Drug therapy during labor and delivery, part 2

High dose vs. low dose oxytocin for labor augmentation: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

To compare the safety and efficacy between high dose and low dose oxytocin administration for labor augmentation.

METHODS

We searched for the available studies during March 2020 in PubMed, Cochrane Library, Scopus, and ISI Web of science. All randomized clinical trials (RCTs) that assessed safety and efficacy of high dose vs. low dose oxytocin for labor augmentation were considered. The extracted data were entered into RevMan software. Dichotomous and continuous data were pooled as odds ratio (OR) and mean difference (MD) respectively, with the corresponding 95% confidence intervals (CI). Our main outcomes were cesarean delivery rate, spontaneous vaginal delivery rate, uterine hyperstimulation and tachysystole, and labor duration from oxytocin infusion.

RESULTS

Eight RCTs with 3,154 patients were included. High dose oxytocin did not reduce cesarean delivery rate compared to low dose oxytocin (OR=0.76, 95% CI [0.52, 1.10], p=0.15). After solving the reported heterogeneity, high dose oxytocin did not increase the rate of spontaneous vaginal deliveries vs. low dose oxytocin (OR=1.06, 95% CI [0.84, 1.32], p=0.64). Low dose oxytocin was linked to a significant decline in uterine hyperstimulation and tachysystole (p>0.001). A reduction in labor duration was found in high dose oxytocin group over low oxytocin regimen (MD=-1.02 h, 95% CI [-1.77, -0.27], p=0.008).

CONCLUSIONS

We found no advantages for high dose oxytocin over low dose oxytocin in labor augmentation except in reducing labor duration. Low dose oxytocin is safer as it decreases the incidence of uterine hyperstimulation and tachysystole. More trials are needed to confirm our findings.

Pregnant Women's Labor Progress, Childbirth Outcome, and Childbirth Satisfaction according to the Presence or Absence of Labor Induction

PURPOSE

To provide accurate information on induced labor and find strategies to enhance women's childbirth satisfaction.

METHODS

Participants were pregnant women expected to have normal vaginal delivery. A total of 113 women with induced labor and 61 women with spontaneous labor were surveyed. Data were collected using a questionnaire and electronic medical records.

RESULTS

The following variables related to labor progress showed significant differences between the induced labor group and the spontaneous labor group: length of the first stage of labor in primigravidas, use of analgesic, incidence of uterine hyperstimulation, incidence of fetal distress, and medical treatment for the expectant mother. Delivery type and the incidence of postpartum complications showed significant difference between the two groups. Induced labor women's childbirth satisfaction was mainly affected by the process of labor whereas spontaneous labor women's childbirth satisfaction was affected by the outcome of childbirth.

CONCLUSION

Medical staff should have accurate information on the risk of induced labor and the benefits of a natural delivery. Moreover, medical staff should provide necessary information and environment for women to participate in the decision-making process.

Assessment, Management, and Health Implications of Early-Onset Preeclampsia

Early-onset preeclampsia is a serious condition of pregnancy with the potential for adverse maternal and fetal health outcomes. A strong body of evidence supports the need for postpartum follow-up and health counseling, because these women and their offspring are at risk for future cardiovascular disease; nurses play a key role in this education. An understanding of the diagnosis, risk screening for, pathogenesis, and management of severe preeclampsia and its sequelae, such as intrauterine growth restriction and pulmonary edema, enables nurses to develop a comprehensive plan of care that will support women and their families through this challenging and dynamic complication of pregnancy.

Effect of misoprostol for cervical priming before gynecological procedures on nonpregnant premenopausal women

BACKGROUND

Misoprostol is very effective in cervical ripening and is used for termination of pregnancy. A similar effect on the nonpregnant uterus will facilitate gynecological operations, and hence we assessed the effect of misoprostol on the nonpregnant uterus of premenopausal women.

MATERIALS AND METHODS

In a prospective double-blinded randomized controlled trial, 280 women were randomly allocated into two groups (12 women did not complete the intervention). Study (A) and control (B) group received 400 μg of misoprostol or 400 mg of metronidazole tablets (as a placebo) respectively in the posterior vaginal wall 6 h prior to gynecological procedures.

RESULTS

The mean cervical dilatation was significantly higher (P < 0.0001) in misoprostol compared to placebo group (4.6 ± 0.96 mm vs. 3.6 ± 0.82 mm), benefit were also observed on secondary outcome measures which were need for further dilatation, time taken for further dilatation, ease of dilatation, subjective assessment of pain by visual analog scale. Only 3.61% patients complained of intolerable pain during dilatation in the study group while in control group 48.74% complained of intolerable pain and required anesthesia. Most common side effects of misoprostol were abdominal pain and mild vaginal bleeding.

CONCLUSION

Misoprostol was effective in cervical ripening of nonpregnant premenopausal uterus to facilitate gynecological procedures.

Effect of early skin-to-skin mother--infant contact during the first 3 hours following birth on exclusive breastfeeding during the maternity hospital stay

This was a nurse-driven, hospital-based, prospective cohort study of data collected in 19 hospitals in San Bernardino and Riverside counties by California Perinatal Services Network on all mothers (n = 21 842) who delivered a singleton infant (37-40 weeks gestation) between July 2005 through June 2006. Multivariate ordinal logistic regression showed that maternal infant-feeding method intention (measured prior to birth), sociodemographic characteristics, intrapartum variables, and early skin-to-skin mother-infant contact during the first 3 hours following birth (controlling for delivery hospital) were correlated with exclusive breastfeeding during the maternity hospitalization. Compared with mothers with no early skin-to-skin contact, exclusive breastfeeding was higher in mothers who experienced skin-to-skin contact for 1 to 15 minutes (odds ratio [OR] 1.376; 95% confidence interval [CI], 1.189-1.593), 16 to 30 minutes (OR 1.665; 95% CI, 1.468-1.888), 31 to 59 minutes (OR 2.357; 95% CI, 2.061-2.695), and more than 1 hour (OR 3.145; 95% CI, 2.905-3.405). The results demonstrate a dose-response relationship between early skin-to-skin contact and breastfeeding exclusivity.

[Fetal assessment of the labor admission in low risk pregnancies]

The assessment of fetal well-being at the beginning of labor must lead to an appropriate monitoring, adapted to the present risks. Even if some medical events are unforeseeable, three ways of reflexions get clear: abnormal maternofetal signs at the admission indicate the need for an increased monitoring (NP5); the reading of the medical file could reveal a high-risk pregnancy; at least, the realization of electronic fetal heart rate monitoring for any woman at the beginning of the labor is recommended: in case of normality, it remains a good criterion of a fetal good health. In this context of admission, there is no evidence supporting that other techniques (amnioscopy, acoustic test, echography, Doppler, etc.) could be beneficial in low-risk women and be recommended (NP5). Research is to be continued in this field.

Evidence-based practices for the fetal to newborn transition

Many common care practices during labor, birth, and the immediate postpartum period impact the fetal to neonatal transition, including medication used during labor, suctioning protocols, strategies to prevent heat loss, umbilical cord clamping, and use of 100% oxygen for resuscitation. Many of the care practices used to assess and manage a newborn immediately after birth have not proven efficacious. No definitive outcomes have been obtained from studies on maternal analgesia effects on the newborn. Although immediate cord clamping is common practice, recent evidence from large randomized, controlled trials suggests that delayed cord clamping may protect the infant against anemia. Skin-to-skin care of the newborn after birth is recommended as the mainstay of newborn thermoregulation and care. Routine suctioning of infants at birth was not been found to be beneficial. Neither amnioinfusion, suctioning of meconium-stained babies after the birth of the head, nor intubation and suctioning of vigorous infants prevents meconium aspiration syndrome. The use of 100% oxygen at birth to resuscitate a newborn causes increased oxidative stress and does not appear to offer benefits over room air. This review of evidence on newborn care practices reveals that more often than not, less intervention is better. The recommendations support a gentle, physiologic birth and family-centered care of the newborn.