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Evidence-based Labor Management: First stage of labor (Part 3)

Leen Alhafez, M.D, Vincenzo Berghella, M.D.

PII: S2589-9333(20)30129-4
DOI: https://doi.org/10.1016/j.ajogmf.2020.100185
Reference: AJOGMF 100185

To appear in: American Journal of Obstetrics & Gynecology MFM

Received Date: 27 April 2020

Revised Date: 1 July 2020
Accepted Date: 11 July 2020

Please cite this article as: Alhafez L, Berghella V, Evidence-based Labor Management: First stage of
labor (Part 3), American Journal of Obstetrics & Gynecology MFM (2020), doi: https://doi.org/10.1016/
j.ajogmf.2020.100185.

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2 Word count: Abstract: 290; Main text: 3,759

3 Condensation: During the first stage of labor, several interventions have maternal and/or

4 perinatal benefits and should be performed.

5 Short title: Evidence-based first stage of labor

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9 AJOG MFM at a Glance

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11 Why was this study conducted?

12 Recent level 1 evidence on interventions for the first stage of labor have been published;

13 however, updated comprehensive guidelines for the clinician are lacking.

14 What are the key findings?

15 There are several interventions during the first stage of labor that have been studied. Vaginal

16 disinfection with chlorhexidine cannot be recommended. Intrapartum antibiotic prophylaxis is

17 recommended for GBS positive women. Antibiotics can be considered in women with term

18 PROM whose latency is expected to be >12 hours. Aromatherapy with essential oils through

19 inhalation or back massage can be considered. Immersion in water can be considered. Oral

20 restriction of fluid or solid food is not recommended. Water and clear fluids can be encouraged

21 as tolerated. In the setting of oral restriction, IVF at a rate of 250ml/hr containing dextrose, are

22 recommended. Upright positions and ambulation are recommended in women without regional

23 anesthesia, and women with regional anesthesia can adopt whatever position they find most

24 comfortable and choose to ambulate or not ambulate. Continuous bladder catheterization cannot

25 be recommended. There is no recommended frequency of cervical exams, or sweeping of

26 membranes. The use of a partogram cannot be recommended as a routine intervention. The

27 routine use of the peanut ball cannot be recommended. Antispasmodics cannot be recommended.

28 Routine amniotomy alone in normally progressing spontaneous first stage of labor cannot be

29 recommended. Oxytocin augmentation is recommended to shorten the time to delivery for

30 women making slow progress in spontaneous labor, and higher doses of oxytocin can be

31 considered. Early intervention with oxytocin and amniotomy for the prevention and treatment of

32 dysfunctional or slow labor is recommended. The routine use of the IUPC cannot be

33 recommended. The routine use an ultrasound is not recommended. Cesarean delivery for arrest

34 should not be performed unless labor has arrested for a minimum of 4 hours with adequate

35 uterine activity, or 6 hours with inadequate uterine activity in a woman with ROM, adequate

36 oxytocin, and ≥6cm cervical dilation.

37 What does this study add to what is already known?

38 Our review adds a concise summary of the best available evidence for interventions during the

39 first stage of labor, to facilitate implementation of evidence-based recommendations by the

40 clinician.

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42 Key words: first stage, evidence-based, systematic review, labor, vaginal disinfection, GBS,

43 premature rupture of membranes, aromatherapy, immersion, nutrition, fluids, maternal position,

44 ambulation, bladder catheterization, cervical exam, membrane sweeping, partogram, peanut ball,

45 antispasmodics, amniotomy, oxytocin, intrauterine pressure catheter, ultrasound, dystocia.

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63 ABSTRACT

64 There are several interventions during the first stage of labor that have been studied. Vaginal

65 disinfection with chlorhexidine cannot be recommended. Intrapartum antibiotic prophylaxis is

66 recommended for GBS positive women. Antibiotics can be considered in women with term

67 PROM whose latency is expected to be >12 hours. Aromatherapy with essential oils through

68 inhalation or back massage can be considered. Immersion in water can be considered. Oral

69 restriction of fluid or solid food is not recommended. Water and clear fluids can be encouraged

70 as tolerated. In the setting of oral restriction, IVF at a rate of 250ml/hr containing dextrose, are

71 recommended. Upright positions and ambulation are recommended in women without regional

72 anesthesia, and women with regional anesthesia can adopt whatever position they find most

73 comfortable and choose to ambulate or not ambulate. Continuous bladder catheterization cannot

74 be recommended. There is no recommended frequency of cervical exams, or sweeping of

75 membranes. The use of a partogram cannot be recommended as a routine intervention. The

76 routine use of the peanut ball cannot be recommended. Antispasmodics cannot be recommended.

77 Routine amniotomy alone in normally progressing spontaneous first stage of labor cannot be

78 recommended. Oxytocin augmentation is recommended to shorten the time to delivery for

79 women making slow progress in spontaneous labor, and higher doses of oxytocin can be

80 considered. Early intervention with oxytocin and amniotomy for the prevention and treatment of
 81 dysfunctional or slow labor is recommended. The routine use of the IUPC cannot be

82 recommended. The routine use an ultrasound is not recommended. Cesarean delivery for arrest

83 should not be performed unless labor has arrested for a minimum of 4 hours with adequate

84 uterine activity, or 6 hours with inadequate uterine activity in a woman with ROM, adequate

85 oxytocin, and ≥6cm cervical dilation.

86 INTRODUCTION

87 This is the third review of our evidence-based labor and delivery (L&D) series (1). The aim of

88 this manuscript is to review the evidence for interventions during the first stage of labor. By

89 definition, the first stage of labor commences when contractions of sufficient frequency,

90 intensity, and duration result in cervical dilation and effacement (2,3,4), and ends when the

91 cervix if fully dilated – 10cm. It is comprised of two phases, latent (up to less than 6cm) and

92 active (6 to 10cm) (5).

93

94 MATERIALS AND METHODS

95 We performed multiple MEDLINE, PubMed, EMBASE, and Cochrane searches with the terms

96 “first stage”, “labor”, “pregnancy”, “interventions”, “randomized trials”, plus each management

97 aspect (e.g. “vaginal disinfection”, “GBS prophylaxis”, “antibiotics for pre labor rupture of

98 membranes”, “aromatherapy”, “immersion in water”, “nutrition”, “IV Fluids”, “maternal

99 position”, “ambulation”, “bladder catheterization”, “cervical exam”, “membrane sweeping”,

100 “partogram”, “peanut ball”, “antispasmodics”, “amniotomy”, “oxytocin” “intrauterine pressure

101 catheter”, “ultrasound”, “dystocia”). The search was between 1960 and February 2020 and was

102 not restricted by language.

103 Aspects related to the first stage of labor are covered in this third article of the series (1).

104 Evidence-based guidelines for ‘Before labor’ preparations (6) and for ‘Induction of labor’ (7)

105 have already been published. This review, as the others in this series, was limited in general to

106 low-risk women, carrying a singleton gestation usually in vertex presentation at term (37 0/7 - 41

107 6/7 weeks). Other aspects of L&D management will be covered in future manuscripts (1). Each

108 retrieved randomized controlled trial (RCT), meta-analysis, Cochrane Review of RCTs, or other

109 studies were carefully evaluated. Any pertinent references from the manuscripts were also

110 obtained and reviewed. The highest level of evidence, which is usually the latest meta-analysis of

111 RCTs, was used for developing the recommendations. In the absence of RCTs covering the

112 intervention, analytical data was reviewed. In the absence of experimental or analytical data,

113 observational data was evaluated. Each intervention in first stage of labor was reviewed

114 separately. 

115 Strength of recommendations and quality of the evidence were assessed using the GRADE

116 guidelines (8). As this was a review of literature, this review was exempt from Institutional

117 Review Board approval.  

118

119 RESULTS (Table 1)9-40

120 Vaginal Disinfection

121 Vaginal disinfection with chlorhexidine in labor, by either irrigation or vaginal wipes, does not

122 prevent maternal or neonatal infections compared to no disinfection. The incidence of

123 postpartum maternal endometritis, neonatal group B streptococcal, other infections, and mother-

124 to-child transmission of HIV infection is not decreased by this intervention (Cochrane review: 3

125 RCTs; 3012 women) (9,10,11).

126 In summary, vaginal disinfection with chlorhexidine cannot be recommended in labor

127 (strong recommendation).

128

129 GBS Prophylaxis

130 Maternal colonization with group B streptococcus (GBS) increases the risk of delivering infants

131 complicated by early-onset group B streptococcal disease (EOGBSD), which is defined as

132 infection as a result of vertical transmission characterized by sepsis, pneumonia, and less

133 commonly meningitis within 7 days after birth, compared to women with negative prenatal GBS

134 cultures (12,13,14). Intrapartum antibiotic prophylaxis (IAP) is recommended for women

135 positive by GBS culture screening. Women with GBS bacteriuria in the current pregnancy, or

136 had a prior infant with GBS sepsis are candidates for IAP and do not need to be screened.

137 The American College of Obstetricians and Gynecologists (ACOG) updated their guidelines in

138 2019 to recommend universal GBS culture screening between 36 0/7 and 37 6/7 weeks of

139 gestation, as well as considering those with a history of GBS positive culture in a previous

140 pregnancy and current pregnancy with unknown status as GBS positive and candidates for IAP

141 (15). The rationale for changing the timing from the previous CDC recommendations of 35-37

142 weeks of gestation, is based on the 5-week validity of the culture to include births that occur up

143 to the gestational age of at least 41 0/7 weeks.

144 IAP consists of penicillin as the first line agent (5 million units loading dose followed by 2.5

145 million units every 4 hours) for GBS positive women (15). Penicillin administered for >4 hours

146 before delivery has been found to be highly effective at preventing EOGBSD (16-19), and

147 durations of >2 hours before delivery might confer some protection (18). Therefore, obstetrical

148 interventions, when deemed necessary, should not be delayed solely to provide 4 hours of
149 antibiotic administration before birth. Such interventions include oxytocin infusion, artificial

150 rupture of membranes, or planned cesarean birth (15). Intravenous (IV) ampicillin is an

151 acceptable alternative if penicillin is not available. For women with a penicillin allergy, the

152 recommended antibiotics for IAP are based on their risk of a severe reaction (i.e., anaphylaxis or

153 non-immunoglobulin E [IgE]-mediated reaction such as Stevens Johnson syndrome) and the

154 susceptibility of the GBS isolate to clindamycin (12). First-generation cephalosporins (i.e.,

155 cefazolin) are recommended for women whose reported penicillin allergy indicates a low risk of

156 anaphylaxis or uncertain severity. Penicillin allergy testing, if available, is safe during

157 pregnancy. For women with a high risk of anaphylaxis, clindamycin is the recommended

158 alternative to penicillin if the GBS isolate is known to be susceptible to clindamycin (12).

159 Intravenous vancomycin remains the only validated option for IAP for women who report a

160 high-risk penicillin allergy and whose GBS isolate is not susceptible to clindamycin, or when

161 susceptibility testing was not performed (Figure 1) (12).

162 For those with an unknown culture result in labor, IAP should be given to all women with

163 recognized risk factors: previous infant affected by GBS sepsis, GBS bacteriuria during current

164 pregnancy, preterm labor < 37 weeks, pre-labor rupture of membranes ≥ 18 hours and/or fever in

165 labor ≥ 38°C, or women known to be colonized with GBS in a prior pregnancy (12). There is no

166 intervention shown to be efficacious for prevention of late-onset GBS sepsis.

167 In summary, women with GBS bacteriuria in the current pregnancy or who had a prior

168 infant with GBS sepsis are candidates for IAP and do not require screening. Universal GBS

169 culture screening is recommended at 36 0/7 and 37 6/7 weeks of gestation. IAP in labor for GBS

170 positive women is recommended to reduce neonatal EOGBSD. Penicillin should be used as the

171 first line agent, 5 million units loading dose followed by 2.5 million units every 4 hours, ideally
172 for >4 hours before delivery. For women with a penicillin allergy that are low risk for

173 anaphylaxis, cefazolin is the recommended antibiotic. Women with a penicillin allergy that are

174 high risk for anaphylaxis, clindamycin is the recommended antibiotic if the GBS isolate is

175 susceptible. If susceptibilities are not available, or the GBS isolate is resistant to clindamycin,

176 vancomycin is the recommended antibiotic for women with a penicillin allergy at high risk of

177 anaphylaxis (strong recommendation) (Table 2) (15).

178 Antibiotic Prophylaxis for Term Pre labor Rupture of Membranes

179 Routine antibiotic prophylaxis for term pre labor rupture of membranes (PROM) is not

180 associated with any benefits in either maternal or neonatal outcomes when compared to no

181 antibiotic prophylaxis. However, in women with latency longer than 12 hours, prophylactic

182 antibiotics are associated with significantly lower rates of intra-amniotic infection by 51% and

183 endometritis by 88%, and a trend for a decrease in neonatal sepsis, RR 0.34 (0.11-1.04). The

184 most commonly used antibiotics were ampicillin and gentamicin. For women with a penicillin

185 allergy, clindamycin or erythromycin were used (meta-analysis: 5 trials; 2699 women) (20).

186 In summary, antibiotic prophylaxis can be considered in women with term PROM in

187 which >12 hours of latency are expected between PROM and delivery (weak recommendation).

188

189 Aromatherapy

190 Administration of aromatherapy (essential oils including lavender, jasmine, rose, almond, or a

191 mixture) through inhalation or back massage during labor is not associated with significant

192 effects on cesarean delivery, instrumental delivery, or use of oxytocin, compared to no

193 aromatherapy. A recent meta-analysis of randomized trials showed a reduction in labor pain and

194 labor duration with aromatherapy. However, due to the heterogeneity across the trials included in
195 the study, a larger trial with a more stringent design is needed to provide a strong

196 recommendation for or against aromatherapy in labor (meta-analysis: 17 RCTs; 958 women)

197 (21).

198 In summary, aromatherapy with essential oils (lavender, jasmine, rose, almond, or a

199 mixture) through inhalation or back massage can be considered in labor (weak recommendation).

200

201 Immersion in water

202 Immersion in water in the first stage of labor is associated with no difference in spontaneous

203 vaginal birth, instrumental vaginal delivery, and cesarean delivery, compared to no immersion.

204 There is insufficient evidence to determine the effect of immersion on estimated blood loss and

205 third-or-fourth degree lacerations. There is a small reduction in the use of regional anesthesia and

206 pain in the immersion in water group. There is insufficient evidence to determine the impact on

207 neonatal outcomes (Cochrane: 15 RCTs; 3663 women) (22).

208 In summary, if desired by the patient and there is reassuring fetal and maternal status,

209 immersion in water in the first stage of labor can be considered (weak recommendation).

210 Nutrition

211 A policy of less restrictive food intake (carbohydrate drinks, honey date syrup, or unrestricted

212 food intake) is associated with a shorter duration of labor without an increase in adverse maternal

213 or neonatal outcomes, compared to a policy which allows only ice chips, water, or sips of water.

214 Given that the aspiration risk in uncomplicated women is 1/1,000,000, there is no evidence to

215 support restriction of oral intake (meta-analysis: 10 RCTs; 3982 women) (23).
216 In summary, oral restriction of fluid or solid food in the first stage of labor is not

217 recommended (strong recommendation).

218

219 Fluids

220 Oral water intake vs no oral intake, or clear fluids oral intake vs no oral intake, have not been

221 compared in any RCTs. Given the evidence above for nutrition, an extrapolation can be made

222 that water or clear fluid intake as desired by the woman in labor is probably not harmful, and

223 may be beneficial.

224 Intravenous fluids (IVF) at a rate of 250 mL/h are associated with a 60-minute shorter duration

225 of labor, compared to IVF at 125 mL/h in low-risk nulliparous women in labor where oral intake

226 is restricted. Moreover, a rate of 250 mL/h seems to be associated with a 30% reduction in the

227 incidence of cesarean delivery compared to 125 mL/h. This review did not find these significant

228 reductions amongst the two trials where oral intake was not restricted. (meta-analysis: 7 RCTs;

229 1215 women) (24).

230 With regards to type of intravenous fluids, those containing dextrose are associated with a 75-

231 minute shorter first stage of labor compared to IVF without dextrose in labor where oral intake is

232 restricted. Similarly to above, this review did not find a significantly shorter duration of labor

233 when trials that had a policy of unrestricted oral intake were assessed. (meta-analysis: 16 RCTs;

234 2503 women) (25).

235 In summary, oral water and clear fluids can be encouraged as tolerated in labor. In the

236 setting of oral restriction, IVF at a rate of 250ml/hr containing dextrose, is recommended (strong

237 recommendation).

238
239 Maternal Position

240 Women without regional anesthesia who sit, stand, squat, or kneel, have a one hour and twenty-

241 two minutes shorter duration of labor, are more likely to have a spontaneous vaginal birth, and

242 have lower rates of operative vaginal delivery compared with those in a recumbent, supine or

243 lateral position. There is no significant difference in rates of cesarean delivery, neonatal, or

244 maternal outcomes.

245 For women with regional anesthesia who sit, stand, squat, or kneel, there is no difference in rates

246 of spontaneous vaginal birth, operative vaginal delivery, or cesarean delivery compared to those

247 in the recumbent, supine, or lateral position (Cochrane: 25 trials; 5218 women) (26). There is

248 also no difference in the duration of labor among women with regional anesthesia with upright

249 compared to recumbent positions (meta-analysis; 5 RTCs: 1161 women) (27).

250 In summary, upright positions in the first stage of labor should be recommended in

251 women without regional anesthesia. Women with regional anesthesia in the first stage can adopt

252 whatever position they find most comfortable (strong recommendation).

253

254 Maternal Ambulation

255 Women without regional anesthesia who ambulate have a shorter duration of labor by

256 approximately three hours and fifty-seven minutes, are more likely to have a spontaneous vaginal

257 birth, are less likely to have an operative vaginal delivery, and have a lower risk of having a

258 cesarean delivery compared to those in a recumbent, supine, or lateral position (Cochrane: 25

259 RCTs; 5218 women) (26).

260 For women with regional anesthesia who ambulate, there is no difference in duration of labor,

261 spontaneous vaginal birth, operative delivery, or cesarean delivery rates compared to those in a

262 recumbent position (meta-analysis; 5 RCTs: 1161) (27).

263 In summary, ambulating should be recommended in the first stage of labor in women

264 without regional anesthesia. Women with regional anesthesia can ambulate or not ambulate in

265 the first stage (strong recommendation).

266

267

268 Bladder catheterization

269 Continuous bladder catheterization during the first stage of labor in patients with an epidural is

270 associated with no differences in the length of labor or incidence of UTIs, but significantly

271 increased the likelihood of cesarean delivery compared to women with intermittent bladder

272 catheterization. However, this is based on one small trial that was unable to reach the sample

273 size from the original power analysis, thus more research is needed on bladder catheterization in

274 labor. (1 RCT; 123 women) (28).

275 In summary, routine continuous bladder catheterization cannot be recommended in labor

276 (weak recommendation).

277

278 Cervical Examinations/Membrane sweeping in labor

279 Two-hourly cervical examinations are not associated with any differences in length of labor,

280 epidural for pain relief, or mode of delivery, compared to four-hourly cervical examinations.

281 There was no data on maternal or neonatal infections in the one RCT evaluating frequency of
282 cervical examinations (1 RCT; 109 women) (29). Membrane sweeping performed once in labor

283 does not decrease the duration of labor compared to no sweeping (1 RCT; 400 women) (30).

284 In summary, there is no recommended frequency of cervical exams, or sweeping of

285 membranes in labor (weak recommendation).

286

287 Partogram

288 A partogram is a preprinted form which provides a pictorial overview of labor to plot progress

289 and alert health professionals to any problems with the mother or baby. As there is no universal

290 definition of ‘normal’ labor, diagnosing abnormal progression of labor is inherently difficult. The

291 use of partogram is not associated with any differences in cesarean delivery rates, oxytocin

292 augmentation, duration of first stage of labor, or Apgar score less than 7 at five minutes

293 compared to no partogram. Moreover, there is insufficient evidence to support the use of any

294 particular partogram or different implementation protocols of the partogram (Cochrane: 11

295 RCTs; 9475 women) (31).

296 In summary, the use of a partogram cannot be recommended as a routine intervention in

297 labor (weak recommendation).

298

299 Peanut Ball

300 The routine use of a peanut ball in labor is associated with a non-significant 79-minute shorter

301 labor, and no decrease in the total length of time to delivery, compared to no peanut ball.

302 However, there were also trends toward an increased incidence in spontaneous vaginal deliveries

303 and lower incidence of cesarean delivery (meta-analysis: 4 RCTs; 648 women) (32).
304 In summary, the routine use of the peanut ball cannot be recommended in labor (weak

305 recommendation).

306

307 Antispasmodics

308 Antispasmodics (e.g. valethamate bromide, hyoscine butyl-bromide, drotaverine hydrochloride,

309 rociverine and camylofin dihydrochloride) are associated with a 74 minute shorter duration of

310 the first stage of labor, and an increased rate of cervical dilatation by an average of 0.61 cm/hour.

311 Antispasmodics are not associated with a significant effect on the duration of second and third

312 stage of labor. The quality of the evidence is low to very low (Cochrane 17 RCTs, 2617 women)

313 (33).

314 In summary, antispasmodics cannot be routinely recommended in labor (weak

315 recommendation).

316

317 Amniotomy

318 Routine amniotomy alone in the first stage of normally progressing spontaneous labor is not

319 associated with a significant reduction in the length of labor, cesarean delivery, or neonatal

320 outcomes compared to no amniotomy (Cochrane; 15 RCTs; 5583 women) (34). The timing of

321 amniotomy during labor, in terms of cervical dilation, was not consistent between trials. There

322 are no RCTs on the use of amniotomy alone for women in dysfunctional labor.

323 In summary, routine amniotomy alone in normally progressing spontaneous first stage of

324 labor cannot be recommended (weak recommendation).

325

326 Oxytocin
327 Treatment with oxytocin for women making slow progress in spontaneous labor is associated

328 with a reduction in the time to delivery by approximately 2 hours, without any difference in

329 cesarean delivery rates compared to no treatment or delayed oxytocin treatment (Cochrane: 8

330 RCTs; 1,338 women) (35). A reasonable starting oxytocin regimen is 2 milliunits/min, and

331 increasing by 2 milliunits/minute (2mL/hr) approximately every 30 minutes (not more frequently

332 than every 20 minutes) as indicated by contraction pattern and fetal tolerance to medication with

333 a maximum dose of 20-40 milliunits per minute. Moreover, higher dose regimens (starting and

334 increments of oxytocin 4 milliunits/min) are associated with a reduction in length of labor and

335 overall cesarean delivery rates, compared with low-dose regimens (defined as starting dose and

336 an increment of less than 4 milliunits/minute), using an increase interval no shorter than every 15

337 minutes (Cochrane: 4 RCTs; 644 women) (36).

338 In summary, oxytocin augmentation is recommended to shorten the time to delivery for

339 women making slow progress in the first stage of spontaneous labor (strong recommendation).

340 Higher doses of oxytocin can be considered (weak recommendation) (Table 3).

341

342 Amniotomy and Oxytocin

343 Early intervention with oxytocin and amniotomy for the prevention of dysfunctional or slow

344 labor is associated with shorter duration of the first stage of labor, and lower rates of cesarean

345 delivery compared to no intervention. For treatment of dysfunctional labor, this intervention also

346 results in shorter duration of the first stage of labor, however there was no difference in cesarean

347 delivery rates – although the number of trials in the treatment group were 3, compared to 11 in

348 the prevention group (Cochrane: 14 RCTs; 8,033 women) (37).

349 In summary, early intervention with oxytocin and amniotomy for the prevention and

350 treatment of dysfunctional or slow labor is recommended (strong recommendation).

351

352 Use of Intrauterine Pressure Catheter (IUPC)

353 The routine use of the IUPC is associated with no differences in the rates of operative vaginal

354 delivery, cesarean delivery, maternal or neonatal infection, or other maternal or perinatal

355 outcomes, compared to no IUPC (Cochrane: 3 RCTs; 1945 women) (38). However, this review

356 was based on 3 studies of moderate quality, and thus there is an overall paucity of evidence to

357 recommend external over internal tocodynamometry. Moreover, this does not preclude the use of

358 an IUPC where clinically indicated, such as morbid obesity with the inability to monitor

359 contraction pattern, or use of IUPC to titrate oxytocin in abnormally progressing labor.

360 In summary, the routine use of the IUPC cannot be recommended in labor, unless

361 clinically indicated (weak recommendation).

362

363

364

365 Use of Ultrasound During the First Stage of Labor

366 Ultrasound evaluation of head position at 8cm dilatation or more is associated with a higher rate

367 of obstetric intervention with no improvement in maternal and neonatal outcome in low risk

368 women, compared to vaginal evaluation alone (RCT: 1903 women) (39).

369 In summary, the routine use of ultrasound during a normally evolving first stage of labor

370 cannot be recommended (weak recommendation).

371

372 Dystocia

373 Dystocia, including terms such as labor arrest, abnormal progression of labor, dysfunctional

374 labor, failure to progress, cephalopelvic disproportion and others, is the reason for the majority

375 of cesarean deliveries, and should not be diagnosed unless all these conditions have been

376 achieved:

377 - rupture of membranes (ROM)

378 - adequate oxytocin to achieve at least 2-3 contractions per 10-minute interval (5).

379 Before performing a cesarean delivery for active phase labor arrest, labor should be arrested for a

380 minimum of 4 hours if uterine activity is greater than 200 Montevideo units as documented with

381 IUPC, or 6 hours if greater than 200 Montevideo units could not be sustained with oxytocin or

382 IUPC is not used (40).

383 In summary, cesarean delivery for arrest in the first stage of labor should not be

384 performed unless labor has arrested for a minimum of 4 hours with adequate uterine activity, or 6

385 hours with inadequate uterine activity in a woman with ROM, adequate oxytocin, and ≥6cm

386 cervical dilation (weak recommendation).

387

388 Comment

389 Our review of the best quality evidence regarding interventions during the first stage of labor for

390 women with a singleton gestation at term with cephalic presentation confers several

391 recommendations (Table 1). These recommendations include that Vaginal disinfection with

392 chlorhexidine cannot be recommended. Intrapartum antibiotic prophylaxis is recommended for

393 GBS positive women. Antibiotics can be considered in women with term PROM whose latency

394 is expected to be >12 hours. Aromatherapy with essential oils through inhalation or back

395 massage can be considered. Immersion in water can be considered. Oral restriction of fluid or

396 solid food is not recommended. Water and clear fluids can be encouraged as tolerated. In the

397 setting of oral restriction, IVF at a rate of 250ml/hr containing dextrose, are recommended.

398 Upright positions and ambulation are recommended in women without regional anesthesia, and

399 women with regional anesthesia can adopt whatever position they find most comfortable and

400 choose to ambulate or not ambulate. Continuous bladder catheterization cannot be

401 recommended. There is no recommended frequency of cervical exams, or sweeping of

402 membranes. The use of a partogram cannot be recommended as a routine intervention. The

403 routine use of the peanut ball cannot be recommended. Antispasmodics cannot be recommended.

404 Routine amniotomy alone in normally progressing spontaneous first stage of labor cannot be

405 recommended. Oxytocin augmentation is recommended to shorten the time to delivery for

406 women making slow progress in spontaneous labor, and higher doses of oxytocin can be

407 considered. Early intervention with oxytocin and amniotomy for the prevention and treatment of

408 dysfunctional or slow labor is recommended. The routine use of the IUPC cannot be

409 recommended. The routine use an ultrasound is not recommended. Cesarean delivery for arrest

410 should not be performed unless labor has arrested for a minimum of 4 hours with adequate

411 uterine activity, or 6 hours with inadequate uterine activity in a woman with ROM, adequate

412 oxytocin, and ≥6cm cervical dilation.

413 Strengths of our review include being based almost exclusively on meta-analysis of RCTs or

414 RCTs (level 1 evidence). Another helpful feature is the quick summary provided in the table

415 (Table 1), so clinicians can quickly access evidence-based clinical guidance (9-40). Limitations
416 are related to interventions not supported by level 1 evidence of heterogeneity found in trials

417 included in meta-analysis.

418 In conclusion, in the first stage of labor, there is high quality evidence for providers to not

419 recommend routine use of vaginal disinfection, to provide intrapartum antibiotic prophylaxis to

420 GBS positive women or those with unknown GBS status and risk factors, to provide oral

421 nutrition, to encourage upright and mobile positions for those without regional anesthesia, to

422 allow women with regional anesthesia to take up their preferred position and ambulate as they

423 please, and to administer oxytocin with early amniotomy to prevent and treat dysfunctional

424 labor.

425
426 References:
427
428
429 1. Berghella V. New Series of reviews on evidence-based L&D management and cesarean
430 delivery! Am J Obstet Gynecol MFM 2020
431 2. American College of Obstetrics and Gynecology Committee on Practice Bulletins-
432 Obstetrics. ACOG Practice Bulletin Number 49, December 2003: Dystocia and
433 augmentation of labor. Obstet Gynecol 2003 Dec;102(6):1445-54
434 3. Hanley GE, Munro S, Greyson D, Gross MM, Hundley V, Spiby H, Janssen PA.
435 Diagnosing onset of labor: a systematic review of definitions in the research literature.
436 BMC Pregnancy Childbirth. 2016 Apr 2;16:71
437 4. Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM,
438 Sheffield JS. Williams Obstetrics 24th Edition. McGraw-Hill Education, New York, 2014
439 5. Zhang J, Landy HJ, Branch DW, Burkman R, Haberman S, Gregory KD, Hatjis CG,
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 Table 1. Evidence-based recommendations for interventions during the first stage of labor

Intervention Recommendation Quality of the Strength of the Reference

Evidence Recommendation
Vaginal Disinfection Vaginal disinfection with chlorhexidine in labor is not recommended High Strong 9-11
GBS Prophylaxis Intrapartum antibiotic treatment (penicillin as first line) is recommended for GBS positive Moderate Strong 12-19
women during labor with an aim of >4 hours of treatment prior to delivery
Antibiotics in PROM Prophylactic antibiotics in term PROM with latency longer than 12 hours can be considered Moderate Weak 20
Aromatherapy Aromatherapy with essential oils (lavender, jasmine, rose, almond, or mixture) through Moderate Weak 21
inhalation or back massage in labor can be considered
Immersion in water Immersion in the first stage of labor can be considered Moderate Weak 22
Nutrition Oral restriction of fluid or solid food is not recommended High Strong 23
Fluids In the setting of oral restriction, IVF at a rate of 250ml/hr containing dextrose, is recommended Moderate Strong 24-25
Maternal Position Upright positions for women without regional anesthesia is recommended. Women with regional High Strong 26,27
anesthesia should be encouraged to take up whatever position they find most comfortable
Ambulation Ambulating should be recommended in the first stage of labor in women without regional High Strong 26,27
anesthesia. Women with regional anesthesia can ambulate or not ambulate in the first stage
Bladder Continuous bladder catheterization cannot be recommended in labor Low Weak 28
catheterization
Cervical exam/ There is no recommended frequency of cervical exams, or sweeping of membranes in labor Low Weak 29,30
membrane sweeping
Partogram The routine use of the partogram is not recommended in labor Low Weak 31
Peanut Ball The routine use of a peanut ball cannot be recommended in labor Low Weak 32
Antispasmodics Antispasmodics are not recommended for routine use in the first stage of labor Low Weak 33
Amniotomy Routine use of amniotomy alone in normally progressing spontaneous labor is not recommended Moderate Strong 34
Oxytocin Use of oxytocin in slow labor progression is recommended Moderate Strong 35,36
Amniotomy and Early amniotomy and oxytocin is recommended in prevention and treatment of dysfunctional High Strong 37
Oxytocin labor
IUPC The routine use of IUPC in the first stage of labor is not recommended Moderate Weak 38
Ultrasound in Labor The routine use of ultrasound during a normally evolving first stage of labor is not Moderate Weak 39
recommended
Dystocia Cesarean for arrest in the first stage of labor should not be performed unless labor has arrested Moderate Weak 40
for a minimum of 4 hours with adequate uterine activity, or 6 hours with inadequate
uterine activity in a woman with ROM, adequate oxytocin, and ≥6cm dilated cervix
Quality of evidence and Strength of recommendation as per GRADE (8).
Table 2. Indications for Intrapartum Antibiotics Prophylaxis to Prevent Neonatal Group B Streptococcal Early-Onset Sepsis

Intrapartum GBS prophylaxis indicated Intrapartum GBS prophylaxis not indicated

Maternal History: • Colonization with GBS in a previous pregnancy (unless
• Previous neonate with invasive GBS disease colonization status in the current pregnancy is unknown
during labor)
Current Pregnancy: • Negative vaginal-rectal GBS culture obtained at 36 0/7 weeks
• Positive GBS culture obtained at 36 0/7 weeks or more during or more during the current pregnancy
the current pregnancy (unless a cesarean delivery is performed • Cesarean birth performed before the onset of labor on a
before the onset of labor for a woman with intact amniotic woman with intact amniotic membranes, regardless of GBS
membranes) colonization status or gestational age
• GBS bacteriuria at any point in the current pregnancy
Intrapartum: • Negative vaginal-rectal GBS culture obtained at 36 0/7 weeks
• Unknown GBS status at the onset of labor (culture not done or or more during the current pregnancy, regardless of
results unknown) and any one of the following: intrapartum risk factors
• Labor at less than 37 0/7 weeks • Unknown GBS status at onset of labor, NAAT result negative
• Amniotic membrane rupture for > 18 hours and no intrapartum risk factors present (ie, less than 37 0/7
• Intrapartum temperature of 100.4°F (38°C) or higher* weeks, amniotic membrane rupture > 18 hours, or maternal
• Intrapartum NAAT positive for GBS temperature of 100.4°F (38°C) or higher
• Intrapartum NAAT negative for GBS but any of the above risk
factors develop
• Known GBS positive status in a previous pregnancy

Abbreviations: GBS, Group B streptococcus; NAAT, nucleic acid amplification test

*If intraamniotic infection is suspected, broad spectrum antibiotic therapy that includes an agent known to be active against GBS
should replace GBS prophylaxis
Modified from Prevention of group B streptococcal early-onset disease in newborns. ACOG Committee Opinion No 782. American
College of Obstetricians and Gynecologists. Obstet Gynecol 2019;134:e19-40.
Table 3. Examples of different oxytocin regimens

Example of low dose regimen Example of high dose regimen

Oxytocin starting dose (milliunits/mL) 2 4
Increase by which interval (minutes) 30 15
Increase by how much oxytocin (milliunits/mL) 2 4
Maximum oxytocin dose (milliunits/mL) 20 40
Figure 1. Determination of Antibiotic Regimen for Group B Streptococcus Prophylaxis in
Labor in women with and without penicillin allergy

Prenatal assessment to determine an

intrapartum antibiotic prophylaxis
regimen

Not allergic to
Allergic to penicillin
penicillin

Penicillin G, 5 million units IV LOW risk^ HIGH risk~ UNKNOWN risk^

load then 2.5-3 million units
IV every 4 hours until
delivery*
or
Request clindamycin
ampicillin 2gm IV load then Cefazolin, 2gm IV susceptibility on Susceptibilities
1gm every 4 hours until load, followed by
1gm IV every 8 hours
laboratory requisition for available? or able to
delivery vaginal-rectal culture
until delivery perform?
done at 36 0/7-37 6/7
weeks of gestation

Yes

No

Clindamycin- Clindamycin-resistant
susceptible GBS GBS

Vancomycin: weight based dosage of

Clindamycin 900mg IV
20mg/kg every 8 hours. Maximum single
every 8 hours until
delivery dose is 2g. Minimum infusion time is 1
hour, or 500mg/30 min for a dose >1g

Abbreviations: GBS, group B streptococcus; IV, intravenous. *Doses ranging from 2.5 to 3.0
million units are acceptable for the doses administered every 4 hours following the initial dose.
The choice of dose within that range should be guided by which formulations of penicillin G are
readily available in order to reduce the need for pharmacies to specially prepare doses.
^Individuals with a history of any of the following: nonspecific symptoms unlikely to be allergic
(gastrointestinal distress, headaches, yeast vaginitis), nonurticarial maculopapular (morbilliform)
rash without systemic symptoms, pruritis without rash, family history of penicillin allergy but no
personal history, or patient reports history but has no recollection of symptoms or treatment.
~Individuals with a history of any of the following after administration of penicillin: a history
suggestive of an IgE-mediated event: pruritic rash, urticaria (hives), immediate flushing,
hypotension, angioedema, respiratory distress or anaphylaxis; recurrent reactions, reactions to
multiple beta-lactam antibiotics, or positive penicillin allergy test; or severe rare delayed-onset
cutaneous or systemic reactions, such as eosinophilia and systemic symptoms/drug-induced
hypersensitivity syndrome, Stevens-Johnson syndrome, or toxic epidermal necrolysis. (Modified
from Verani JR, McGee L, Schrag SJ. Prevention of perinatal group B streptococcal disease:
revised guidelines from CDC, 2010. Division of Bacterial Diseases, National Center for
Immunization and Respiratory Diseases, Centers for Disease Control and Prevention [CDC].
MMWR Recomm Rep 2010;59(RR-10):1–36.)
Evidence-based Labor Management: First stage of labor (Part 3)

Leen Alhafez M.D,1 Vincenzo Berghella M.D.1

1
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Jefferson

Medical College of Thomas Jefferson University, Philadelphia, PA

Correspondence:

Vincenzo Berghella, MD

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine

Thomas Jefferson University

833 Chestnut Street, First Floor

Philadelphia, PA 19107, USA

E-mail: [email protected]

Disclosure: The authors report no conflict of interest

Financial Support: No financial support was received for this manuscript