the effects of IV fluids at an infusion rate of 250 mL/h as compared with 125 mL/h on labor outcomes in nulliparous women.

SEARCH STRATEGY

We searched six databases for relevant studies through a search strategy containing the relevant keywords "IV hydration", "IV fluids", and "labor" from the inception of these databases to May 1, 2023, without any applied restrictions.

SELECTION CRITERIA

Search results were imported to Covidence for screening of eligible articles for this review. Randomized controlled trials (RCTs) assessing the impact of IV fluids at 250 mL/h on the outcomes of labor in nulliparous women at term (>37 weeks) as compared with 125 mL/h were included only.

DATA COLLECTION AND ANALYSIS

Data regarding the characteristics of included studies, participant's baseline characteristics, and concerned outcomes were collected in an Excel spreadsheet and all the concerned outcomes were pooled as risk ratios (RR) or mean difference (MD) with 95% confidence interval (CI) in the meta-analysis models using RevMan 5.4.

MAIN RESULTS

Pooled data from 11 RCTs with 1815 patients showed that 250 mL/h infusion rate had a significant reduction in cesarean section rate (RR 0.70, 95% CI 0.56-0.88, P = 0.002), the first stage of labor duration (MD -46.97, 95% CI -81.79 to -12.14, P = 0.008), the second stage of labor duration (MD -2.69, 95% CI -4.34 to -1.05, P = 0.001), prolonged labor incidence (RR 0.72, 95% CI 0.58-0.89, P = 0.003), as compared with 125 mL/h. Also, the vaginal delivery rate (RR 1.07, 95% CI 1.02-1.12, P = 0.009) was higher with a 250 mL/h infusion rate.

CONCLUSION

IV fluids at an infusion rate of 250 mL/h during labor in nulliparous women decreased the cesarean delivery rate, increased the vaginal delivery rate, shortened the first and second-stage labor duration, decreased the incidence of prolonged labor as compared with 125 mL/h. These findings suggest enhanced labor progression and a lower risk of labor complications with higher infusion rates. However, future research involving a more diverse population and exploring the potential benefits of combining IV infusion rates with other interventions, such as adding dextrose or less restrictive oral intake during labor, is needed.

Intravenous Ringer's lactate versus usual care during labor in nulliparous women: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Due to limited research on the effectiveness and safety of intravenous (IV) fluids administered during labor, there are no guidelines available. Thus, this meta-analysis aims to evaluate efficacy of IV Ringer's lactate during labor as compared to usual care.

METHODS

Six databases were searched for the randomized controlled trials (RCTs) comparing the effects of IV Ringer's lactate at 125 mL/h or 250 mL/hr during labor in nulliparous women at term as compared to usual care, and the search results were imported to Covidence for screening of the articles. All the concerned outcomes were pooled as risk ratios (RR) or mean difference (MD) with 95% CI in the meta-analysis models using RevMan 5.4.

RESULTS

Pooled data from 7 RCTs with 967 nulliparous women showed that the active stage of labor duration (MD -32.16 with 95% CI [40.43 to -23.90], p < 0.00001), need of oxytocin augmentation (RR 0.72 with 95% CI [0.54 to 0.96], p = 0.03) and incidence of prolonged labor (RR 0.57 with 95% CI [0.34 to 0.95], p = 0.03) was significantly lower with IV Ringer's lactate. However, the total duration of labor (p = 0.23), duration of second stage of labor (p = 0.31) and cesarean section rate (p = 0.070) did not differ between the two groups. The test for subgroup analysis based on infusion rate was significant (p = 0.01) for the active stage of labor.

CONCLUSION

IV Ringer's lactate reduced the duration of active labor, the need for oxytocin augmentation and the prolonged labor incidence. However, it did not differ in effect on immediate neonatal health but was found to have more potential for reducing maternal vomiting as compared to usual care with unrestricted oral intake. Further research is needed to explore its effects in the larger and more diverse populations and with different IV fluids for evidence-based guidelines.

Effect of prenatal aerobic exercises on maternal and neonatal outcomes: A systematic review and meta-analysis

Aim

This study aimed to evaluate the effect of prenatal aerobic exercises on maternal and neonatal outcomes.

Design

A systematic review and meta‐analysis.

Method

A search was carried out in databases including PubMed, ProQuest, EMBASE, Cochrane Library, Scopus, Web of Science, Magiran and SID until 30 September 2020. Two reviewers independently assessed the articles for quality and risk of bias using the Cochrane handbook. The statistical heterogeneity was determined using the Cochran's Q test and Higgins' I² coefficient.

Results

Of the 2,790 extracted articles, 16 were included in this review. The results of the meta‐analysis showed that prenatal exercise can increase the frequency of vaginal delivery significantly (RR: 1.24; 95% CI: 1.08–1.43), but had no statistically significant effect on other maternal and neonatal outcomes, such as first, second and third stages of labour, gestational age at birth, first and fifth‐minute Apgar score, umbilical cord pH, neonatal weight, height and head circumference (p > .05).

Conclusions

The meta‐analysis results suggested that prenatal exercise can reduce the frequency of caesarean section.

Efficacy of "optimal hydration" during labor: HYDRATA study protocol for a randomized clinical trial

There is a lack of consensus in the international scientific community with respect to the most suitable hydration strategies when attending nulliparous women during low-risk births. This paper describes the protocol for a randomized controlled trial to compare two hydration strategies and their influence on maternal and neonatal morbidity. The study population consists of nulliparous women admitted to the obstetrics department of a University Hospital. The women are being randomized into two groups: the "optimal hydration" group, which will be guaranteed 300 ml/hr liquids (crystalloids and bottled mineral water) with a minimum diuresis of 35 ml/hr; and the "variability in hydration" group, which will receive intravenous (alternating normal saline, Ringer's lactate solution, glucose, or Voluven®) and clear (bottled mineral water or isotonic drinks [Aquarius®]) liquids, without any established perfusion rate, and without established minimum diuresis. Outcomes for mothers include duration of labor, cesarean section, fever, and dehydration. Outcomes for newborns are respiratory distress, hypoglycemia, hyponatremia, jaundice, weight loss over 48 hr, and breastfeeding difficulties. Analysis will be per-protocol. Administering optimal hydration may improve health and safety for mothers and their newborn and reduce maternal and neonatal morbidity. The study is registered at www.clinicaltrials.gov. The project received funding by the Ministry of Health of Spain and is approved by the Research Ethics Committee.

Timing and Outcomes of an Indication-Only Use of Intravenous Cannulation During Spontaneous Labor

INTRODUCTION

In the United States, most women presenting in spontaneous labor undergo intravenous (IV) cannulation on admission to hospital labor and birth units. There is limited evidence for this routine practice in pregnant women at low risk for adverse outcomes during labor or birth.

METHODS

A retrospective, exploratory, descriptive study of an indication-only practice of IV cannulation on admission for women presenting in spontaneous labor and cared for by a nurse-midwife service was performed. Descriptive data included the timing of IV cannula placement (admission, during labor or postpartum period, or not at all) and indications for placement. Maternal outcomes of interest were estimated blood loss, postpartum hemorrhage rates, and management; neonatal outcome was 5-minute Apgar scores.

RESULTS

Records for 1069 women cared for by nurse-midwives who presented in spontaneous labor were reviewed. In this cohort, 445 (41.6%) had IV access established on admission, 325 (30.4%) had an IV cannula placed during labor or postpartum, and 299 (28%) never had IV access during their hospital stay. For the 325 women with IV cannulas placed after admission, 25 (7.7%) were placed urgently for excessive postpartum bleeding. Further analysis of the subset of women who had a postpartum hemorrhage after vaginal birth (defined as >500 mL estimated blood loss) indicated that urgent IV cannulation was not associated with a lower mean postpartum hemoglobin or hematocrit or an increase in blood transfusion rate when compared with women who had an IV cannula placed earlier in their labor course.

DISCUSSION

Indication-only IV cannulation for women experiencing an uncomplicated labor and birth is a reasonable practice in settings where IV access can be established urgently if needed.

Comparison of Transcutaneous Electrical Nerve Stimulation and Lidocaine on Episiotomy Complication in Primiparous Women: A Randomized Clinical Trial

INTRODUCTION

Transcutaneous electrical nerve stimulation (TENS) through the skin is a nonpharmacological method of pain relief. The present study aimed to compare TENS and lidocaine on episiotomy complication in primiparous women.

MATERIAL AND METHODS

In a randomized, controlled clinical trial, 80 participants were included from March to July 2011 at the antenatal clinic and postdelivery ward in the Social Security Organization Hospital, Khorramabad, Lorestan, Iran. Data were collected using a demographic questionnaire, visual analog scale and redness, edema, ecchymosis, discharge, and approximation scales. The participants were randomized into two groups with equal number of participants. All participants received 5 cc of local infiltration of 1% lidocaine before episiotomy, and TENS electrodes were placed on He Gu and Shenmen points during the crowning of fetal head. The TENS group received TENS with 100; 250 μs, the output range of 15-20 mm amplifier from crowning of first stage of labor to the end of the episiotomy repairing. The lidocaine group received 10 cc of local infiltration of 1% lidocaine before episiotomy repair while did not receive TENS electrodes. The pain intensity during and after episiotomy repair was recorded.

RESULTS

TENS and lidocaine have similar effects on pain relief at the episiotomy cutting, the start of the episiotomy repair, and at end of the episiotomy repair; however, the pain relief of both the interventions was different during the episiotomy repair. The effect of TENS in reducing edema was statistically significant (P = 0.001).

CONCLUSIONS

TENS and lidocaine are effective for the episiotomy complications during and after episiotomy repair.

Severe asymptomatic maternal antepartum hyponatremia leading to neonatal seizures: prevention is better than cure

Background

Pre-delivery maternal electrolyte derangements may reflect themselves in the newborn, since placental homeostasis determines electrolyte equilibrium between mother and fetus.

Case presentation

A term newborn, transferred to our Neonatal Intensive Care Unit 1 h after birth for an apnoea episode, presented with initially left-sided, and subsequently generalized tonic-clonic seizures due to severe hyponatremia (119 mmol/L). Seizures rapidly ceased after electrolyte correction plus a phenobarbital bolus. Deep hyponatremia was also detected in the mother (123 mmol/L).

Conclusions

As placental homeostasis determines electrolytes equilibrium between mother and fetus, obstetrics and neonatologists should be aware that any maternal dyselectrolytemia will reflect itself in the newborn; hence, it is fundamental to detect possible maternal electrolyte imbalances before delivery, in order to be prepared to timely correction of electrolyte derangements in the newborn.

A multi-center randomized trial of two different intravenous fluids during labor

OBJECTIVE

To determine if the intrapartum use of a 5% glucose-containing intravenous solution decreases the chance of a cesarean delivery for women presenting in active labor.

METHODS

This was a multi-center, prospective, single (patient) blind, randomized study design implemented at four obstetric residency programs in Pennsylvania. Singleton, term, consenting women presenting in active spontaneous labor with a cervical dilation of <6 cm were randomized to lactated Ringer's with or without 5% glucose (LR versus D5LR) as their maintenance intravenous fluid. The primary outcome was the cesarean birth rate. Secondary outcomes included labor characteristics, as well as maternal or neonatal complications.

RESULTS

There were 309 women analyzed. Demographic variables and admitting cervical dilation were similar among study groups. There was no significant difference in the cesarean delivery rate for the D5LR group (23/153 or 15.0%) versus the LR arm (18/156 or 11.5%), [RR (95% CI) of 1.32 (0.75, 2.35), p = 0.34]. There were no differences in augmentation rates or intrapartum complications.

CONCLUSIONS

The use of intravenous fluid containing 5% dextrose does not lower the chance of cesarean delivery for women admitted in active labor.

Effect of infertility on the quality of life, a cross- sectional study

INTRODUCTION

Infertility is a major life crisis which causes serious mental problems and stressful experience of infertile couples. Therefore, the aim of the present study was to compare the quality of life in fertile and infertile women.

MATERIALS AND METHODS

In a cross - sectional study compared the quality of life in 450 women attending both public and private health centers in Ilam, western of Iran, in 2013. Participants were divided in two groups' fertilities and infertilities women. Data was collected by trained research midwives using demographic and SF-36 questionnaires. SPSS software Package 16 was used to analyze the data of this project. Differences were regarded statistically significant with an alpha error of 0.05.

RESULTS

Significant difference was reported in mean age between fertile and infertile women (p=0.003). Mean scores of all Mental dimensions of quality of life were higher in fertile women in comparison with infertile women. This difference was statistically significant (58.35±19.43 vs 56.56±13.18 respectively) (p= 0.000).The mean score of all physical dimensions have not statistically significant difference in fertile and infertile women (79.77± 23.19 vs 74.96±23.45 respectively) (p= 0.441).

CONCLUSION

In most infertile women, the mean score of Mental dimensions of quality of life is lower in comparison with fertile women, therefore, it is necessary the used of counseling and treatment programs in infertile women.

Comparison effect of oral propranolol and oxytocin versus oxytocin only on induction of labour in nulliparous women (a double blind randomized trial)

BACKGROUND AND AIM

Today, research on new methods for preventing caesarean sections owing to labour induction, have been requested in obstetric practice, because of the increased morbidity related to caesarean section. Therefore, the aim of this study was to compare the effect of Oral Propranolol and Oxytocin versus Oxytocin only on induction of labour in nulliparous women.

MATERIAL AND METHODS

A double blind randomized controlled trial was performed at the Ilam Mostafa Hospital, Ilam, Iran, from March 2010 to March 2011 on 146 nulliparous pregnant women who had gestational age of 40-42 weeks of pregnancy and a Bishop score of ≤5. Participants were divided in two groups (with 73 participants in each group). In the first group (placebo plus Oxytocin group = 73), Oxytocin was used for the induction of labour. In the second group (Propranolol plus Oxytocin group = 73 cases), before the use of Oxytocin, 20 mg Propranolol was administrated orally and then the Oxytocin was initiated. Twenty mg Propranolol was repeated after 8 hours if good contraction was not obtained.

RESULTS

The mean duration for obtaining good contractions was significantly shorter in the Propranolol group than in the placebo group, on both the first and second day of induction (p<.05). The mean duration of latent phase was shorter in the first in Propranolol group (p<.05). In Propranolol plus Oxytocine group, frequency of cesarean deliveries significantly decreased than in the placebo plus Oxytocin group (21% versus 39.7%). No significant differences in neonate outcome, such as Apgar scores of minutes 1 and 5 and need of admissions to NICU, were found between the groups (p>.05) DISCUSSION AND CONCLUSION: Our study showed that oral Propranolol was effective for labour induction and that it could decrease the frequency of caesarean deliveries without producing any adverse effects on mothers or neonates.

Effect of acupressure on post-operative nausea and vomiting in cesarean section: a randomised controlled trial

BACKGROUND

Because of potential side effects of chemical treatments and in order to decrease the risk of nausea and vomiting in post-operative patients, there is a necessary requirement for some alternative therapeutic methods such as Acupressure.

AIM

The present randomized clinical trial study aimed to compare the effects of Acupressure and Metoclopramide on postoperative nausea and vomiting in Caesarean Sections.

SETTING AND DESIGN

The patients who were subjected to caesarean surgeries, who were referred to the Ilam Mustafa Hospital in the west of Iran, were enrolled in this randomised clinical trial study.

MATERIAL AND METHODS

Totally, 102 patients who were selected for elective Caesarean Section were included in this study. Patients were randomly assigned to one of three groups, with 34 cases in each group. All groups were matched for effective factors on nausea and vomiting in inclusion and exclusion criteria. The control group did not receive any intervention, the second group received 10 mg Metoclopramide intravenously, immediately prior to anaesthesia induction and in the third group, Acupressure bands were applied at the P6 points on both wrists, 15 minutes before anaesthesia induction. Intra-operative and post-operative emetic episodes were recorded by a trained investigator. The patients who experienced nausea were evaluated on a linear numeric scale which ranged from 0 (no) to 10 (severe). Statistics and Results: The incidence of nausea and vomiting in postoperative periods was lower in Metoclopramide and Acupressure groups as compared that in the control group. The frequency of anti-emetic which was used was significantly higher in control group as compared to those in the other groups (p<0.001). No side effects or complications were caused by any intervention.

CONCLUSION

In parturients who underwent caesarean deliveries which were performed under spinal anaesthesia in this study, use of Metoclopramide and Acupressure was found to be equally effective for reducing emetic symptoms (nausea, retching, and vomiting).

Intravenous fluids for reducing the duration of labour in low risk nulliparous women

BACKGROUND

Several factors may influence the progression of normal labour. It has been postulated that the routine administration of intravenous fluids 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 fluids may reduce caesarean sections (CS) for prolonged labour. However, the routine administration of intravenous fluids 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 fluids that are required, or indeed, whether intravenous fluids are at all necessary. Women may be able to adequately hydrate themselves if they were allowed oral fluids during labour.Furthermore, excessive volumes of intravenous fluids may pose risks to both the mother and her newborn and different fluids are associated with different risks.

OBJECTIVES

To evaluate whether the routine administration of intravenous fluids to low-risk nulliparous labouring women reduces the duration of labour and to evaluate the safety of intravenous fluids on maternal and neonatal health.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 February 2013).

SELECTION CRITERIA

Randomised controlled trials of intravenous fluid 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.

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 Ringer's 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 Ringer's lactate group (mean difference (MD) -28.86 minutes, 95% confidence interval (CI) -47.41 to -10.30). There was no statistical reduction in the number of CS in the Ringer's 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 fluids with free oral fluids in both groups. Women receiving a greater hourly volume of intravenous fluids (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 significant reduction in the number of CS in the 250 mL intravenous fluid 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 fluids 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, findings must be interpreted with caution as there was high heterogeneity amongst trials (I(2) = 53%). There was a significant reduction in CS in women receiving the higher rate of intravenous fluid infusion (RR 1.56, 95% CI 1.10 to 2.21; P = 0.01). There was no difference identified 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 significant 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 fluids compared with oral intake alone demonstrated a reduction in the duration of labour, this finding emerged from only two trials. The findings 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 fluids 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 justifiable 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 fluids. Interpreting the results from trials was hampered by the low number of trials contributing data and by variation between trials. In trials where oral fluids were not restricted there was considerable variation in the amount of oral fluid 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.