TABLE 1

Evidenced-based recommendations for labor and delivery

Intervention
First stage
Self-diagnosis of active labor

Recommendationa

Qualitya

Commentb

Poor

Fewer visits to L&D suite

Radiographic pelvimetry

Good

Higher CD

Home births

Poor

No trials

Home-like births

Good

Trend for higher perinatal mortality

Midwife vs conventional care

Good

1/100 less CD, 1/1000 more perinatal

mortality

Teamwork training

Fair

One cluster RCT: no effect

Delayed admission

Fair

Trend for less CD

Fetal admissions tests

Fetal heart rate tracing

C
Good Similar neonatal

Amniotic fluid volume

Good outcomes

Estimate of fetal weight

Poor

No effect on outcome

Enemas

Fair

Similar neonatal outcomes

Perineal shaving

Fair

Old trials

Chlorhexidine vaginal irrigation D

Good

No benefit

Ingestion of liquids/ nutrition

Poor

No trials of solid foods

Intravenous fluids

Fair

250 or 125 mL/h studied

Ambulation (walking)

Good

Let the woman choose

Water immersion

First stage
C
in analgesia

Good

Decrease

Second stage
Trial too small

Poor

Massage

Fair

Only 1 small trial

Aromatherapy

Fair

Insufficiently powered trials

Support person (doula)

Good

One of the most effective interventions

Routine early AROM

Good

Trend for higher CD

Partogram

Fair

Most trials compared different action

lines of Partogram

Cervical examinations

Poor

No specific trials

Oxytocin augmentation

Poor

No specific trials

Active management of labor

Good

Individual intervention should be tested,

analyzed, and used clinically separately

Training of birth assistants

Good

In developing countries

IUPC

Poor

No trials

Meperidine for abnormal progression of labor

Fair

Worse perinatal outcome

Prophylactic oxygen

Fair

Lower cord pH

Prophylactic tocolysis

Fair

Labor prolongation

Upright position

Good

Includes sitting, semirecumbent,

kneeling, and squatting

Delayed pushing

Good

Similar outcomes

Pushing using a closed glottis C

Good

Similar neonatal outcomes

Perineal massage from 34 wks on

Good
Higher chance of intact
perineum for nulliparous women

Perineal massage during second stage

B

Good

Lower chance of third-degree

lacerations

Warm packs

Good

Lower incidence of third- and fourthdegree lacerations

Operative delivery for abnormalprogression

I

Poor

No specific trials

Hands on method

Good

Higher incidence of third-degree

lacerations and episiotomies

Fundal pressure

Good

Women less satisfied

Episiotomy

Good

Episiotomy should be avoided if at all

possible

Second stage

Intervention
First stage

Recommendationa

Qualitya

Commentb

Self-diagnosis of active labor

Poor

Fewer visits to L&D suite

Radiographic pelvimetry

Good

Higher CD

Home births

Poor

No trials

Home-like births

Good

Trend for higher perinatal mortality

Midwife vs conventional care

Good

1/100 less CD, 1/1000 more perinatal

mortality

Teamwork training

Fair

One cluster RCT: no effect

Delayed admission

Fair

Trend for less CD

Fetal admissions tests

Fetal heart rate tracing

Good

Similar neonatal

Amniotic fluid volume

Good

outcomes

Estimate of fetal weight

Poor

No effect on outcome

Enemas

Fair

Similar neonatal outcomes

Perineal shaving

Fair

Old trials

Good

Chlorhexidine vaginal irrigation

No benefit

Ingestion of liquids/ nutrition

Poor

No trials of solid foods

Intravenous fluids

Fair

250 or 125 mL/h studied

Ambulation (walking)

Good

Let the woman choose

Water immersion

First stage

Good

Decrease in analgesia

Second stage

Poor

Trial too small

Massage

Fair

Only 1 small trial

Aromatherapy

Fair

Insufficiently powered trials

Support person (doula)

Good

One of the most effective interventions

Routine early AROM

Good

Trend for higher CD

Partogram

Fair

Most trials compared different action lines of

Partogram

Cervical examinations

Poor

No specific trials

Oxytocin augmentation

Poor

No specific trials

Active management of labor

Good

Individual intervention should be tested,

analyzed, and used clinically separately

Training of birth assistants

Good

In developing countries

IUPC

Poor

No trials

Meperidine for abnormal progression of labor

Fair

Worse perinatal outcome

Second stage
Prophylactic oxygen

Fair

Lower cord pH

Prophylactic tocolysis

Fair

Labor prolongation

Upright position

Good

Includes sitting, semirecumbent, kneeling, and

squatting

Delayed pushing

Good

Similar outcomes

Pushing using a closed glottis

Good

Perineal massage from 34 wks on

Good
Higher chance of intact perineum
for nulliparous women

Perineal massage during second stage

B

Good

Lower chance of third-degree lacerations

Warm packs

Good

Lower incidence of third- and fourth-degree

lacerations

Operative delivery for abnormalprogression

I

Poor

No specific trials

Hands on method

Good

Higher incidence of third-degree lacerations

and episiotomies

Fundal pressure

Good

Women less satisfied

Episiotomy

Good

Episiotomy should be avoided if at all possible

Similar neonatal outcomes