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An overview of systematic reviews of normal labor and delivery management

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 Review
Article

An overview of systematic reviews of normal labor and

delivery management
Mina Iravani1, Mohsen Janghorbani2, Elahe Zarean3, Masoud Bahrami4

Abstract
Background: Despite the scientific and medical advances for management of complicated health issues, the current maternity
care setting has increased risks for healthy women and their babies. The aim of this study was to conduct an overview of published
systematic reviews on the interventions used most commonly for management of normal labor and delivery in the first stage of labor.
Materials and Methods: The online databases through March 2013, limited to systematic reviews of clinical trials were searched.
An updated search was performed in April 2014. Two reviewers independently assessed data inclusion, extraction, and quality
of methodology.
Results: Twenty‑three reviews (16 Cochrane, 7 non‑Cochrane), relating to the most common care practices for management of
normal labor and delivery in the first stage of labor, were included. Evidence does not support routine enemas, routine perineal
shaving, continuous electronic fetal heart rate monitoring, routine early amniotomy, and restriction of fluids and food during labor.
Evidence supports continuity of midwifery care and support, encouragement to non‑supine position, and freedom in movement
throughout labor. There is insufficient evidence to support routine administration of intravenous fluids and antispasmodics during
labor. More evidence is needed regarding delayed admission until active labor and use of partograph.
Conclusions: Evidence‑based maternity care emphasizes on the practices that increase safety for mother and baby. If policymakers
and healthcare providers wish to promote obstetric care quality successfully, it is important that they implement evidence‑based
clinical practices in routine midwifery care.

Key words: Childbirth, evidence‑based practice, intrapartum care, labor, overview of systematic reviews, quality improvement

Introduction interventions consistent with safety.[2] Despite the scientific

and medical advances for management of complicated health

G
iving birth is a life‑changing event, and the care that issues, the current maternity care setting has increased risks
a woman receives during labour has the potential to for healthy women and their babies.[3] There are worries all
affect her both physically and emotionally the short over the world that non–evidence‑based interventions and
and longer term.”[1] The World Health Organization (WHO) practices during labor and delivery remain the standard
states that the aim of intrapartum care is achieving a practice.[4] So, there remains a widespread underuse of
healthy mother and child using the least possible number of beneficial practices, overuse of harmful or ineffective
practices, and hesitancy about the effects of insufficiently,
1
Department of Midwifery and Reproductive Health, Student’s inadequately evaluated practices.[5] Therefore, improving the
Research Center, Faculty of Nursing and Midwifery, Isfahan quality of maternity care in both developed and developing
University of Medical Sciences, Isfahan, Iran, Department of countries is an important part of attempts made to decrease
Midwifery, Reproductive Health Promotion Research Center, maternal and neonatal mortality and morbidity.[6] One of
Faculty of Nursing and Midwifery, Ahvaz Jundishapur University the best approaches for quality improvement of care in
of Medical Sciences, Ahvaz, Iran, 2Department of Epidemiology,
clinical environments with limited resources is application of
School of Health, Isfahan University of Medical Sciences, Isfahan,
Iran, 3Department of Obstetrics and Gynecology, School of Medicine, evidence‑based standards for management of spontaneous
Isfahan University of Medical Sciences, Isfahan, Iran, 4Department of vaginal births. [7,8] Evidence‑based labor and delivery
Adult Health Nursing, Nursing and Midwifery Care Research Center, management apply the best available research on the
Faculty of Nursing and Midwifery, Isfahan University of Medical safety and effectiveness of special practices to help decide
Sciences, Isfahan, Iran on maternity care and achieve the best possible outcomes
Address for correspondence: Prof. Mohsen Janghorbani, in mothers and newborns.[5] It is essential that obstetricians
Department of Epidemiology, School of Public Health, Isfahan and midwives who provide care during labor ensure that
University of Medical Sciences, Isfahan, Iran. intrapartum care is evidence‑based clinical practice[9] A
E‑mail: janghorbani@hlth.mui.ac.ir large number of studies of maternity care interventions
Submitted: 12-May-14; Accepted: 16-Dec-14 have been published. It is obvious that systematic reviews

Iranian Journal of Nursing and Midwifery Research | May-June 2015 | Vol. 20 | Issue 3 293
 Iravani, et al.: Overview of normal labor management
of individual studies were needed to evaluate, summarize, first stage of labor. Each aspect of labor and delivery was
and bring together available studies in a single place.[10] The reviewed separately. We have used systematic reviews that
objective of the overview of reviews is to summarize multiple included interventions with placebo/no treatment or with a
intervention reviews for the identification of the effects of different intervention.
two or more interventions for a single situation in relation
to health issues.[11] In obstetric care, many interventions are Data extraction
complex, containing a number of different components which We extracted data on systematic reviews (the first author’s
may have an effect on the impact of the interventions in last name, year of publication, number of papers included in
healthcare settings.[12] Several Cochrane and non‑Cochrane the review, methodological details, midwifery intervention,
systematic reviews have assessed different types of outcome measured, and results). For each review, the data
interventions for normal labor and delivery management. were independently extracted by two investigators (MI and
We intend to summarize their results for decision‑makers, EZ), and if their evaluations differed, the discrepancy was
such as clinicians, policymakers, or informed consumers, in resolved by discussion.
an overview of systematic reviews. This overview will serve
as a user‑friendly “digest” by evaluating and synthesizing Quality assessment
current evidence which will allow the reader a quick overview It is important to consider the type of evidence included in
of different interventions used most commonly for normal reviews, i.e. was the review restricted to randomized trials
labor and delivery management. only or other types of studies included, and also to assess
how well the review was conducted methodologically. As
Materials and Methods such, a two‑stage process was employed: Firstly, the level
of evidence was graded and secondly, the methodological
The present overview of systematic reviews was done in quality was assessed. All eligible reviews were assessed
accordance with the Preferred Reporting Items of Systematic using a measurement tool for the assessment of multiple
Reviews Meta‑Analyses (PRISMA) guidelines for reviews of systematic reviews (AMSTAR). AMSTAR is an 11‑item tool
clinical trials.[13] to assess the methodological quality of systematic reviews
that has been internally and externally validated and has
Search strategy been found to have good reliability.[37] The 11 items were
A literature search of online databases (PubMed, Web assessed for each review and the total number of positive
of Science, Google Scholar, and Cochrane Library) answers for each was documented. The reviews were then
through March 2013 was performed. An updated  search divided into the following categories: High quality: 9 or
was performed in April 2014 in Cochrane Library. We more positive answers; intermediate quality: 5–8 positive
translated the search strategy for each database plus each answers; and low quality: 4 or less positive answers. Two
management aspect (e.g. early admission, early rupture of authors (MI and EZ) independently performed quality
membranes) using the appropriate controlled vocabulary assessment. Disagreements were resolved by discussion or
as applicable. The search was limited to systematic reviews consultation with a third individual (MJ).
of clinical trials. We also reviewed the reference lists of
identified publications for additional pertinent reviews. No Judgments about the quality of the primary studies were
language restrictions were imposed. The titles and abstracts taken from the respective systematic reviews.   We assessed
were obtained and the decision process for eligibility was the Cochrane reviews using the domain‑based evaluation
followed. Full text was obtained of all eligible reviews and for assessment of risk of bias. [38] For non‑Cochrane
those whose eligibility could not be discerned from reading systematic reviews, we have summarized the methods used
the abstract. to assess methodological quality, including details regarding
the tools used and the dimensions assessed, e.g. sequence
Eligibility criteria generation, allocation sequence concealment, blinding,
Twenty‑three systematic reviews of randomized or incomplete outcome data, etc.
quasi‑randomized controlled trials were considered for
inclusion in this overview of systematic reviews on the Data synthesis
management of normal labor and delivery in the first We have presented characteristics of included reviews and
stage of labor.[14‑36] The participants in these reviews were AMSTAR ratings for each systematic review in summary
limited to low‑risk, healthy women with an uncomplicated tables. We have provided a narrative summary of the results
pregnancy, with a singleton gestation in vertex presentation, of the individual reviews for all outcomes reported by the
entering spontaneous labor, and having a gestational age studies for each of the aspects of normal labor and delivery
of 37–41 weeks. We considered aspects of interventions management. It was not anticipated that we would be able
used for management of normal labor and delivery in the to perform any quantitative data analyses.

Iranian Journal of Nursing and Midwifery Research | May-June 2015 | Vol. 20 | Issue 3 294
 Iravani, et al.: Overview of normal labor management

Results unit spent less time in the labour ward, were less likely to
receive intrapartum oxytocics and analgesia, than women
Figure 1 shows a flow diagram describing the study selection who were admitted directly to the labour ward.”[14]
process. The initial search yielded 1190 research reports,
of which 54 were excluded for having the same title or We found one systematic review [including three
authors and 1136 were excluded due to not having eligible randomized controlled trials (RCTs) involving 1039
study design (including non‑human studies, case reports, women] of perineal shaving for women on admission in
comment, letter, and observational study). Additional 36 the labor ward. Based on this review, “there was insufficient
studies were found irrelevant to the original research question evidence to recommend perineal shaving for women on
and were excluded. Of the 90 remaining studies, 67 either admission in labor. Also there is sufficient evidence that
updated by another included review, not systematic review, avoiding routine perineal shaving for women prior to
inappropriate population, inappropriate intervention, or labor is safe.” Furthermore, “the potential for side‑effects
not meet inclusion criteria. A total of 23 systematic reviews suggests that shaving should not be part of routine clinical
were included in our overview [Table 1]. All systematic practice.”[15]
reviews assessed interventions used most commonly for
labor and delivery management in the first stage of labor. One systematic review (four RCTs including 1917 women)
All reviews were published between 1996 and 2013, with was related to use of enemas during labor. Only one study
the majority (n = 18) having been published from 2000 was judged as having low risk of bias: “Scientific research
to 2013. Overall quality of the existing systematic reviews evidence does not support the routine use of enemas during
was variable. The quality of Cochrane reviews was high, the first stage of labor; therefore, such practice should be
but the quality of non‑Cochrane reviews was intermediate discouraged.”[16]
or low [Table 2]. To avoid losing meaning, the findings
contain direct quotes as those authors of systematic reviews We found one meta‑analysis (21 RCTs including 3286
have stated. women) of administering antispasmodics during labor.
Most studies included in this review lacked methodological
In this overview, one systematic review was related to the rigor. Only four studies were considered as having a low
time of admission of women with low‑risk pregnancy to the risk of bias. Authors of this review concluded, “There
labor ward. In this review, only one study of 209 women is low quality evidence that antispasmodics reduce the
was included. The trial was of excellent quality. Authors of duration of first stage of labor and increase the cervical
this review concluded, “Labor assessment programs, which dilatation rate. Also there is very low quality evidence
aim to delay hospital admission until active labor, may that antispasmodics reduce the total duration of labor.”
benefit women with term pregnancies. The review found, Furthermore, “there is insufficient evidence to make any
women who were randomised to the labour assessment conclusions regarding the safety of these drugs for both
mother and baby.”[17]

V\VWHPDWLFUHYLHZVIRXQG There were two systematic reviews related to use of

intravenous fluids during labor. Authors of these reviews
implied that “there is no robust evidence to recommend
([FOXGHGEDVHGRQ routine administration of intravenous fluids.”[18] They
5HFRUGVDIWHUGXSOLFDWHVUHPRYHG also reported that “future trials should examine the use of
5HFRUGVQRWUHODWHGWRWKHWRSLF
different types of intravenous and oral fluids on clinically
important outcomes and include women’s perception and
satisfaction with care during labor and birth.”[19]
5HFRUGVVFUHHQHG 5HFRUGVH[FOXGHG

VWXGLHVH[FOXGHG
One systematic review (6 studies including 7706 women)
RQRUPRUHFULWHULD was related to use of partogram during labor: Two trials
XSGDWHGE\DQRWKHU comparing partogram versus no partogram and three
UHOHYDQWVWXGLHVVHOHFWHGIRU LQFOXGHGUHYLHZ
HYDOXDWLQJE\UHDGLQJIXOOWH[W QRWV\VWHPDWLFUHYLHZ trials comparing different partogram formats. Four of the
LQDSSURSULDWH five trials were of good quality. In the remaining trial, the
SRSXODWLRQ method of allocation concealment and the method of
,QDSSURSULDWH
,QWHUYHQWLRQ randomization were unclear. Authors reported, “Based on
6WXGLHVLQFOXGHGLQ 1RWPHHWLQFOXVLRQ the evidence in this review, we couldn’t recommend routine
TXDOLWDWLYHV\QWKHVLV &ULWHULD
use of the partogram as part of standard labor management
Figure 1: Flow diagram of the review-selection process and care.”[20]

Iranian Journal of Nursing and Midwifery Research | May-June 2015 | Vol. 20 | Issue 3 295
 Iravani, et al.: Overview of normal labor management
Table 1: Summary of included systematic reviews for normal labor and delivery management
Source Intervention Search No. of Study Inclusion Comparison Key finding Quality of
strategy studies population criteria for interventions review
included and no. of “types of
participants participants”
Lauzon Delaying admission Cochrane 1 209 women All pregnant Direct Women have shorter High quality
et al., 2009[9] to the labor ward review women at term admission to labor ward stays, feel
until active phase (2004) gestation labor wards more controlled, and
in labor use fewer drugs to
progress labor or for
pain relief
Basevi Perineal shaving Cochrane 3 1039 All primiparous No perineal There is insufficient High quality
et al., 2009[10] review women and shaving evidence to
(2008) multiparous recommend perineal
women shaving for women
on admission in labor
Reveiz Enemas applied Cochrane 4 1917 Women during No enema Evidence does not High quality
et al., 2013[11] during the first review women the first stage support the routine
stage of labor (2013) of labor use of enemas during
the first stage of
labor; therefore, such
practice should be
discouraged
Rohwer Use of Cochrane 21 3296 Women Placebo or no There is insufficient High quality
et al., 2013[12] antispasmodics review women with term medication evidence to make any
on labor in term (2013) pregnancies conclusions regarding
pregnancies the safety of these
drugs for both mother
and baby
Dawood Routine Cochrane 9 1781 Low‑risk Oral intake There is no robust High quality
et al., 2013[13] administration of review women nulliparous alone or evidence to
intravenous fluids to (2013) women oral intake recommend routine
low‑risk nulliparous restricted administration of
laboring women intravenous fluids
Toohill Use of intravenous Cochrane No trials 0 Women No Future trials should High quality
et al., 2012[14] fluids or increased review with an intervention examine the use of
oral intake (2008) uncomplicated different types of
administered to pregnancy intravenous and oral
women in labor for fluids on clinically
the treatment of important outcomes
ketosis
Lavender Use of partogram Cochrane 6 7706 All women No Cannot recommend High quality
et al., 2013[15] on perinatal and review women with singleton partogram, or routine use of the
maternal morbidity (2013) pregnancies comparison partogram as part
and mortality and cephalic between of standard labor
presentations, different management and
in spontaneous partogram care
labor at term designs
Smyth Amniotomy alone Cochrane 15 5583 Pregnant Intention to Do not recommend High quality
et al., 2013[16] review women women with preserve the that amniotomy be
(2013) singleton membranes introduced routinely
pregnancies as part of standard
entry in labor management
spontaneous and care
labor
Brisson‑Carroll Amniotomy Non‑ 7 3098 Multi‑ and Attempt to No support for the Intermediate
et al., 1996[17] Cochrane women nulliparous conserve the hypothesis that routine quality
review women in membranes early amniotomy
labor reduces the risk of
cesarean delivery

Contd...

Iranian Journal of Nursing and Midwifery Research | May-June 2015 | Vol. 20 | Issue 3 296
 Iravani, et al.: Overview of normal labor management
Table 1: Contd...
Source Intervention Search No. of Study Inclusion Comparison Key finding Quality of
strategy studies population criteria for interventions review
included and no. of “types of
participants participants”
Singata Oral fluid or food Cochrane 5 3130 Women in Women free Since the evidence High quality
et al., 2013[18] restriction during review women labor to eat and shows no benefits
labor (2013) drink or harms, there is no
justification for the
restriction of fluids
and food in labor for
women at low risk of
complications
O’Sullivan Use of light diet Non‑ 5 973 women Multiparae Water only Do not support the Low quality
et al., 2007[19] or isotonic drinks Cochrane and nulliparae, concept that caloric
(carbohydrate) review singleton data shortens the
fetus, cephalic duration of labor
presentation, or decreases the
gestation cesarean section rate
>37 weeks
Lawrence Encouraging Cochrane 25 5218 Women in the Recumbent There is evidence High quality
et al., 2013[20] women to assume review women first stage of positions in that walking and
different upright (2013) labor the first stage upright positions in
positions (including of labor the first stage of labor
walking, sitting, reduce the duration
standing, and of labor, the risk of
kneeling) cesarean birth, the
need for epidural,
and do not seem to
be associated with
increased intervention
or negative effects on
mothers and babies
Souza Encouraging Non‑ 9 2220 Women with No Adoption of the upright Intermediate
et al., 2006[21] women to adopt an Cochrane women normal labor intervention position or ambulation quality
upright position or teview during the first stage
to ambulate during of labor may be safe,
the first stage of but considering the
labor available evidence
and its consistency,
it cannot be
recommended as an
effective intervention
to reduce the duration
of the first stage of
labor
Hodnett Continuous, Cochrane 22 15,288 Pregnant Usual care Continuous support High quality
et al., 2013[22] one‑to‑one review women women, in during labor has
intrapartum support (2013) labor clinically meaningful
benefits for women
and infants and no
known harm
Zhang Continuous labor Non‑ 7 Unknown Young, Routine In these women, Low quality
et al., 1996[23] support Cochrane low‑income, intrapartum not only labor
review primiparous care without was shorter, but
women in a labor also oxytocin use,
labor attendant analgesic needs,
and cesarean
delivery rates were
significantly reduced.
Supported mothers
felt less fatigued
during and after labor,
and delivery and
were more satisfied
Contd...

Iranian Journal of Nursing and Midwifery Research | May-June 2015 | Vol. 20 | Issue 3 297
 Iravani, et al.: Overview of normal labor management
Table 1: Contd...
Source Intervention Search No. of Study Inclusion Comparison Key finding Quality of
strategy studies population criteria for interventions review
included and no. of “types of
participants participants”
Scott Continuous support Non‑ 11 4230 Women with Intermittent The continuous Intermediate
et al., 1999[24] provided by doulas Cochrane women normal labor support presence of a doula quality
during labor review during labor during labor and
delivery appears
to have a greater
beneficial effect than
the support provided
on an intermittent
basis
Sandall Midwife‑led models Cochrane 13 16,242 Pregnant Other models Women who had High quality
et al., 2013[25] of care review women women of care for midwife‑led models
(2013) classified as childbearing of care were less
having low or women and likely to experience
mixed risk of their infants regional analgesia,
complications episiotomy, and
instrumental delivery,
and were more likely
to experience no
intrapartum analgesia/
anaesthesia,
spontaneous vaginal
birth, and feeling
in control during
childbirth
Waldenström Continuity of Non‑ 7 9148 Women with Standard Continuity of Intermediate
et al., 1998[26] midwifery care Cochrane women normal labor maternity midwifery care is quality
review care associated with
lower intervention
rates than standard
maternity care
Devane Admission CTG Cochrane 4 13,000 Low‑risk Intermittent The findings support High quality
et al., 2012[27] with intermittent review women pregnant auscultation recommendations
auscultation of the (2011) women of the FHR that the admission
FHR CTG not be used for
women who are at
low risk on admission
in labor
Alfirevic Continuous CTG Cochrane 13 37,000 Pregnant No fetal Continuous CTG was High quality
et al., 2013[28] during labor review women women in monitoring or associated with an
(2012) labor and their intermittent increase in cesarean
babies auscultation sections and
or intermittent instrumental vaginal
CTG births
Wei Early augmentation Cochrane 14 8033 Pregnant Standard Early intervention High quality
et al., 2013[29] with amniotomy review women women in care with amniotomy and
and oxytocin for (2013) spontaneous oxytocin appears to
prevention of, or labor be associated with a
therapy for, delay in modest reduction in
labor progress the rate of cesarean
section over standard
care
Fraser Early augmentation Non‑ 12 5111 women Women with A less active Early augmentation Intermediate
et al., 1998[30] with amniotomy and Cochrane normal labor form of does not appear to quality
oxytocin review in prevention management provide benefit over
trials a more conservative
form of management
in the context of care
of nulliparous women
with mild delays in
the progress of labor
Contd...

Iranian Journal of Nursing and Midwifery Research | May-June 2015 | Vol. 20 | Issue 3 298
 Iravani, et al.: Overview of normal labor management
Table 1: Contd...
Source Intervention Search No. of Study Inclusion Comparison Key finding Quality of
strategy studies population criteria for interventions review
included and no. of “types of
participants participants”
Brown Active management Cochrane 7 5390 Healthy Women Active management High quality
et al., 2013[31] of labor review women pregnant receiving is associated with
(2013) women with routine care small reductions in
spontaneous the CS rate, but it is
labor at term highly prescriptive
and interventional
CTG: Cardiotocography, FHR: Fetal heart rate

Table 2: Assessment of the quality of included systematic reviews (AMSTAR ratings)

Systematic review AMSTAR question Total Quality of
score review
1 2 3 4 5 6 7 8 9 10 11
Lauzon et al., 2009[9] Yes Yes Yes Yes Yes Yes Yes Yes Not No Yes 9 High
applicable
Basevi et al., 2009[10] Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 10 High
Reveiz et al., 2013 [11]
Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 10 High
Rohwer et al., 2013[12] Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11 High
Dawood et al., 2013 [13]
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11 High
Toohill et al., 2012[14] Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 10 High
Lavender et al., 2013 [15]
Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 10 High
Smyth et al., 2013[16] Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 10 High
Brisson‑Carroll et al., 1996 [17]
Yes Yes Yes Can’t Yes Yes Yes No Yes No No 7 Intermediate
answer
Singata et al., 2013[18] Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 10 High
O’Sullivan et al., 2007[19] Can’t No No No No Yes No No Yes No No 2 Low
answer
Lawrence et al., 2013[20] Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 10 High
Souza et al., 2006[21] Yes Yes Can’t Yes No Yes Yes No Yes No Yes 7 Intermediate
answer
Hodnett et al., 2013[22] Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 10 High
Zhang et al., 1996 [23]
Can’t Yes No Yes No Yes No No Yes No No 4 Low
answer
Scott et al., 1999[24] Can’t Yes Yes Can’t No Yes Yes No Yes No No 5 Intermediate
answer answer
Sandall et al., 2013[25] Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 10 High
Waldenström et al., 1998 [26]
Yes Yes Yes Can’t No Yes Yes No Yes No No 6 Intermediate
answer
Devane et al., 2012[27] Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 10 High
Alfirevic et al., 2013[28] Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 10 High
Wei et al., 2013 [29]
Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 10 High
Fraser et al.,1998[30] Can’t Yes No Can’t Yes Can’t Yes Yes Yes No Yes 6 Intermediate
answer answer answer
Brown et al., 2013[31] Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes 10 High
AMSTAR: Assessment of multiple systematic reviews

There were two systematic reviews related to use of routine intervention actually received. On the basis of the findings
amniotomy during labor. In the Smyth et al. review,[21] a of this review, we do not recommend that “amniotomy be
total of 5583 women were recruited in 15 trials comparing introduced routinely as part of standard labor management
amniotomy with intention to preserve the membranes. and care.” The meta‑analysis by Brisson‑Carroll et al.[22]
All data in the review were presented by the allocated implied that “routine amniotomy is associated with both
group (intention‑to‑treat analysis) and not by the benefits and risks. Benefits include a reduction in labor

Iranian Journal of Nursing and Midwifery Research | May-June 2015 | Vol. 20 | Issue 3 299
 Iravani, et al.: Overview of normal labor management
duration and a possible reduction in abnormal 5‑minute women should have support throughout labor and birth.”
Apgar scores. The evidence provides no support for the In the review of Zhang et al.,[28] four studies (1349 patients)
hypothesis that routine early amniotomy reduces the were included. The authors reported, “Continuous labor
risk of Caesarean delivery. An association between early support by labor attendants for young, low‑income,
amniotomy and Caesarean delivery for fetal distress was primiparous women ameliorates the effect of dysfunctional
noted in one large trial, suggesting that amniotomy should uterine activity. In these women, not only was labor shorter,
be reserved for patients with abnormal labor progress.” but oxytocin use, analgesic needs and Caesarean delivery
rates were significantly reduced. Supported mothers felt
There were two systematic reviews related to the restriction less fatigued during and after labor and delivery and were
of fluids and food in labor. Singata et al.[23] identified five more satisfied. In the postpartum period, mothers who had
studies (3130 women). In this Cochrane review, the overall labor support showed increased mother infant bonding
quality of the evidence was reasonable. The authors and breast‑feeding.” Scott et al.,[29] in a meta‑analysis,
concluded that “since the evidence shows no benefits or demonstrate that “the continuous presence of a doula during
harms, there is no justification for the restriction of fluids labor and delivery appears to have a greater beneficial effect
and food in labor for women at low risk of complications.” than the support provided on an intermittent basis. Thus,
The meta‑analysis by O’Sullivan et al.[24] (5 studies, 973 every effort should be made to ensure that women’s birth
women) suggested that current evidence does not support environments are empowering, non‑stressful, afford privacy,
the concept that caloric data shortens the duration of labor. communicate respect and are not characterized by routine
Authors of this review implied that “current studies do not interventions that add risk without clear benefit.”[39]
support the claim that oral intake decreases the Cesarean
section (CS) rate.” Two systematic reviews were related to continuity of
midwifery care during labor. A Cochrane review of
We found two systematic reviews of maternal position and 13 studies (16,242 women) determined that “most women
mobility during labor. Lawrence et al.[25] included 25 studies should be offered midwife‑led models of care and women
with a total of 5218 women. Overall, the quality of the should be encouraged to ask for this option although
studies included in the review was mixed and most studies caution should be exercised in applying this advice to
provided little information on the methods. Authors of this women with substantial medical or obstetric complications.”
Cochrane review concluded that “walking and upright The methodological quality of the included trials based on
positions in the first stage of labour reduces the duration of allocation concealment was “high quality” for nine trials and
labour, the risk of caesarean birth, the need for epidural, and “unclear” for two trials.[30] Waldenström et al.,[31] in another
does not seem to be associated with increased intervention review, reported, “Continuity of midwifery care is associated
or negative effects on mothers’ and babies’ well being. with lower intervention rates than standard maternity care.
Women should be encouraged to take up whatever position No statistically significant differences were observed in
they find most comfortable in the first stage of labor.” maternal and infant outcomes. However, more research
is necessary to make definite conclusions about safety, for
Another meta‑analysis by Souza et al.[26] implied that the infant as well as for the mother. This review illustrates
“adoption of the upright position or ambulation during first the variation in the different models of alternative and
stage of labor may be safe, but considering the available standard maternity care, and thus the problems associated
evidence and its consistency, it cannot be recommended with pooling data from different trials.”
as an effective intervention to reduce duration of the first
stage of labor.” Therefore, “Women should be encouraged Two systematic reviews were related to cardiotocography
to take up whatever position they find most comfortable (CTG) during labor. Devane et al.[32] found no evidence of
while avoiding spending long periods supine. Women’s benefit for the use of admission CTG for low‑risk women
preferences may change during labor. Many women may on admission in labor. The findings of current evidence
choose an upright or ambulant position in early first stage of support recommendations that “the admission CTG should
labor and choose to lie down as their labor progresses.”[25] not be used for women who are at low risk on admission
in labor. Women should be informed that admission CTG
We found three systematic reviews of continuous labor is likely associated with an increase in the incidence of CS
support during labor. In Hodnett et al.’s[27] review, the without evidence of benefit.” Alfirevic et al.[33] implied that
methodological quality of the trials was generally good “continuous CTG during labor is associated with a reduction
to excellent. Authors of this Cochrane review reported, in neonatal seizures, but no significant differences in
“Continuous support during labor has clinically meaningful cerebral palsy, infant mortality or other standard measures
benefits for women and infants and no known harm. All of neonatal well‑being. However, continuous CTG was

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 Iravani, et al.: Overview of normal labor management
associated with an increase in CSs and instrumental quality of the included studies. Although all reviews are
vaginal births. The real challenge is how best to convey this summarized and reported, we focused our conclusion on
uncertainty to women to enable them to make an informed reviews of higher quality (AMSTAR > 5).
choice without compromising the normality of labor.”
Based on this overview, scientific evidence does not
The use of oxytocin for speeding up labor with normal support routine enemas, routine perineal shaving,
progress has not been studied as a primary isolated continuous electronic fetal heart rate monitoring, routine
intervention. There were two systematic reviews related to early amniotomy, and restriction of fluids and food in
augmentation by amniotomy and oxytocin. In prevention labor; these practices can be associated with complications
trials, “early intervention with amniotomy and oxytocin without sufficient benefits, and should probably be avoided.
appears to be associated with a modest reduction in the Evidence supports of continuous support, continuity of
rate of CS over standard care.”[34] Fraser reported, “Early midwifery care, encouragement of non‑supine position,
augmentation does not appear to provide benefit over a and freedom in movement throughout labor; these practices
more conservative form of management in the context should be routinely performed. There is insufficient
of care of nulliparous women with mild delays in the evidence to routine administration of intravenous fluids and
progress of labor.”[35] Evidence of the research suggested antispasmodics during labor; therefore, it should probably
that only women with truly abnormal labor progress be left for women to decide. More evidence is needed
should have amniotomy and that only women with truly regarding delayed admission until active labor and use of
prolonged labors and sluggish uterine activity should receive partograph.
oxytocin.[40]
The WHO classifies routine use of pubic shaving, enema,
Brown et al.[36] compared low‑risk women receiving a intravenous infusion, and routine use of the supine position
predefined package of care (active management) with during labor as practices that are clearly harmful or ineffective
women receiving routine care. In this review, the quality of and should be eliminated; allowing women to drink
the included studies was variable. Authors of this review fluids during labor and fetal monitoring with intermittent
reported, “Active management is associated with small auscultation, use of partogram in labor, empathic support by
reductions in the CS rate, but it is highly prescriptive and caregivers during labor, offering oral fluids during labor and
interventional. It is possible that some components of the delivery, freedom in position and movement throughout
active management package are more effective than others. labor, and encouragement of non‑supine position in labor
Further work is required to determine the acceptability of as practices that are demonstrably useful and should be
active management to women in labor.” encouraged; routine early amniotomy in the first stage of
labor as a practice for which insufficient evidence exists
Discussion to support a clear recommendation and which should
be used with caution while further research clarifies the
Our main objective was to find, summarize, and bring issue; and lists   electronic fetal monitoring during labor,
together existing systematic reviews in a single place as the restriction of food and fluids during labor, and oxytocin
authors of these papers have reported. Due to the breadth augmentation of labor as practices that are frequently used
of the topic, it was not possible, in this review, to describe inappropriately.[41] Although the recommendations dated
comprehensively all intrapartum interventions that have from1996, researchers have found that they are still useful
been subjected to systematic review, but this review of because they are in line with today’s recommendations
systematic reviews was aimed at identifying high‑quality and evidence.[42]
reviews on the interventions used most commonly for
management of normal labor and delivery in the first stage The guide to effective care in pregnancy and childbirth
of labor. This overview included 23 systematic reviews categorizes routine pubic shaving and enema forms of care
including 16 Cochrane reviews and 7 non‑Cochrane that are likely to be ineffective or harmful (ineffectiveness or
reviews. harm demonstrated by clear evidence); routine intravenous
infusion in labor, routine use of IVs and not allowing women
It was not surprising that all Cochrane reviews received to eat or drink during labor as forms of care that are unlikely
high‑quality grading. For the non‑Cochrane reviews, scores to be beneficial (evidence against these forms of care not
were intermediate or low; this was commonly because some as firmly established); amniotomy to augment slow labor
features of the review process may not have been clearly as a form of care that is likely to be beneficial; emotional
stated in the published reviews. Our study showed that the and psychological support in labor as beneficial form of
Cochrane reviews had a greater level of appraisal for the care (effectiveness demonstrated by clear evidence from

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 Iravani, et al.: Overview of normal labor management
controlled trials); admission CTG tests as form of care of Clinical Guidelines, No. 55).
unknown effectiveness (insufficient or inadequate quality 2. Sandin‑Bojo AK, Kvist LJ. Care in labor: A Swedish survey using
data upon which to base a recommendation for practice); the Bologna Score. Birth 2008;35:321‑8.
and lists early use of oxytocin to augment slow or prolonged 3. Lothian JA. Safe, healthy birth: What every pregnant woman
needs to know. J Perinat Educ 2009;18:48‑54.
labor and “active management” of labor as forms of care 4. Khresheh R, Homer C, Barclay L. A comparison of labour and
with unknown effectiveness.[43] birth outcomes in Jordan with WHO guidelines: A descriptive
study using a new birth record. Midwifery 2009;25:e11‑8.
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a comprehensive search strategy. Second, duplicate is and what it can achieve. Childbirth Connection. New York:
screening, data extraction, and quality assessments were Milbank Memorial Fund; 2008. Available from: http://www.
childbirthconnection.org [Last accessed on 2013 March 20].
conducted. Third, a validated instrument (AMSTAR) was
6. Freedman L, Graham WJ, Brazier E, Smith JM, Ensor T,
used to evaluate the methodological quality of included Fauveau V, et al. Practical lessons from global safe motherhood
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for maternity care practices and should be implemented
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throughout the clinical centers. et al. From ‘culture of dehumanization of childbirth’ to
‘childbirth as a transformative experience’: Changes in five
Our overview has several limitations. First, the aim of this municipalities in north‑east Brazil. Int J Gynaecol Obstet
overview was to evaluate the systematic reviews instead 2001;75(Suppl 1):S67‑72.
of the individual initial studies, which means there is a risk 9. Gülmezoglu AM. Promoting standards for quality of maternal
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of rarifying the results of high‑quality studies by including
10. Smith V, Devane D, Begley CM, Clarke M. Methodology in
low‑quality data. The second limitation of this review is conducting a systematic review of systematic reviews of
the variation in practices. Third, it is possible that some of healthcare interventions. BMC Med Res Methodol 2011;11:5.
the newly published studies have not yet been included in 11. Becker LA, Oxman AD. Overviews of reviews (Part 3:
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Version 5.1.0 [Last updated on 2011 Mar 12].
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midwifery care: Reflections on the design and evaluation of an
Some of the routine interventions that are common during algorithm for the diagnosis of labour. Midwifery 2011;27:654‑9.
labor and birth might not always be essential or beneficial for 13. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group.
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care be incorporated into clinical practice setting. This 14. Lauzon L, Hodnett E. Labour assessment programs to delay
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18. Dawood F, Dowswell T, Quenby S. Intravenous fluids for
This study as part of PhD thesis of the first author was approved reducing the duration of labour in low risk nulliparous women.
by Isfahan University of Medical Sciences, Iran (with code of Cochrane Database Syst Rev 2013;(6):CD007715.
391206). Hereby, the researchers appreciate the Faculty of 19. Toohill J, Soong B, Flenady V. Interventions for ketosis during
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