Chapters 5-21 of Optimal Care in Childbirth end with mini-reviews that synthesize the available literature about the safety and effectiveness of various labor and birth care practices. The methods for identifying studies and  the criteria for inclusion/exclusion are described in Chapter 3. Click the plus-sign to read the mini-review titles for each chapter.

The Case Against Liberal Use of Cesarean Surgery

1. Cesarean surgery increases the likelihood of maternal death.

2. Women who have cesarean surgery are more likely to experience serious morbidity than women having vaginal birth.

3. Cesarean surgery increases the likelihood of hysterectomy in both primary cesarean and subsequent deliveries.

4. Certain rare, life-threatening maternal complications are associated with cesarean surgery.

5. Women who have cesarean surgery are more likely to experience pain after hospital discharge compared with women having spontaneous vaginal birth. (See chapter 14 for the effect of instrumental vaginal delivery.)

6. Women who have cesarean surgery are more likely to experience serious health problems in the weeks and months following delivery than women having vaginal birth.

7. Cesarean surgery can cause dense adhesions.

8. Cesarean surgery is associated with decreased fertility, probably mostly by choice.

9. Cesarean surgery is associated with an increased likelihood of pregnancy loss and fetal and neonatal death.

10. Prior cesarean surgery is associated with increased likelihood of preterm birth, LBW, and possibly SGA babies.

11. Cesarean surgery increases the likelihood of neonatal respiratory morbidity in term newborns, not all of which is averted by scheduling surgery at 39 completed weeks.

12. Cesarean delivery is associated with development of autoimmune diseases in the child.

13. Prior cesarean results in more maternal and neonatal morbidity at the next delivery.

14. Even one prior cesarean increases the risk of abnormal placental attachment in ensuing pregnancies.

15. Abnormal placental attachment can have severe consequences for women with prior cesareans and their babies, and outcomes can be worse compared with women with no prior cesarean.

16. Planned cesarean is associated with fewer traumatic and hypoxic injuries, but the relationship is not straightforward.

17. Cesarean surgery does not protect against sexual dysfunction.

18. Cesarean surgery does not protect against anal incontinence.

19. Planned cesarean surgery offers modest protection against urinary incontinence and probably no protection against moderate to severe incontinence.

20. Cesarean surgery offers modest protection against symptomatic pelvic floor prolapse, but studies do not control for modifiable elements of vaginal birth management.

The Case Against Elective Repeat Cesarean

1. Maternal mortality rates favor planned VBAC over planned and elective repeat cesarean.

2. Rates of some maternal morbidities (hysterectomy, thromboembolism) appear to favor planned VBAC while other rates appear similar (surgical injury, transfusion), and infection rates may favor planned cesarean; however, most morbidity in planned VBACs occurs in those that end in cesareans.

3. Scar rupture is more likely to occur in VBAC labors, but planned cesarean is not completely protective, and perinatal mortality and severe morbidity associated with scar rupture are rare.

4. It is questionable whether PMR favors planned repeat cesarean over planned VBAC; data conflict on NMR; HIE rates appear to favor planned cesarean; resuscitation rates may also favor planned cesarean; and rates of transient tachypnea are similar.

5. Accumulating cesarean surgeries is associated with a dose-dependent increase in risk of placenta previa, placenta accreta, and the two in combination.

6. Accumulating cesarean surgeries is associated with a dose-dependent increased risk of severe adverse outcomes.

7. Having a VBAC reduces the likelihood of scar rupture in future labors and increases the likelihood of repeat VBAC.

8. In most cases where care providers deter women from VBAC on grounds of excess risk of scar rupture, at least 95% of women and generally more will have no problem with the scar.

9. Prior vaginal birth increases the likelihood of VBAC and decreases the likelihood of scar rupture.

10. In almost all cases where care providers deter women from VBAC on grounds that VBAC is less likely, the majority of women will birth vaginally.

11. Inducing labor is associated with increased probability of scar rupture, although variation in rates suggests that the effect likely depends on patient selection and induction protocol.

12. Inducing labor is associated with reduced likelihood of VBAC.

13. Augmenting labor may increase risk of scar rupture.

Inducing Labor: Patience is a Virtue

1. Inducing with an unfavorable cervix increases the likelihood of cesarean surgery in both nulliparous and parous women regardless of the use of ripening agents.

2. Inducing labor increases excess risk of life-threatening complications and severe outcomes.

3. Trials of induction before 42 w have weaknesses that cast doubt on the conclusion that induction results in fewer perinatal deaths and similar cesarean rates.

4. Prophylactic induction for suspected macrosomia reduces neither cesarean rates nor shoulder dystocia rates.

5. Clinician bias and practice variation determine cesarean rates with suspected macrosomia.

6. Inducing labor for term PROM has minimal effect on maternal infectious symptoms and does not reduce neonatal infection rates, but neither does it increase cesarean rates.

7. Breast stimulation reduces the number of women not in labor 72 h after beginning treatment but should not be used in high-risk women until safety concerns are resolved.

8. Acupuncture trials disagree on its effectiveness at inducing labor; differences are probably a placebo effect.

9. Stripping/sweeping membranes reduces pregnancy duration but has no effect on cesarean surgery rates and may increase PROM rates.

10. Balloon catheter appears to be the method of first choice for cervical ripening.

11. Low-dose/long-interval oxytocin protocols achieve similar vaginal birth rates with less uterine hyperstimulation.

12. Misoprostol imposes excess risk of harm with no compensating clinical benefits compared with PGE2.

13. PGE2 fails to decrease the cesarean rate compared with placebo/no treatment and increases the likelihood of uterine hyperstimulation syndrome.

Promoting Progress in First-Stage Labor: Yes We Can

1. Labor environments that are designed to encourage mobility and autonomy may facilitate physiologic labor progress and reduce the need for pharmacologic augmentation and other interventions.

2. RCTs have failed to find clinically significant benefits for ambulation or upright positioning, but they suffer from weaknesses that handicap their ability to detect differences.

3. Movement and upright positioning are associated with increased maternal comfort and satisfaction.

4. Maternal movement and upright positioning in labor do no harm.

5. The hands-and-knees position does no harm and may be beneficial when the fetus is in an occipitoposterior position.

Augmentation: Forced Labor

1. Hospital admission in latent labor increases the likelihood of medical interventions, including cesarean surgery, and differences in labor management and practice variation are culprits.

2. Partograms increase use of medical interventions, including cesarean surgery, without improving neonatal outcomes, probably because the labor curves and typical action lines represent neither mean labor progress nor the point at which intervention improves neonatal outcomes.

3. Early intervention with amniotomy and high-dose, short-interval oxytocin regimens has minimal, if any, effect on cesarean rates.

4. Routine early amniotomy probably increases the likelihood of cesarean surgery.

5. Early amniotomy has potential adverse effects, including possible increased likelihood of nonreassuring FHR, persistent OP fetus, and infection, and it can precipitate umbilical cord prolapse.

6. Allowing more time before augmenting for progress delay does not increase cesarean rates while early augmentation increases rate of uterine hyperstimulation with accompanying nonreassuring FHR.

7. Limiting trial of oxytocin augmentation to two hours before proceeding to cesarean surgery increases cesarean rates without improving outcomes.

8. Augmentation with high-dose oxytocin appears to result in a modest decrease in cesarean surgery rates compared with low-dose oxytocin; however, low-dose protocols are capable of achieving equally low cesarean rates.

9. We have little data, and studies are flawed, but ambulation and breast stimulation show promise for reducing the need for oxytocin augmentation in cases of progress delay in active labor.

Electronic Fetal Monitoring (Cardiotocography): Minding the Baby

1. Continuous EFM fails to improve short- and long-term perinatal outcomes in high- and low-risk women with the exception of reducing neonatal seizures, a difference that may be explained by modifiable management factors.

2. Continuous EFM fails to reduce the incidence of cerebral palsy.

3. Continuous EFM increases the likelihood of cesarean surgery and instrumental vaginal delivery.

4. Internal monitoring may increase the likelihood of maternal and neonatal complications.

5. The admission test strip (routine use of continuous EFM at hospital admission for a limited time) increases use of intervention without improving neonatal outcomes.

6. Fetal scalp-blood sampling shows no evidence of benefit.

7. FHR acceleration (reactivity) in response to scalp stimulation appears to give reasonable, although not complete, confidence that a fetus with nonreassuring FHR patterns is not acidotic.

Routine IVs Versus Oral Intake in Labor:
Water, Water Everywhere, Nor Any Drop to Drink

1. Fasting does not guarantee an empty stomach.

2. Oral intake in labor has little or no effect on vomiting.

3. Women digest food ingested in labor, but this does not appear to decrease use of oxytocin or increase spontaneous vaginal birth rates, although medical-model management is a confounding factor.

4. Excessive oral fluid intake can cause serious complications.

5. IVs can cause symptomatic fluid overload.

6. Research data offer little support for giving bolus IV fluid before inducing epidural analgesia.

7. Electrolyte-free and sodium-deficient IV infusions can cause hyponatremia.

8. IVs containing glucose (dextrose) or lactate can cause neonatal morbidity, but administration at low infusion rates appears to be harmless.

Epidurals and Combined Spinal-Epidurals: The “Cadillacs” of Analgesia

1. Epidural analgesia decreases the likelihood of spontaneous vaginal birth.

2. Individual variation in practice style accounts for the relationship between epidurals and cesarean section.

3. Women having epidurals are more likely to experience anal sphincter laceration because they are more likely to have instrumental vaginal delivery, episiotomy, or both.

4. Early epidural administration appears to increase the risk of persistent malposition, which could increase cesarean and instrumental vaginal delivery rates.

5. Epidural analgesia can cause severe, life-threatening, or fatal complications.

6. Epidural analgesia increases the likelihood of maternal fever, which has indirect and possibly direct adverse consequences.

7. Narcotic administration, whether intrathecal or epidural, causes itching and probably increases the likelihood of nausea and vomiting, although the strength of the association is less clear and may vary according to agent.

8. Epidural analgesia appears to make a small but clinically significant contribution to problems establishing breastfeeding and shortened duration of breastfeeding; fentanyl appears to be a culprit.

9. Intravenous preloading before epidural or CSE analgesia may not reduce the incidence of hypotension.

10. Reducing the anesthetic dose has no effect on cesarean deliveries but may reduce instrumental vaginal deliveries somewhat.

11. Data conflict, but delaying epidural administration does not appear to decrease cesarean rates, probably because provider propensity for initiating cesareans overrides any effect of epidural timing.

12. Data contradict the theory that aggressive use of oxytocin will eliminate excess cesareans for dystocia in women with epidurals.

13. Ambulation and upright positioning in first stage does not affect mode of delivery compared with recumbence in women with regional analgesia.

14. Discontinuing epidural analgesia late in first stage may result in a modest reduction in instrumental vaginal delivery rates but has no effect on cesarean or fetal malposition rates, and it increases pain.

15. Delaying pushing decreases instrumental vaginal delivery rates, though they remain high in both groups, but it has no effect on cesarean or episiotomy rates, the latter being excessively high in both groups as well.

16. Some evidence suggests that upright position in second stage may reduce instrumental and cesarean delivery.

17. CSE analgesia offers no advantages over epidural analgesia but increases the likelihood of adverse effects.

Second-Stage Labor: Lead, Follow, or Get Out of the Way?

1. Nonsupine positioning in second stage shortens the duration of second stage, especially when the upright position is squatting.

2. Nonsupine positioning in the second stage of labor results in a small decrease in the likelihood of instrumental vaginal delivery.

3. Giving birth in a nonsupine position is associated with an overall decrease in perineal trauma, primarily resulting from decreased use of episiotomy.

4. Among nonsupine positions, kneeling and sidelying are associated with the least perineal trauma while squatting is associated with increased risk.

5. Nonsupine positions increase the likelihood of > 500 mL of estimated blood loss, but there is no evidence of an association with any clinically significant excess.

6. Women who give birth nonsupine are less likely to report severe pain at birth.

7. Supine positioning may result in fetal compromise, although no studies demonstrate clinically significant differences in newborn outcomes.

8. Compared with coached pushing, spontaneous pushing may increase total duration of second stage but does not increase amount of time spent actively pushing or the likelihood of operative delivery.

9. Coached pushing may result in excess perineal damage.

10. Coached pushing is associated with postpartum pelvic floor weakness.

11. No study has demonstrated that coached pushing benefits babies, and some evidence suggests it reduces fetal oxygenation during labor.

12. Instructing a woman to push before she feels a strong urge may increase the chance of instrumental vaginal delivery and exacerbate postpartum fatigue.

13. Birthing the baby’s head between contractions, rather than with a contraction, is associated with decreased likelihood of genital tract trauma.

Instrumental Vaginal Delivery and Fundal Pressure:
When Push Comes to Pull – Or Shove 

1. Studies generally fail to find increased risk of neonatal morbidity with longer second stages.

2. Instrumental vaginal delivery increases the likelihood of neonatal and infant mortality, although excess risk is extremely small.

3. Instrumental vaginal delivery increases the likelihood of severe neonatal morbidity, but it is rare.

4. Instrumental vaginal delivery increases the likelihood of severe maternal injury, and forceps delivery is more likely to do severe damage than vacuum extraction.

5. Instrumental vaginal delivery may increase the likelihood of severe bleeding.

6. Instrumental vaginal delivery appears to have only minor impact on anal incontinence, but effects may be greater than they appear.

7. Instrumental vaginal delivery does not appear to have a major impact on clinically significant stress urinary incontinence, and forceps delivery appears to pose more risk than vacuum extraction.

8. Instrumental delivery does not appear to be associated with pelvic floor prolapse, but we have little data.

9. Forceps delivery is more likely to result in maternal injury than vacuum extraction.

10. With the exception of shoulder dystocia, which occurs more often with vacuum extraction, and facial nerve injury, which occurs more often with forceps delivery, neonatal harms associated with instrumental vaginal delivery occur at similar rates.

11. Forceps are more likely to succeed at delivery, although success rates are high with either instrument.

12. Risk of maternal injury and neonatal morbidity is highest when both vacuum and forceps are used.

13. Median episiotomy increases the risk of anal sphincter injury with instrumental delivery, but studies disagree on whether mediolateral episiotomy prevents anal sphincter tears compared with no episiotomy.

14. Fundal pressure is both ineffective and harmful.

Episiotomy: The Unkindest Cut

1. Median episiotomy predisposes to anal sphincter laceration, but studies conflict on whether mediolateral episiotomy increases risk or has no effect.

2. Performing episiotomy for “imminent tear” does not decrease anal sphincter injury rates.

3. Episiotomy has no effect on neonatal outcomes.

4. Episiotomy causes more pain in the postpartum period than spontaneous tears.

5. Episiotomy causes more healing complications than spontaneous tears.

6. Episiotomy does not preserve pelvic floor functioning as measured by pelvic floor muscle strength, urinary incontinence, and anal incontinence.

7. Studies consistently find episiotomy adversely affects sexual functioning.

8. Episiotomy neither prevents nor relieves shoulder dystocia.

9. Anal lacerations rarely recur at subsequent births provided no median episiotomy is done.

Third-Stage Labor Active Management: The Wrong Answer to the Right Question

1. AMTSL fails to decrease clinically significant maternal morbidity.

2. AMTSL introduces harms.

3. Treatment of excessive bleeding produces equally good outcomes as prophylaxis.

4. Modifiable labor management practices contribute to severe postpartum blood loss.

Newborn Practices: Don’t Just Do Something, Sit There! 

1. Routine newborn suctioning does not improve newborn outcomes and may be harmful.

2. Immediate cord clamping increases the likelihood of infant anemia and other hematologic deficiencies up to six months after birth.

3. Immediate cord clamping does not prevent symptomatic polycythemia.

4. Evidence that immediate clamping reduces the incidence of jaundice requiring treatment is mixed, but if delayed clamping imposes an excess risk, the absolute excess is small.

5. Early skin-to-skin contact after birth results in improved initiation and duration of breastfeeding and a greater likelihood of exclusive breastfeeding.

6. Early skin-to-skin contact prevents hypothermia and improves blood glucose levels.

7. Early skin-to-skin contact reduces infant crying.

8. Early skin-to-skin contact results in improved mother-infant attachment behavior.

Supportive Care in Labor: Mothering the Mother Versus Serving the Doctor

1. Women universally want the same elements of supportive care, and inadequate supportive care negatively affects perception of the birth experience.

2. Continuous one-to-one female labor support confers benefits on women laboring in hospitals without introducing harms.

3. Stronger beneficial effects of continuous one-to-one female labor support are seen with providers who are not hospital staff members and in environments more conducive to physiologic care.

4. Intrapartum nurses provide minimal supportive care.

5. Systemic and cultural factors hinder nurse provision of supportive care.

6. Doulas may meet with resistance from medical staff.

7. Fathers may not be able to provide adequate labor support.

8. Adding a doula complements and enhances labor support by fathers and is viewed positively by them.

Midwife-Led Care: Organizing an Optimal Maternity Care System

1. Midwifery care in labor and birth reduces the likelihood of operative delivery.

2. Midwifery care in labor and birth reduces the likelihood of genital tract trauma.

3. Midwifery care in labor and birth reduces the use of pharmacologic pain management methods.

4. Women cared for by midwives in labor are more likely to use nonpharmacologic pain relief methods.

5. Midwives rely less on restrictive or invasive intrapartum procedures.

6. With one exception, which may be explained by systemic factors, midwifery care results in equivalent or superior newborn outcomes compared with physician management.

7. Midwifery care reduces the likelihood of maternal morbidity.

8. Midwife-led care produces equally good or better maternal and infant outcomes as physician-led or shared care with lower procedure and medication rates.

9. Both midwifery care and midwife-led models of care appear to be safe and beneficial for medically and sociodemographically moderate-risk and high-risk women and their infants.

The Place of Birth: Birth Homes

1. Intrapartum stillbirth and neonatal death occur rarely with freestanding birth center care, with no significant difference between planned birth center care and planned hospital birth.

2. Freestanding birth center care does not appear to increase risk of severe neonatal morbidity when compared with hospital management.

3. Available data suggest that perinatal mortality in birth center populations is disproportionately concentrated in postterm births, but it does not tell us whether deaths could be averted by planned hospital delivery.

4. Freestanding birth center care does not appear to increase the risk of maternal mortality or severe morbidity when compared with hospital management.

5. Women who begin their care in freestanding birth centers experience fewer interventions in labor than similar women receiving hospital-based care.

6. Women who begin their care in freestanding birth centers experience fewer restrictions in labor than similar women receiving hospital-based care.

7. Fewer women beginning care in freestanding birth centers have instrumental vaginal delivery or cesarean surgery compared with similar women receiving hospital-based care.

8. Women who begin care in freestanding birth centers are less likely than similar women receiving hospital-based care to have episiotomies, lacerations requiring sutures, or both.

9. Rates of transfer to hospital care after birth center admission vary widely and are disproportionately higher among nulliparous women; most transfers occur for non-acute indications.

10. Intrapartum transfers from birth center care to hospitals are infrequently urgent; women transferred in labor urgently are often managed expectantly once they arrive at the hospital, suggesting no imminent danger to the woman or her baby.

11. Freestanding birth centers situated in rural communities or areas with low population density provide healthy, screened women a safe alternative to traveling long distances for labor and birth and may therefore represent an efficient model of rural health care delivery.

The Place of Birth: Home Birth

1. Among infants of low-risk women planning home birth in an integrated system, perinatal mortality and morbidity rates are low and similar to comparable populations having planned hospital births; some evidence suggests a small but significant excess risk with planned home birth for nulliparous women.

2. Data on the safety of planned home birth in the presence of specific risk factors is scarce, although what is available suggests disproportionate mortality occurs in planned home births of twins, breech babies, and pre-term and post-term infants and when meconium is present in the amniotic fluid; planned home birth after cesarean was not associated with mortality in available studies, but these studies are too small to determine safety.

3. Compared with planned home birth, planned hospital birth decreases the likelihood of spontaneous vaginal birth in healthy women.

4. Severe maternal morbidity is rare in low risk women regardless of planned place of birth, but controlled studies suggest outcomes favor planned home birth.

5. Compared with planned hospital birth, planned home birth decreases both the likelihood and severity of genital tract trauma.

6. When urgent complications occur, they are almost always managed safely in the home or result in a transfer of care with a favorable outcome.

7. Planned home birth is associated with very low rates of obstetrical interventions compared with planned hospital birth in similar women.