The Cochrane Collaboration released a new review last week looking at amniotomy and whether or not it offers any benefit to women and their babies.

The researchers reviewed 14 studies that included 4,893 women who had their membranes broken routinely on admission to hospital where labor had started spontaneously, and also women who had started labor spontaneously but labor progressed had slowed down.

Length of labor

The length of labor was not statistically different between the experimental group (with amniotomy) and the control group (no amniotomy). The first stage of labor was 20 minutes shorter on average in the experimental group. The authors highlight that there is no evidence that a shorter labor is beneficial, either in terms of maternal and infant health, or in terms of maternal satisfaction.

Cesarean section

There was a slight increase in the numbers of cesarean sections in the experimental group, although this was not statistically significant. The authors point out that many of the studies that were reviewed did not state whether or not women in the study had continual fetal monitoring. Since this routine intervention is known to increase the cesarean rate without any medical benefit, they were unable to adjust for this factor. If women in the control group received continual fetal monitoring it may have increased the incidence of cesarean section.

Infant wellbeing

There was a slight increase in the number of babies born with an Apgar score of less than 7 at five minutes in the control group compared to the experimental group. However, there was no statistical difference in the number of babies admitted to special care units, with abnormal heart rate traces, or meconium aspiration, acidosis or infant death. Although there were slightly more babies in the control group with low Apgar scores, it did not appear to have any effect on their health.

Use of oxytocin

The review found that there was no difference between the two groups in the use of oxytocin (e.g. pitocin or syntocinon). However, some of the studies excluded women who were given oxytocin so this may have affected the results. ased on t his review, there is no way of knowing whether or not amniotomy increases the use of oxytocin.

Other interventions

There was no difference between the two groups in terms of use of pain relief, forceps delivery or postpartum hemorrhage.

Discussion

There are a number of questions raised by this review. The authors noted that in 8 of the 14 trials, 30% of women who were in the control group (no amniotomy) actually received amniotomy at some point in their labor. This has significant implications for affecting the results. If the women in the control group actually did receive amniotomy they are no longer an effective control!

The authors of the Cochrane review concluded:

"On the basis of the findings of this review, we do not recommend that amniotomy be introduced routinely as part of standard labour management and care."

There does not appear to be any evidence for supporting the use of routine amniotomy. It offers no advantages to either the mother or baby, and may increase the cesarean rate.

How does this affect your clients?

If you are working with women who have chosen active management caregivers, there is a high risk of them having amniotomy performed routinely. Part of the protocol of active management is the breaking of the waters when the woman is admitted to hospital, or when her labor does not progress at the expected rate. Recognizing that a caregiver is likely to carry out this procedure provides omen with the opportunity to determine whether or not they have chosen a caregiver that meets their needs.

As a doula or childbirth educator you can discuss this intervention with women, helping them to formulate questions that explore this intervention and others. It also provides them with the opportunity to discuss whether they want themselves and their babies exposed to routine practices, or prefer a model of personalized care that takes into account their own needs and preferences.

It can be difficult to cover these issues in childbirth classes - there are so many interventions that to discuss each of them individually can lead to a focus on intervention rather than normal birth. This is the perfect topic to write up in a client handout, discussing the procedure itself, together with the benefits and risks, based on the evidence. Rather than focusing on each individual intervention, it can be more beneficial to discuss questions that help clients to determine their caregivers philosophy and then techniques for how they can explore their options, including the option of choosing a caregiver who is more in line with their needs.

Childbirth International's take on research

We often see comments on the latest research reported on news websites, magazines and the various lists and discussion forums related to childbirth. What is challenging for a birth professional is determining how good the research was and whether it is adding anything to the literature about evidence-based care in pregnancy, birth and parenting.

It appears that journalists may report on the latest research using the abstract or the press release as the sole source of information. The problem with this is that the abstract is not always showing all the information that was gleaned from a study, or may be skewed towards what the authors were hoping to find.

News is often taken from organizations like Reuters. Again, this is a brief overview of the research, intended to highlight the most relevant points. Critical information about risks and complications may be left out.

Generally these news briefings do not provide any information on the number of people in a study and the methods used when the study was carried out. Nor do they usually mention any potential bias from the authors of the study, for example when a study author has financial interests that may be affected by the study results.

Childbirth International aims to highlight the issues related to some of the latest research and examine some of the relevant issues, enabling you to help your clients find their way through the maze of options available to them and understand evidence-based care.

For more information on training with Childbirth International, take a look at our website at www.childbirthinternational.com, or contact us.

Childbirth International offers training programs for Birth Doulas, Postpartum Doulas, Childbirth Educators and Breastfeeding Counselors. In June 2009 we introduced a business course for birth professionals to help you build and grow your business.

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