Interrelations Between Four Antepartum Obstetric Interventions and Cesarean Delivery in Women at Low Risk: A Systematic Review and Modeling of the Cascade of Interventions

Authors

  • Michel Rossignol MD, MSc, FRCPC,

    Medical Advisor, Professor
    1. Institut national d'excellence en santé et en services sociaux (INESSS), QC, Canada
    2. Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
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  • Nils Chaillet PhD,

    Senior Researcher
    1. Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, University of Sherbrooke, Sherbrooke, QC, Canada
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  • Faiza Boughrassa MD, MSc,

    Researcher
    1. Institut national d'excellence en santé et en services sociaux (INESSS), QC, Canada
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  • Jean-Marie Moutquin MD, MSc, FRCSC

    Professor
    1. Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
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Address correspondence to Michel Rossignol, INESSS, 2021 Avenue Union, Suite 10.083, Montreal, QC H3A 2S9, Canada.

Abstract

Objectives

To critically appraise the literature on the relations between four intrapartum obstetric interventions—electronic fetal monitoring (EFM), epidural analgesia, labor induction, and labor acceleration; and two types of delivery—instrumental (forceps and vacuum) and cesarean section.

Methods

This review included meta-analyses published between January 2000 and April 2012 including at least one randomized clinical trial published after 1995 and presenting results on low-risk pregnancies between 37 and 42 weeks of gestation, searched in the databases Medline, Cochrane Library, and EMBASE with no language restriction.

Results

Of 306 documents identified, 8 fulfilled the inclusion criteria and presented results on women at low risk. EFM at admission (vs intermittent auscultation) was associated with cesarean delivery (odds ratio [OR] = 1.20, 95% confidence interval [CI] 1.00–1.44) and epidural analgesia (OR = 1.25, 95% CI 1.09–1.43). Epidural on request was associated with cesarean delivery (OR = 1.60, 95% CI 1.18–2.18), instrumental delivery (OR = 1.21, 95% CI 1.03–1.44), and oxytocin use (OR = 1.20, 95% CI 1.01–1.43) when compared with epidural on request plus nonpharmacological labor pain control methods such as one-to-one support, breathing techniques, and relaxation. Induction and acceleration of labor showed heterogeneous patterns of associations with cesarean delivery and instrumental delivery.

Conclusions

Complex patterns of associations between obstetric interventions and modes of delivery were illustrated in an empirical model. Intermittent auscultation and nonpharmacological labor pain control interventions, such as one-to-one support during labor, have the potential for substantially reducing cesarean deliveries.

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