Is it time to ban oxytocin for poor labour progress?

Oxytocin causes myometrial contractions and prostaglandin release. It is commonly used as an intervention for women in established labour with slow progress. However recent large randomised trials of oxytocin for this indication have shown no difference in caesarean section rates associated with its use. This may be due to inadequate doses of oxytocin and small randomised studies have suggested high dose oxytocin may indeed reduce caesarean delivery. The results of a high quality large randomised trial of high versus low dose oxytocin for women with slow progress are keenly awaited. There is no evidence to support the concept of turning the oxytocin off once contractions have been established, although this certainly merits further investigation. Recent evidence of contemporary labour patterns indicate that our whole concept of slow progress in labour is fundamentally flawed

Advanced maternal age

The average age of women at childbirth in industrialised nations has been increasing steadily for approximately 30 years. Women aged 35 years or over have an increased risk of gestational hypertensive disease, gestational diabetes, placenta praevia, placental abruption, perinatal death, preterm labour, fetal macrosomia and fetal growth restriction. Unsurprisingly, rates of obstetric intervention are higher among older women. Of particular concern is the increased risk of antepartum stillbirth at term in women of advanced maternal age. In all maternal age groups, the risk of stillbirth is higher among nulliparous women than among multiparous women. Women of advanced maternal age (more than 40 years) should be given low dose aspirin (in the presence of an additional risk factor for pre-eclampsia) and offered serial ultrasounds for fetal growth and wellbeing; given the increased risk of antepartum stillbirth, induction of labour from 39 weeks’ gestation should be discussed with the woman

Discrepancies between registration and publication of randomised controlled trials: an observational study

Abstract OBJECTIVES: To determine the consistency between information contained in the registration and publication of randomised controlled trials (RCTs). DESIGN: An observational study of RCTs published between May 2011 and May 2012 in the British Medical Journal (BMJ) and the Journal of the American Medical Association (JAMA) comparing registry data with publication data. PARTICIPANTS AND SETTINGS: Data extracted from published RCTs in BMJ and JAMA. MAIN OUTCOME MEASURES: Timing of trial registration in relation to completion of trial data collection and publication. Registered versus published primary and secondary outcomes, sample size. RESULTS: We identified 40 RCTs in BMJ and 36 in JAMA. All 36 JAMA trials and 39 (98%) BMJ trials were registered. All registered trials were registered prior to publication. Thirty-two (82%) BMJ trials recorded the date of data completion; of these, in two trials the date of trial registration postdated the registered date of data completion. There were discrepancies between primary outcomes declared in the trial registry information and in the published paper in 18 (47%) BMJ papers and seven (19%) JAMA papers. The original sample size stated in the trial registration was achieved in 24 (60%) BMJ papers and 21 (58%) JAMA papers. CONCLUSIONS: Compulsory registration of RCTs is meaningless if the content of registry information is not complete or if discrepancies between registration and publication are not reported. This study demonstrates that discrepancies in primary and secondary outcomes and sample size between trial registration and publication remain commonplace, giving further strength to the World Health Organisation's argument for mandatory completion of a minimum number of compulsory fields

Delivery at term: when, how and why

The optimal timing of delivery for the baby is 39 weeks, avoiding the morbidity associated with early term birth and reducing the risk of antepartum stillbirth. There is compelling evidence that among high-risk pregnancies and in settings where cesarean rates are high (>20%), induction of labor at 37 to 40 weeks does not, as previously thought, result in a further increased risk of cesarean delivery. The only advantage to planned cesarean delivery over induction of labor is the avoidance of the morbidity associated with emergency cesarean delivery; controversy exists on the other reported benefits. There is a growing number of well-conducted randomized controlled trials that provide some support for induction of labor shortly before term for a variety of indications (hypertensive disorders, gestational diabetes, suspected growth restriction, macrosomia, and advanced maternal age)

Maternal position in the second stage of labour for women with epidural anaesthesia

© 2018 The Cochrane Collaboration. Background: Epidural analgesia in labour prolongs the second stage and increases instrumental delivery. It has been suggested that a more upright maternal position during all or part of the second stage may counteract these adverse effects. This is an update of a Cochrane Review published in 2017. Objectives: To assess the effects of different birthing positions (upright or recumbent) during the second stage of labour, on maternal and fetal outcomes for women with epidural analgesia. Search methods: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (5 June 2018), and the reference lists of retrieved studies. Selection criteria: All randomised or quasi-randomised trials including pregnant women (primigravidae or multigravidae) in the second stage of induced or spontaneous labour receiving epidural analgesia of any kind. Cluster-randomised controlled trials would have been eligible for inclusion but we found none. Studies published in abstract form only were also eligible. We assumed the experimental intervention to be maternal use of any upright position during the second stage of labour, compared with the control condition of remaining in any recumbent position. Data collection and analysis: Two review authors independently assessed trials for inclusion, assessed risks of bias, and extracted data. We contacted study authors to obtain missing data. We assessed the quality of the evidence using the GRADE approach. We carried out a planned sensitivity analysis of the three studies with low risks of bias for allocation concealment and incomplete outcome data reporting, and further excluded one study with a co-intervention (this was not prespecified). Main results: We include eight randomised controlled trials, involving 4464 women, comparing upright positions versus recumbent positions in this update. Five were conducted in the UK, one in France and two in Spain. The largest UK trial accounted for three-quarters of all review participants, and we judged it to have low risk of bias. We assessed two other trials as being at low risk of selection and attrition bias. We rated four studies at unclear or high risk of bias for both selection and attrition bias and one study as high risk of bias due to a co-intervention. The trials varied in their comparators, with five studies comparing different positions (upright and recumbent), two comparing ambulation with (recumbent) non-ambulation, and one study comparing postural changes guided by a physiotherapist to a recumbent position. Overall, there may be little or no difference between upright and recumbent positions for our combined primary outcome of operative birth (caesarean or instrumental vaginal): average risk ratio (RR) 0.86, 95% confidence interval (CI) 0.70 to 1.07; 8 trials, 4316 women; I 2 = 78%; low-quality evidence. It is uncertain whether the upright position has any impact on caesarean section (RR 0.94, 95% CI 0.61 to 1.46; 8 trials, 4316 women; I 2 = 47%; very low-quality evidence), instrumental vaginal birth (RR 0.90, 95% CI 0.72 to 1.12; 8 trials, 4316 women; I 2 = 69%) and the duration of the second stage of labour (mean difference (MD) 6.00 minutes, 95% CI -37.46 to 49.46; 3 trials, 456 women; I 2 = 96%), because we rated the quality of the evidence as very low for these outcomes. Maternal position in the second stage of labour probably makes little or no difference to postpartum haemorrhage (PPH), (PPH requiring blood transfusion): RR 1.20, 95% CI 0.83 to 1.72; 1 trial, 3093 women; moderate-quality evidence. Maternal satisfaction with the overall childbirth experience was slightly lower in the upright group: RR 0.95, 95% CI 0.92 to 0.99; 1 trial, 2373 women. Fewer babies were born with low cord pH in the upright group: RR 0.43, 95% CI 0.20 to 0.90; 2 trials, 3159 infants; moderate-quality evidence. The results were less clear for other maternal or fetal outcomes, including trauma to the birth canal requiring suturing (average RR 1.00, 95% CI 0.89 to 1.13; 3 trials, 3266 women; I 2 = 46%; low-quality evidence), abnormal fetal heart patterns requiring intervention (RR 1.69, 95% CI 0.32 to 8.84; 1 trial, 107 women; very low-quality evidence), or admission to neonatal intensive care unit (RR 0.54, 95% CI 0.02 to 12.73; 1 trial, 66 infants; very low-quality evidence). However, the CIs around some of these estimates were wide, and we cannot rule out clinically important effects. In our sensitivity analysis of studies at low risk of bias, upright positions increase the chance of women having an operative birth: RR 1.11, 95% CI 1.03 to 1.20; 3 trials, 3609 women; high-quality evidence. In absolute terms, this equates to 63 more operative births per 1000 women (from 17 more to 115 more). This increase appears to be due to the increase in caesarean section in the upright group (RR 1.29; 95% CI 1.05 to 1.57; 3 trials, 3609 women; high-quality evidence), which equates to 25 more caesarean sections per 1000 women (from 4 more to 49 more). In the sensitivity analysis there was no clear impact on instrumental vaginal births: RR 1.08, 95% CI 0.91 to 1.30; 3 trials, 3609 women; low-quality evidence. Authors' conclusions: There may be little or no difference in operative birth between women who adopt recumbent or supine positions during the second stage of labour with an epidural analgesia. However, the studies are heterogeneous, probably related to differing study designs and interventions, differing adherence to the allocated intervention and possible selection and attrition bias. Sensitivity analysis of studies at low risk of bias indicated that recumbent positions may reduce the need for operative birth and caesarean section, without increasing instrumental delivery. Mothers may be more satisfied with their experience of childbirth by adopting a recumbent position. The studies in this review looked at left or right lateral and semi-recumbent positions. Recumbent positions such as flat on the back or lithotomy are not generally used due to the possibility of aorto-caval compression, although we acknowledge that these recumbent positions were not the focus of trials included in this review

Timing and mode of delivery with advancing maternal age

In 2017, 23% of all live births in the United Kingdom were to women aged over 35 years. Decisions around the timing of delivery for such women must balance the risks of prolongation of the pregnancy and of iatrogenic harm from timed delivery. Women of advanced maternal age have a small age-related elevated risk of term stillbirth. Antenatal monitoring and the route of delivery should not differ from those for younger women. The induction of labour at 39 weeks for such women does not appear to increase the risk of emergency caesarean section or to have any short-term adverse effects on mother or baby. There have been no studies on the long-term effects of induction in this group. Nevertheless, it seems reasonable to offer women of advanced maternal age, induction of labour at 39 weeks where resources are available to safely provide this

Techniques for managing an impacted fetal head at caesarean section: A systematic review

A complication arising at caesarean birth when the baby's head is deeply engaged in the pelvis and may be difficult to deliver, is known as an ‘impacted fetal head’. This obstetric emergency occurs in 16% of second stage caesarean sections. Multiple techniques are described in the literature to manage the complication but there is no consensus regarding which technique results in the best maternal and neonatal outcomes. The objective of this review is to determine which technique for managing impacted fetal head at caesarean section has the best maternal and neonatal outcomes. A literature search of three electronic databases was conducted in November 2021. Studies directly comparing two methods for the management of impacted fetal head at caesarean section in the second stage were included. Systematic reviews, meta-analyses, case-control studies, and studies not fitting the search criteria were excluded. Data was extracted in Covidence and meta-analysis of the six most commonly reported outcomes was conducted using RevMan 5.4. In total, 16 studies (3344women) were included. 13 studies (2506women) compared the push method with reverse breech extraction. meta-analysis showed that risk of extension of the uterine incision, blood transfusion, bladder injury, postpartum haemorrhage, NICU admission and Apgar score <7 at 5 min were significantly higher with the push method compared with reverse breech extraction. Three studies (838women) compared the push method with Patwardhan's technique. meta-analysis of studies comparing the push method with Patwardhan's technique found no significant differences between the two groups in any of the six maternal or neonatal outcomes. Evidence derived from small, inadequately powered studies suggests reverse breech extraction is associated with better outcomes than the push method. The method which produces the best outcomes is still unknown as not all methods have been tested. Further high quality, adequately powered RCTs are warranted for definitive conclusions to be drawn and to ameliorate the paucity of evidence on how best to manage this complication

Childbirth experience questionnaire 2: Validating its use in the United Kingdom

© 2019 The Authors Objective: To validate the Childbirth Experience Questionnaire 2 (CEQ2) in the UK to see if it is an effective tool for evaluating labour experience. Study design: The CEQ2 and part of the Care Quality Commission Maternity Survey (2010) was sent to 475 women one month and six weeks after birth. It was tested for face validity among 25 postnatal mothers. Demographic data and delivery data was used to establish construct validity using the method of known-groups validation. The results of the scored CEQ2 sent out twice were used to measure test-retest reliability by calculating the quadratic weighted index of agreement between the two scores. Criterion validity was measured by calculating the Pearson correlation coefficient for the CEQ2 and Maternity Survey scores. Results: Face validity of the CEQ2 in a UK population was demonstrated with all respondents stating it was easy to understand and complete. A statistically significantly higher CEQ2 score for subgroups of women known to report a better birth outcome demonstrated construct validity. A weighted kappa of 0.55 demonstrated test-retest reliability. A Pearson correlation co-efficient of 0.56 demonstrated a moderate correlation between the results of the CEQ2 and the results of the ‘gold standard’ assessment of childbirth experience in the UK: the Maternity Survey and hence criterion validity. Conclusions: This study demonstrates that the Childbirth Experience Questionnaire version 2 (CEQ2) is a valid and reliable measure of childbirth experience in the UK population

The challenges of randomised control trials in obstetrics and gynaecology

In this short article we explore some of the challenges faced by those conducting randomised trials in obstetrics and gynaecology. We discuss the current status of trials comparing induction of labour versus expectant management, so called ‘deliver or delay’ trials. We consider the benefits of utilising routine data for collecting trial outcome data. Although cluster trials can provide a useful methodology for answering difficult questions, we illustrate with an example that cluster trials are at risk of delivering a misleading result. We discuss the importance of long term outcomes in randomised trials