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 
Hospital practices
1
2
3
4
Introduction
First impression
Clinical assessment
Preparation procedures
4.1 Enemas
4.2 Pubic shaving
5 Nutrition
5.1 Risks of aspiration
5.2 Measures to reduce volume and acidity of stomach
contents
5.2.1 Restriction of oral intake
5.2.2 Routine intravenous infusions
5.2.3 Pharmacological approaches
6 Maternal position during the first stage of labor
6.1 Effects on blood flow and uterine contractility
6.2 Effects on the mother and the baby
7 Conclusions
1 Introduction
Most births now take place in hospitals. Like other large institutions,
hospitals (and the professionals working in them) depend on rules and
routines for efficient functioning; it is probably essential that they
continue to do so. Professionals need a structure within which to do
their work. This structure necessarily involves working rules and at
least some routines intended to serve the interests of other people
working in and using the institution. Change can be slow because
familiar rules and routines are comforting, and because it takes time
to develop and agree on new policies – time that may be seen as better
spent providing clinical care.
The marked variations in the type of care women receive, therefore,
tend to depend more on which maternity unit a woman happens to
attend, and which professional she consults, than on her individual
SOURCE: Murray Enkin, Marc J.N.C. Keirse, James Neilson, Caroline Crowther, Lelia Duley, Ellen Hodnett, and
Justus Hofmeyr. A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. Oxford, UK: Oxford University
Press, 2000.
DOWNLOAD SOURCE: Maternity Wise™ website at www.maternitywise.org/prof/
© Oxford University Press 2000
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needs or preferences. These differences in practice, which may occur
in remarkably similar settings, are often so dramatic that they cannot
possibly be explained by differences in medical indications or by the
characteristics of women attending different hospitals.
2 First impression
A woman entering a hospital in labor may have experienced months
or even years of anticipation, fear, and uncertainty about childbirth.
Much of that anticipation, fear, and uncertainty is focused on the
moment when she enters the labor ward. This is the time when she
feels, and is, most vulnerable. She needs to be welcomed into the
strange environment, and given comfort and care. It may be especially
difficult to meet these needs if the woman has not met any of her caregivers before.
The midwife or labor-room nurse may have an entirely different set
of priorities. Her main concerns are probably to discover what stage of
labor the woman is in, and to reassure herself that the mother and
baby are well. She will also have record-keeping tasks and, sometimes,
may be responsible for other women in labor. Providing appropriate
care for each individual woman, with her own distinct needs, is a
daunting task.
Various recommendations for changes in admission practices have
been made to help alleviate the anxiety and fear felt by women entering
the hospital labor ward. Caregivers should welcome and support
mothers and their companions from the moment of arrival. They
should introduce themselves and give information about others whom
the mother might see during labor. It would be helpful if midwives or
nurses also asked women how they wish to be addressed. This is
common courtesy and should be universal.
Admission in labor provides an opportunity to discuss a woman’s
requests and plans for (and worries and concerns about) labor and
birth. Sometimes these discussions are formalized by completing a
written ‘birth plan’. The birth plan may help to facilitate communication of the woman’s wishes to all members of the health care team.
The support of a partner or other companion may be particularly
important to a woman when she first arrives and during the initial
examination. Unfortunately, some hospitals have policies that exclude
companions at this time. Surveys show that only a small proportion of
women prefer not to have anyone with them at this point. Most women
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interviewed expressed pleasure and relief when their partner or
companion could stay, and disappointment when they were unable to
do so, whether because of work or childcare responsibilities, or because
they were excluded as the result of a hospital regulation.
A woman is usually asked to undress when she first arrives in labor.
If this is done insensitively, it can be a humiliating experience for her.
Many women prefer the option of bringing a comfortable nightdress
from home, rather than having to wear a hospital gown; this gives them
a little more dignity and individuality.
3 Clinical assessment
The main clinical tasks when a woman comes into hospital are to assess
her progress in labor, her condition and that of her baby, and to make
decisions about care. To do so, caregivers may use a variety of measures,
including a discussion with the woman about her history, symptoms,
and obstetric records; observation of her temperature, blood pressure,
and general condition; abdominal and vaginal examination; and some
form of monitoring of the fetal heart. Most women want to be involved
in decisions about their care, and almost all will appreciate an explanation of what is being done and why.
The ‘diagnosis’ of labor has received relatively little research attention. The advice given to a woman antenatally about the onset of labor,
what she is told over the telephone when she calls in, and whether or
not a caregiver can assess her at home first, will influence her decision
on when to come to hospital. What she experiences when she arrives
will depend on hospital policies and the decisions made by her caregivers. If she is judged not to be in labor, she may be sent home or to
another hospital ward. A small trial in the USA showed that a specific
education program can reduce the number of admissions of women
who are not in active labor.
In North American hospitals ‘early labor assessment’ or ‘triage’ areas
have become popular. Rather than being directly admitted to the
hospital labor ward, women who believe they are in labor are assessed
in a homelike area that is usually near to the labor ward. The goal is
to ensure that only women in active labor are admitted to the labor
ward, on the assumption that women who do not ‘need’ to be in a
labor ward should not be there (either because they may be exposed
to unnecessary procedures, become more anxious, or because they add
to the workload of the labor ward staff). Depending on the results of
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the initial assessment, women are either admitted and sent to the labor
ward, observed for several hours in the assessment area, or sent home.
A Canadian trial of 209 women found that women in the early-labor
assessment group were less likely to use analgesia or anesthesia during
labor and birth, less likely to have oxytocics during first stage labor,
and rated their birth experiences more positively, than those who were
admitted directly to the labor ward. The trial was not large enough,
however, to determine whether pre-admission labor assessment
reduces the cesarean section rate, or is associated with important
adverse events such as unplanned out-of-hospital birth. Hospital
administrators tend to believe that pre-admission labor assessment
reduces costs (in that labor ward nurses are not giving care to those
who are not in active labor), but no formal economic evaluations have
been reported. Furthermore the assumption that women who are not
in active labor do not require ongoing professional support and advice
is open to question. Highly anxious women may have great need for,
and benefit from, extra support during the latent or early phase of
labor. Further research on this practice is required.
4 Preparation procedures
At one time, admission to hospital in labor included the routine use
of bowel preparation with enemas or suppositories, and the shaving of
the pubic and perineal area. Although these practices are only of historical interest in many countries, in others they still continue.
4.1 Enemas
The supposed benefits of bowel preparation were to allow the fetal head
to descend, to stimulate contractions and thereby shorten labor, and
to reduce contamination at delivery thereby minimizing the risks of
infection in mother and baby. The practice is uncomfortable, and not
without risk. Cases of rectal irritation, colitis, gangrene, and anaphylactic shock have all been reported.
Two randomized, controlled trials have evaluated the effects of
routinely giving enemas on admission to hospital in labor. Without an
enema, the fecal soiling was mainly slight and it was easier to remove
than the soiling after an enema. No effects on the duration of labor or
on neonatal infection or perineal wound infection were detected. Of
the women who had enemas or suppositories, a small number were
pleased or had requested this, half of the remainder either did not mind
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or were prepared to have whatever was necessary, while the other
half expressed negative feelings such as embarrassment, discomfort, or
reluctance. The majority of women who did not have an enema were
pleased or relieved.
As routinely administering enemas to women in labor confers no
benefit, the results of trials of different types of enema are largely irrelevant. Nevertheless, for situations in which an enema is deemed necessary, or is requested by the mother, it is worth noting that no
advantages have been shown for a medicated over a tap-water enema,
and that soapsuds enemas should not be used because they frequently
cause cramps and griping.
4.2 Pubic shaving
Predelivery shaving was formerly believed to lessen the risk of infection and to make suturing of perineal trauma easier and safer. As early
as 1922, these assumptions were challenged by a controlled trial. That
trial and the only other controlled trial that examined this practice,
were unable to detect any effect of perineal shaving on lowering
puerperal morbidity; rather there was a tendency towards increased
morbidity in the shaved groups.
The results of these trials are supported by those of non-randomized
cohort studies, and of randomized trials of pre-operative shaving in
surgical patients. Other writers have drawn attention to the disadvantages in terms of women’s embarrassment during the procedure, their
discomfort during the weeks in which the hair grows back, as well as
to the minor abrasions caused by shaving.
5 Nutrition
The belief that food and drink should be withheld or severely restricted
once labor has commenced is widely accepted in current hospital care.
A small minority hold equally strong views that, except for women at
high risk of needing general anesthesia, the benefits of nourishment in
accordance with women’s wishes far outweigh the possible benefits
of more restrictive policies.
Surveys of labor ward policies in England and the United States
showed that in the late 1980s most units prohibited all solid foods.
Almost 50% allowed no oral intake except ice chips; most of the
remainder allowed only sips of clear fluids; and only about one in ten
units allowed women to drink as much fluid as they desired. None of
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the hospitals surveyed in the United States permitted women to eat
and drink as they wished. Policies about oral intake have come under
scrutiny in recent years, and have been liberalized in many units, with
no detrimental effects on mother or baby reported. Nevertheless,
restrictive policies remain in force in many centers.
For many women, these restrictions do not present a problem. Most
women do not want to eat during the active phase of labor. For those who
are in the early phase of labor and do want to eat, enforced hunger can be
a highly unpleasant experience. Enforced fasting may also lead to poor
progress in labor, the diagnosis of dystocia, and a cascade of interventions culminating in a cesarean delivery. The work of labor has been
likened to the work of continuous moderate exercise. In longer labors in
which oral intake is prohibited, there is a progressive rise in urinary
ketones. In an American study of women who had had elevated ketones
in labor, women reported that hunger was one of their most unpleasant
sensations during labor. Why then are such restrictive policies employed
when some women so obviously find them distressing? The explanation
lies in the widespread concern that eating and drinking during labor will
put women at risk of aspirating stomach contents during regurgitation.
5.1 Risks of aspiration
This concern is real and serious, but perhaps misguided. The risk of
aspiration is almost entirely associated with the use of general anesthesia. The degree of risk, therefore, relates directly to the frequency
with which general anesthesia accompanies childbirth, and to the care
and skill with which the anesthetic is administered. The level of risk
has always been low and is now very low. Aspiration plays a very small
role in maternal mortality, although it remains a largely unquantified
factor in maternal morbidity.
Policies that restrict oral intake during labor have the laudable aim
of reducing the risk of regurgitation and inhalation of gastric contents.
Aspiration of food particles of sufficient size to obstruct a main stem
or segmental bronchus may result in a collapse of lung tissue beyond
the obstruction. Even in the absence of food particles, if the stomach
contents are sufficiently acidic they can cause chemical burns in the
airways. It is this syndrome of acid aspiration in particular, described
by Mendelson over 50 years ago, that constitutes the greatest risk in
pregnant women who undergo general anesthesia.
Over the years, a number of specific measures have been introduced
to avoid aspiration. It has been pointed out repeatedly that failure to
apply proper anesthetic technique is the major reason that deaths
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from aspiration of gastric contents still occur. Most cases of aspiration
could be prevented by a combination of decreasing the frequency of
procedures that require anesthesia (particularly cesarean section), the
use of regional anesthesia whenever feasible, and meticulous attention
to safe anesthetic technique.
5.2 Measures to reduce volume and acidity of stomach contents
Measures to reduce the volume and acidity of gastric contents cannot
compensate for inadequate anesthetic technique. Such measures are,
however, widely used.
5.2.1 Restriction of oral intake
Fasting is the most commonly used measure to reduce the stomach
contents. Fasting during labor does not have the desired effect of
ensuring an empty stomach. To quote the conclusions of one study ‘the
myth of considering the time interval between the last meal and either
delivery or the onset of labor as a guide to gastric content volume
should now be laid firmly to rest’. Withholding food and drink during
labor will not ensure an empty stomach, should general anesthesia
become necessary. No time interval between the last meal and the onset
of labor guarantees a stomach volume of less than 100 ml.
The use of a low residue, low-fat diet with the aim of providing palatable, attractive, small meals at frequent intervals is a reasonable
alternative to fasting. Such a diet could consist of tea, fruit juice, lightly
cooked eggs, crisp toast and butter, plain biscuits, clear broth, and
cooked fruits. Some women prefer high-calorie snacks and drinks.
Nor can fasting during labor be relied on to lower the acidity of the gastric contents. One author commented provocatively: ‘Is it not intriguing
that, in England and Wales, the number of maternal deaths from acidaspiration apparently rose only after the institution of severe dietary
restriction in labor, amounting in most units almost to starvation?’
Restricting food and drink during labor may result in dehydration
and ketosis. Whether the degree of ketosis that occurs in some women
during labor is a harmless physiological state or a pathological condition that interferes with uterine action is uncertain. There are no
published data about the nutritional needs of laboring women. For
some women, these are likely to be similar to those of an individual
engaged in strenuous athletic activity.
The most common response to the problems of dehydration and
ketosis in maternity units where eating during labor is prohibited is
the use of intravenous glucose and fluid. The effects of this practice
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should be carefully weighed against those of the alternative option of
allowing women to eat and drink as they desire. The first controlled
trial to compare a policy of encouraging women to eat and drink
during labor involved 328 women in a Canadian hospital. Women
enjoyed being able to control their own oral intake; no other benefits
or harmful effects were found.
5.2.2 Routine intravenous infusions
The biochemical effects of intravenous glucose solutions during labor
have been evaluated in a number of controlled trials. The rise in the
mother’s blood sugar level is accompanied by a rise in the production
of insulin. The available data show no consistent effect on either
maternal pH or lactate levels.
Infusions of glucose solutions to the mother result in increased blood
sugar levels in the baby, and also in a decrease in umbilical arterial
blood pH. Excessive insulin production in the fetus occurs when
women receive more than 25 g glucose intravenously during labor, and
this can result in low blood sugar and raised levels of blood lactate in
the baby. A further danger is that the excessive use of salt-free intravenous solutions can result in serious hyponatremia, in both the
mother and the fetus. Thus, the use of intravenous glucose and fluids
to prevent or combat ketosis and dehydration in the mother may have
serious unwanted effects on the baby.
Currently, intrapartum intravenous protocols typically involve the
use of Ringers Lactate, a non-glucose based solution that does not
provide a source of energy. The potential hazards of intravenous infusions might be obviated by the more natural approach of allowing
women to eat and drink during labor.
5.2.3 Pharmacological approaches
The frequency of unpredictably large volumes and equally unpredictable
acidity of the stomach contents, whether women fast or do not fast during labor, has led to the use of a number of agents in attempts to decrease
both the content and the acidity of the stomach in laboring women.
The stomach contents can be emptied mechanically with a stomach
tube, or vomiting can be induced with pre-operative apomorphine. A
comparison of these two methods for women in labor who required a
general anesthetic, showed no statistically significant difference in the
mean gastric aspirate during the operation. Most women having the
stomach tube passed found it ‘very unpleasant’, whereas the majority
of those receiving apomorphine found the procedure only ‘slightly
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unpleasant’. Neither method guarantees that the stomach will be
empty. Hydrogen ion inhibitors, such as cimetidine and ranitidine, can
increase the rate of gastric emptying and thus result in quite striking
decreases in stomach contents.
The stomach contents can be made less acid by the use of antacids
such as aluminium hydroxide, magnesium trisilicate, or sodium citrate,
and by acid suppressing agents such as cimetidine, ranitidine, or
omeprazole. Randomized comparisons between different agents have
provided no evidence that any particular agent or class of agents influences gastric pH more effectively than others.
The effectiveness of these agents in reducing acidity, however, does
not necessarily mean that they will have an effect on the incidence or
severity of Mendelson’s syndrome. Although from 1966 onward there
has been a movement towards the routine administration of antacids
to all women before cesarean section, cases of Mendelson’s syndrome
still occur in women who had a full regimen of antacid treatment.
6 Maternal position during the first stage of labor
Interest in maternal position during the first stage of labor has existed
throughout the twentieth century, but until recently there has been
little well-controlled research to assess the validity of the various
strongly held opinions. Lying down in labor continues to be routine
practice in many maternity units. The available data cast doubt on the
wisdom of this policy.
6.1 Effects on blood flow and uterine contractility
The supine position (lying flat on the back) causes a reduction in cardiac output. It is associated with a greater decline in femoral than in
brachial arterial pressure, which does not occur in the lateral position or
when the uterus is tilted to the left. This observation suggests that the
supine position can compromise uterine blood flow during labor.
Contraction intensity is consistently reduced, and contraction frequency is often increased, when the laboring woman sits or lies supine
after being upright. Standing and lying on the side are associated with
greater contraction intensity. The efficiency of the contractions (their
ability to accomplish cervical dilatation) is also increased by standing
and by the lateral position.
The results of several studies suggest that the supine position can
adversely affect both the condition of the fetus and the progression of
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labor, by interference with the uterine blood supply and by compromising the efficiency of uterine contractions. Frequent changes of
maternal position may be a way of avoiding the adverse effects of
supine recumbency. No evidence from controlled studies suggests that
the supine position should be encouraged.
6.2 Effects on the mother and the baby
The results of controlled trials show that women who were asked to
stand, walk, or sit upright during labor had, on the average, shorter
labors than women asked to remain lying flat. Trials in which an
upright position was compared with lying on the side showed no
striking differences in the length of labor.
In the only trial in which labor was found to be longer in the ambulant than in the non-ambulant group, women in the recumbent group
were permitted to get up if they desired and women in the ambulant
group were allowed to rest in bed ‘whenever they wanted’. Women in
the upright group preferred to recline in bed as labor progressed, often
at about 5–6 cm dilatation. This suggests that free choice of position
may be the most important consideration.
Women allocated to an upright posture used less narcotic analgesics
or epidural anesthesia, and received fewer oxytocics to augment labor.
In part this may be because it was easier to administer such drugs to
women who were lying in bed. The available data provide no evidence
of a consistent effect of position during the first stage of labor on the
likelihood of instrumental delivery.
Similarly, there is no consistency in the findings with respect to the
condition of the baby. Only one trial reported significantly lower
incidences of fetal heart-rate abnormalities and depressed Apgar
scores associated with an upright position. Other investigators, some of
whom used telemetry (a means of electronically monitoring the
fetal heart while the woman is mobile) in conjunction with ambulation,
did not detect differences in fetal heart-rate patterns or Apgar scores.
No information is available about the effect of position during the first
stage of labor on more substantive indicators of the babies’ well-being.
7 Conclusions
Hospital routines are necessary for efficient functioning. The challenge
faced by professionals working in maternity units is firstly to introduce
or maintain only those routines and rules that have been shown, on
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balance, to do more good than harm, and secondly, to apply those
routines flexibly in a way that takes the needs of each individual childbearing woman into account.
The presence of a companion when women first come into hospital
and during the initial examination is important to many women. The
presence of companions whom women choose should be encouraged
and facilitated.
Caregivers should pay attention to ways of maintaining the woman’s
dignity, of providing privacy, and of treating women as adults, for
example, in styles of address and introductions. Abandoning the traditional hospital gown is a step towards this goal.
Women appreciate the efforts of caregivers to inform and consult
them about their progress in labor and the care they are to receive.
When choices about care are offered, they should be presented in a
manner that allows women to ask for what they want, and discuss their
uncertainties.
There is no evidence to support outmoded practices, such as administering enemas routinely or perineal shaving, which cause discomfort
and embarrassment for women.
No presently known measures can ensure that a laboring woman’s
stomach is empty, or that her gastric juices will have a pH greater than
2.5. Enforced fasting in labor, the use of antacids, or pre-anesthetic
mechanical or chemical emptying of the stomach are only partially
effective. All of these have unpleasant consequences and are potentially
hazardous to the mother, and possibly her baby.
The syndrome of aspiration of stomach contents under general anesthesia is rare but serious. It is wise to avoid general anesthesia for
delivery whenever possible, and to use a proper anesthetic technique with meticulous attention to the known safeguards when general
anesthesia must be used.
Professional requirements that women lie flat during the first stage
of labor are less widespread than they used to be, but they still exist.
The available evidence suggests that this policy compromises effective
uterine activity, prolongs labor, and leads to an increased use of oxytocics to augment contractions.
Controlled trials are required, not only to evaluate the effects of
routine hospital policies and practices, but also to evaluate methods of
implementing changes when these practices are ineffective, inefficient,
or counter-productive.
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Sources
Effective care in pregnancy and childbirth
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