Active management of labor

Efficacy of phloroglucinol in shortening the first stage of labor: systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Protracted labor is associated with an elevated risk of maternal and fetal complications. Results of randomized controlled trials on the efficacy in labor of phloroglucinol (PHL), a pure antispasmodic drug, are uncertain.

OBJECTIVES

To evaluate whether PHL is effective in shortening the first stage of labor.

SEARCH STRATEGY

MEDLINE, EMBASE, LILACS, Scopus, ClinicalTrials.gov, and the Cochrane Library were searched from inception to July 2020.

SELECTION CRITERIA

Randomized controlled trials (RCTs) concerning women with a singleton vertex pregnancy at term who were treated with PHL.

DATA COLLECTION AND ANALYSIS

Relevant data were extracted and tabulated. Review Manager 5.3 was used for data analysis. Primary outcome evaluated was the mean reduction of the first stage of labor.

MAIN RESULTS

Five RCTs, including 487 pregnant women, were analyzed. The first stage of labor duration was significantly shorter in the treatment arm compared to the control group [MD-113.21 min (95% CI-119.63,-106.79)]. A significant shortening of the second stage was achieved in the PHL group [MD-11.12 min (95% CI-12.64,-9.75)] while no differences were reported for the third stage.

CONCLUSIONS

PHL might represent an effective treatment to shorten the duration of the first and second stage of labor.

SYNOPSIS

A meta-analysis of 5 trials found that Phloroglucinol favorably impacts on the total duration of the labor in primiparae and multiparae women with a singleton pregnancy.

Efficacy of hyoscine butyl-bromide in shortening the active phase of labor: Systematic review and meta-analysis of randomized trials

INTRODUCTION

Prolonged labor increases the risk of maternal and fetal complications. The active management of labor has been proven effective in lowering neonatal and maternal morbidity by shortening the duration of labor. Several pharmaceutical and non-pharmaceutical approaches are currently being used in the active management of labor. Hyoscine Butyl-bromide (HBB) is an antispasmodic and anticholinergic drug that acts as a cervical spasmolytic agent. It has been widely used in everyday practice for shortening the active phase of labor. Nonetheless, only a few trials have been conducted on the topic.

OBJECTIVE

This review aimed to evaluate whether HBB is effective in decreasing the mean duration of the active phase of labor.

STUDY DESIGN

An electronic search was conducted on Medline (through PubMed), Scopus, ClinicalTrials.gov, EMBASE, PROSPERO, and Cochrane Library from the beginning of all databases to December 2019. Results were limited to randomized trials. Restriction for English language was applied. Inclusion criteria were: randomized clinical trials regarding primiparae or multiparae women with a singleton vertex pregnancy at term who were randomized to HBB versus placebo or other drugs. Primary outcome evaluated was the mean reduction of the active phase of labor.

DATA COLLECTION AND ANALYSIS

Eight randomized clinical trials, including 1159 pregnant women, were analyzed. Significant heterogeneity (I² = 99 %) between studies was noted for the primary outcome. The active phase of labor duration was significantly reduced in the treatment arm compared to controls [mean difference (MD) -83.93 min (95 % confidence interval (CI) -163.61, -4.25)]. Achieved reduction in primiparae women was -55.09 min [95 % CI -68.83, -41.35; I² = 37 %].

CONCLUSION

HBB is an effective treatment to shorten the duration of the active phase of labor in primiparae and multiparae women.

A randomised controlled study comparing Drotaverine hydrochloride and Valethamate bromide in the augmentation of labour

OBJECTIVES

Cervical dilatation is a poorly understood process. Various drugs have been used to facilitate this process and reduce the duration of labour and thereby reduce feto-maternal complications. The present study is an attempt to compare and evaluate the efficacy of Drotaverine hydrochloride and Valethamate bromide in the process of cervical dilatation and labour augmentation.

STUDY DESIGN

A prospective randomised trial of 146 low-risk women in spontaneous labour was conducted. 49 women were given Drotaverine (Group 1), 49 women were given Valethamate (Group 2) and 48 women were given placebo (Group 3). At 4 cm of cervical dilatation, elective amniotomy was done and the injection was given intramuscularly, and repeated every hour for a maximum of three doses.

RESULTS

There was a statistically significant difference in the mean injection-delivery times (time from first injection to delivery of the baby), which was 183.2 min (SD 78.8) in the Drotaverine group compared to 206.5 min (SD 69.7) in the Valethamate group, and 245 min (SD 70.9) in the control group. The mean cervical dilatation rate (cm/h) was 3 (SD 1.4), 2.4 (SD 0.9) and 1.9 (SD 0.6) in groups 1, 2 and 3, respectively, and these differences were statistically significant. There were no statistically significant differences in the duration of second and third stage of labour. Transient side effects such as foeto-maternal tachycardia, flushing of the face and dryness of mouth were noted with Valethamate. A few patients complained of headache in the Drotaverine group.

CONCLUSIONS

Both Drotaverine and Valethamate appear to significantly help cervical dilatation and augment first stage of labour. But, Drotaverine is superior to Valethamate with fewer side effects.

Active Management of Labor

A source of great controversy, the active management of labor as classically defined, is routinely misunderstood and misapplied in many clinical settings. Aggressive induction protocols, early amniotomy, operative delivery, epidural analgesia, and even early admission to labor and delivery units are actions frequently thought to be synonymous with "active management of labor". To regain an understanding of the active management of labor, one needs to examine the goal of this management scheme and become more familiar with its components.