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thStrictly Embargoed until 00:01 hours (BST), 17 October 2007
This release focuses on two Cochrane Systematic Reviews on birthing publishing
next week in The Cochrane Library, 2007, Issue 4, and their implications for practice.
To receive a full copy of the Reviews highlighted in this newsletter, or to arrange an
interview with an author, contact Jennifer Beal +44 (0)1243 770633 or by email,
Reviews highlighted in this newsletter:
? Don‟t „break the waters‟ during labour without good clinical reason,
A Cochrane Review concluded that amniotomy, also known as breaking the
waters, should not be used routinely as part of standard labour management
and care. It found that it doesn’t affect the woman’s satisfaction with her
childbirth experience, and doesn’t result in the child being in better condition
immediately after birth.
? Don‟t routinely use enemas during labour
Giving women enemas during labour does not shorten labour or decrease the
risk of infection to mother or baby. Consequently there is no evidence for any
routine use of enemas in labour, a Cochrane Review has found.
Don‟t „break the waters‟ during labour without good clinical reason, concludes
“We do not recommend that amniotomy, also known as breaking the waters, should
be used routinely as part of standard labour management and care” says Cochrane
Researcher Rebecca Smyth, after completing a systematic review of relevant
research studies. “Women should be informed that it doesn’t shorten the first or
second stage of labour, it doesn’t affect the woman’s satisfaction with her childbirth
experience, and doesn’t result in the child being in better condition immediately after
This Cochrane Systematic Review found that breaking the waters may be associated
with a slightly (non-significantly) higher rate of Caesarean section. Breaking the
waters may cause changes in the baby’s heart rate.
The aim of breaking the waters is to speed up and strengthen contractions, with the
intention of shortening labour. The membranes are punctured using a long handled
hook, and it is thought that hormones in the amniotic fluid that flows out will stimulate
contractions. In some centres, it is performed as a routine part of care for all women
in labour – in others it is used only for women with a clinical need to have their waters broken.
Ms Smyth came to these conclusions after she and colleagues had identified 14
relevant studies that involved almost 5,000 women. The overall quality of the studies
was variable, making it difficult for the group to give firm recommendations about the
use of amniotomy. There is a need for further research in this area.
“Our evidence suggesting this lack of effect should be discussed with women in the
antenatal period,” says Smyth.
Smyth RMD, Alldred SK, Markham C. Amniotomy for shortening spontaneous labour. Cochrane
Database of Systematic Reviews 2007, Issue 4. DOI: 10.1002/14651858.CD006167.pub2.
Don‟t routinely use enemas during labour
Giving women enemas during labour does not shorten labour or decrease the risk of
infection to mother or baby. Consequently there is no evidence for any routine use of
enemas in labour, a Cochrane Review has found.
Enemas are frequently given to women early in labour so that they empty their back
passage. The idea is that this will give more room for the baby as it passes through
the pelvis. It is also hoped that it will reduce the chance of the woman leaking faecal
material while she is giving birth, a situation that is both embarrassing to the woman
and a potential source of infection to mother and child.
A team of Cochrane Researchers coordinated from Bogota, Colombia, searched for
studies involving the use of enemas and found three relevant randomised controlled
trials that included 1765 women. Analysing all the data showed no differences in the
rates of any form of infection in the women or their babies for at least one month after
the birth. There was a slight trend towards labours being shorter in women given
“This evidence does not support the routine use of enemas during labour, and
consequently the practice of routinely giving them should be discouraged,” says lead
researcher Dr Ludovic Reveiz, who works at the Research Institute of the Fundación
Universitaria Sanitas in Bogota.
Reveiz L, Gaitán HG, Cuervo LG. Enemas during labour. Cochrane Database of Systematic Reviews
2007, Issue 4. DOI: 10.1002/14651858.CD000330.pub2.
Extracts from a selection of other Cochrane Systematic Reviews
This section contains extracts from 2 selected updated reviews also publishing in The
Cochrane Library 2007, Issue 4 from the Cochrane Pregnancy and Childbirth Group
To receive a full copy of the results from this selection, or to arrange an interview with an
author, contact Jennifer Beal on +44 (0)1243 770633 or by email, firstname.lastname@example.org.
“Continuous versus interrupted sutures for repair of episiotomy or second
(CD000947) by C Kettle, RK Hills, KMK Ismail
Millions of women worldwide undergo perineal suturing after childbirth and the type of repair
may have an impact on pain and healing. For more than 70 years, researchers have been
suggesting that continuous non-locking suture techniques for repair of the vagina, perineal
muscles and skin are associated with less perineal pain than traditional interrupted methods.
Extract from the Implications for Practice findings
The continuous suturing techniques for perineal closure, compared to interrupted methods,
are associated with less short-term pain. Moreover, if the continuous technique is used for all
layers (vagina, perineal muscles and skin) compared to perineal skin only, the reduction in
pain is even greater. The evidence produced by this review shows that continuous suturing
techniques for perineal closure is associated with less short-term pain. However, if the
continuous technique is used for all layers (vagina, perineal muscles and skin), the benefit in
terms of reducing pain is even greater. For every five women who were sutured using the
continuous suturing technique (for all layers), there will be one less complaining of pain up to
day 10 postpartum compared to the interrupted method groups. The continuous technique is
easily performed by the novice or inexperienced operator. In addition, it has economical
advantages in that the continuous technique requires one packet of suture material per
perineal repair compared to two or more packets for the interrupted method (Kettle 2002).
Therefore, the non-locking continuous suturing technique is recommended for repair of vagina
and perineal muscles with a continuous subcutaneous stitch to close the perineal skin.
“Hands and knees posture in late pregnancy or labour for fetal malposition
(lateral or posterior)” (CD001063) by S Hunter, GJ Hofmeyr, R Kulier
Lateral and posterior position of the baby's head (the back of the baby's head facing to the
mother's side or back) may be associated with more painful, prolonged or obstructed labour
and difficult delivery. It is possible that certain positions adopted by the mother may influence
the baby's position.
Extract from the Implications for Practice findings
Use of hands and knees position for 10 minutes twice daily to correct occipito-posterior
position of the fetus in late pregnancy cannot be recommended as an intervention. This is not
to suggest that women should not adopt this position if they find it comfortable. The use of
position in labour was associated with reduced backache. Further trials are needed to assess
the effects on other labour outcomes. Use of hands and knees posture for 10 minutes twice
daily to correct occipito-posterior position of the fetus in late pregnancy cannot be
recommended as an intervention. This is not to suggest that women should not adopt this
position if they find it comfortable. The use of this position during labour was associated with a
significant reduction in persistent back pain. Women may therefore be encouraged to use this
position for comfort in labour.
- Ends -
Notes for editors
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ª Jadad AR, Cook DJ, Jones A, Klassen TP, Tugwell P, Moher M, et al. Methodology and reports of
systematic Reviews and meta-analysies: a comparison of Cochrane Reviews with articles published in