Intravenous fluids for reducing the duration of labour in low risk nulliparous women.

BACKGROUND: Several factors may influence the progression of normal labour. It has been postulated that the routine administration of intravenous fluids to keep women adequately hydrated during labour may reduce the period of contraction and relaxation of the uterine muscle, and may ultimately reduce the duration of the labour. It has also been suggested that intravenous fluids may reduce caesarean sections (CS) for prolonged labour. However, the routine administration of intravenous fluids to labouring women has not been adequately elucidated although it is a widely-adopted policy, and there is no consensus on the type or volume of fluids that are required, or indeed, whether intravenous fluids are at all necessary. Women may be able to adequately hydrate themselves if they were allowed oral fluids during labour.Furthermore, excessive volumes of intravenous fluids may pose risks to both the mother and her newborn and different fluids are associated with different risks.

OBJECTIVES: To evaluate whether the routine administration of intravenous fluids to low-risk nulliparous labouring women reduces the duration of labour and to evaluate the safety of intravenous fluids on maternal and neonatal health.

SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 February 2013).

SELECTION CRITERIA: Randomised controlled trials of intravenous fluid administration to spontaneously labouring low-risk nulliparous women.

DATA COLLECTION AND ANALYSIS: The review authors independently assessed trials for inclusion, trial quality and extracted data.

MAIN RESULTS: We included nine randomised trials with 1781 women. Three trials had more than two treatment arms and were included in more than one comparison.Two trials compared women randomised to receive up to 250 mL/hour of Ringer's lactate solution as well as oral intake versus oral intake only. For women delivering vaginally, there was a reduction in the duration of labour in the Ringer's lactate group (mean difference (MD) -28.86 minutes, 95% confidence interval (CI) -47.41 to -10.30). There was no statistical reduction in the number of CS in the Ringer's lactate group (risk ratio (RR), 0.73 95% CI 0.49 to 1.08).Three trials compared women who received 125 mL/hour versus 250 mL/hour of intravenous fluids with free oral fluids in both groups. Women receiving a greater hourly volume of intravenous fluids (250 mL) had shorter labours than those receiving 125 mL (MD 23.87 minutes, 95% CI 3.72 to 44.02, 256 women). There was no statistically significant reduction in the number of CS in the 250 mL intravenous fluid group (average RR 1.00, 95% CI 0.54 to1.87, three studies, 334 women). In one study the number of assisted vaginal deliveries was lower in the group receiving 125 mL/hour (RR 0.47, 95% CI 0.27 to 0.81).Four trials compared rates of intravenous fluids in women where oral intake was restricted (125 mL/hour versus 250 mL/hour). There was a reduction in the duration of labour in women who received the higher infusion rate (MD 105.61 minutes, 95% CI 53.19 to 158.02); P < 0.0001, however, findings must be interpreted with caution as there was high heterogeneity amongst trials (I(2) = 53%). There was a significant reduction in CS in women receiving the higher rate of intravenous fluid infusion (RR 1.56, 95% CI 1.10 to 2.21; P = 0.01). There was no difference identified in the assisted delivery rate (RR 0.78, 95% CI 0.44 to 1.40). There was no clear difference between groups in the number of babies admitted to the NICU (RR 0.48, 95% CI 0.07 to 3.17).Two trials compared normal saline versus 5% dextrose. Only one reported the mean duration of labour, and there was no strong evidence of a difference between groups (MD -12.00, 95% CI -30.09 to 6.09). A trial reporting the median suggested that the duration was reduced in the dextrose group. There was no significant difference in CS or assisted deliveries (RR 0.77, 95% CI 0.41 to 1.43, two studies, 284 women) and (RR 0.59, 95% CI 0.21 to 1.63, one study, 93 women) respectively. Only one trial reported on maternal hyponatraemia (serum sodium levels < 135 mmol/L ). For neonatal complications, there was no difference in the admission to NICU) or in low Apgar scores, however 33.3% of babies developed hyponatraemia in the dextrose group compared to 13.3 % in the normal saline group (RR 0.40, 95% CI 0.17 to 0.93) (P = 0.03). One trial reported a higher incidence of neonatal hyperbilirubinaemia in the dextrose group of babies. There was no difference in neonatal hypoglycaemic episodes between groups.

AUTHORS' CONCLUSIONS: Although the administration of intravenous fluids compared with oral intake alone demonstrated a reduction in the duration of labour, this finding emerged from only two trials. The findings of other trials suggest that if a policy of no oral intake is applied, then the duration of labour in nulliparous women may be shortened by the administration of intravenous fluids at a rate of 250 mL/hour rather than 125 mL/hour. However, it may be possible for women to simply increase their oral intake rather than being attached to a drip and we have to consider whether it is justifiable to persist with a policy of 'nil by mouth'. One trial raised concerns about the safety of dextrose and this needs further exploration.None of the trials reported on the evaluation of maternal views of being attached to a drip during their entire labour. Furthermore, there was no objective assessment of dehydration. The evidence from this review does not provide robust evidence to recommend routine administration of intravenous fluids. Interpreting the results from trials was hampered by the low number of trials contributing data and by variation between trials. In trials where oral fluids were not restricted there was considerable variation in the amount of oral fluid consumed by women in different arms of the same trial, and between different trials. In addition, results from trials were not consistent and risk of bias varied. Some important research questions were addressed by single trials only, and important outcomes relating to maternal and infant morbidity were frequently not reported.