CD007715 PDF

Cochrane Database of Systematic Reviews
Intravenous fluids for reducing the duration of labour in low

risk nulliparous women (Review)
Dawood F, Dowswell T, Quenby S
Dawood F, Dowswell T, Quenby S.

Intravenous fluids for reducing the duration of labour in low risk nulliparous women.
Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD007715.
DOI: 10.1002/14651858.CD007715.pub2.
www.cochranelibrary.com
Intravenous fluids for reducing the duration of labour in low risk nulliparous women (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Analysis 4.1. Comparison 4 Intravenous fluids + oral intake versus oral intake alone, Outcome 1 Mean duration of labour. 39
Analysis 4.2. Comparison 4 Intravenous fluids + oral intake versus oral intake alone, Outcome 2 Caesarean section. . 40
Analysis 4.4. Comparison 4 Intravenous fluids + oral intake versus oral intake alone, Outcome 4 Fluid overload. . . 40
Analysis 4.5. Comparison 4 Intravenous fluids + oral intake versus oral intake alone, Outcome 5 Admission to neonatal
unit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Analysis 4.6. Comparison 4 Intravenous fluids + oral intake versus oral intake alone, Outcome 6 Low Apgar scores (< 7 at 5
mins). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Analysis 5.1. Comparison 5 125 mL/hour intravenous fluids + oral intake versus 250 mL/hour intravenous fluids + oral
intake, Outcome 1 Mean duration of labour in minutes. . . . . . . . . . . . . . . . . . . . 42
intake, Outcome 2 Caesarean section. . . . . . . . . . . . . . . . . . . . . . . . . . 43
intake, Outcome 3 Assisted delivery. . . . . . . . . . . . . . . . . . . . . . . . . . . 43
intake, Outcome 4 Fluid overload. . . . . . . . . . . . . . . . . . . . . . . . . . . 44
intake, Outcome 5 Admission to neonatal unit. . . . . . . . . . . . . . . . . . . . . . . 45
intake, Outcome 6 Low Apgar scores (< 7 at 5 mins). . . . . . . . . . . . . . . . . . . . . 45
Analysis 6.1. Comparison 6 125 mL/hour fluids versus 250 mL/hour fluids (restricted oral intake in both arms), Outcome
1 Mean duration of labour in minutes. . . . . . . . . . . . . . . . . . . . . . . . . . 46
2 Caesarean section. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
3 Assisted delivery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
4 Fluid overload. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
5 Admission to neonatal unit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
6 Low Apgar scores (< 7 at 5 mins). . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Analysis 8.1. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 1 Mean duration of labour in minutes. 50
Analysis 8.2. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 2 Caesarean section. . . . . . 51
Analysis 8.3. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 3 Assisted delivery. . . . . . 52
Analysis 8.4. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 4 Fluid overload. . . . . . . 52
Analysis 8.5. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 5 Admission to neonatal unit. . 53
Intravenous fluids for reducing the duration of labour in low risk nulliparous women (Review) i
Analysis 8.6. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 6 Low Apgar scores (< 7 at 5 mins). 53
Analysis 8.9. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 9 Maternal hyponatraemia (sodium
level < 135 mmol/L). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Analysis 8.12. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 12 Neonatal hyponatraemia (cord
sodium level < 135 mmol/L). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Analysis 8.13. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 13 Neonatal hyperbilirubinaemia. 55
Analysis 8.14. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 14 Neonatal hypoglycaemia (< 40
mg/dL). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . 57
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Intravenous fluids for reducing the duration of labour in low risk nulliparous women (Review) ii
[Intervention Review]
Intravenous fluids for reducing the duration of labour in low

risk nulliparous women
Feroza Dawood1 , Therese Dowswell2 , Siobhan Quenby3
1 Liverpool
Women’s NHS Foundation Trust, Liverpool, UK. 2 Cochrane Pregnancy and Childbirth Group, Department of Women’s
and Children’s Health, The University of Liverpool, Liverpool, UK. 3 Clinical Sciences Research Institute, University of Warwick,
Coventry, UK
Contact address: Feroza Dawood, Liverpool Women’s NHS Foundation Trust, Crown Street, Liverpool, L8 7SS, UK.
feroza.dawood@lwh.nhs.uk. fdawood@liv.ac.uk.
Editorial group: Cochrane Pregnancy and Childbirth Group.

Publication status and date: New, published in Issue 6, 2013.
Review content assessed as up-to-date: 17 June 2013.
Citation: Dawood F, Dowswell T, Quenby S. Intravenous fluids for reducing the duration of labour in low risk nulliparous women.
Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD007715. DOI: 10.1002/14651858.CD007715.pub2.
ABSTRACT
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.
Intravenous fluids for reducing the duration of labour in low risk nulliparous women (Review) 1
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 (I2 = 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.
PLAIN LANGUAGE SUMMARY

Intravenous fluids for preventing prolonged labour in women giving birth to their first baby
Labour may be considered to be a period of prolonged exercise. Labouring women may become dehydrated as a result of the physical
exertion caused by the muscles of the womb contracting. In many institutions women are subjected to a questionable policy of restricted
oral intake. Only sips of water or ice chips are allowed. In institutions where this is employed, women are given routine intravenous
fluids (through a “drip”).The aim of this review was to evaluate the impact of the routine administration of intravenous fluids (using a
’drip’) on the duration of labour in women who were in their first pregnancy. We also wanted to determine any side-effects of intravenous
fluids on the mother and the newborn.
We included nine randomised controlled trials.The review demonstrated that in women who are not freely drinking fluids during the
course of their labour, additional fluids through a ’drip’ (intravenously) reduces the duration of their labour. The number of caesarean
sections was also reduced when women received normal saline or Ringer’s lactate at a rate of 250 mL/hour compared to 125 mL/hour.
Dextrose-containing fluids reduced the sodium levels (hyponatraemia) of both the labouring mother and their newborns.
However, the differences in the methodology and quality of several of the trials do not provide sufficient evidence to recommend
routinely attaching labouring women to a drip. Further research needs to be undertaken as to whether or not women who are freely
drinking, even need to have a drip, and the policy of restricted oral intake needs to be urgently reviewed.
BACKGROUND required for adequate fetal oxygenation, but also for the delivery
of nutrients and the elimination of waste products from the con-
tracting myometrium. Furthermore, labouring women who are
Description of the condition not adequately hydrated may have alterations in the acid-base bal-
ance of the fluid surrounding the myometrial fibres resulting in a
Human labour is physically demanding and there are several fac- decrease in the pH. Changes in the pH have been shown to affect
tors that may influence the normal progression of labour. One of calcium signalling and the force of myometrial contractility, pro-
the rationales for administering intravenous fluids during labour longing the course of labour (Pierce 2003).
is the need to provide an adequate metabolic environment to sup- Some studies have therefore postulated that dysfunctional or pro-
port the demands of labour. While the physiological calorific re- longed labour, a leading indication for primary caesarean section
quirement for a labouring uterus has been reported to be approx- delivery, could, at least in part, be caused by inadequate uterine
imately ten grams of carbohydrates per hour (Morton 1985), the forces or inappropriately co-ordinated contractions because of in-
actual amount of hydration that a labouring uterus requires for adequate hydration. The hypothesis that was developed was that
efficient contraction, has not been quantified. It does seem logi- women who are adequately hydrated with routine administration
cal that adequate hydration and perhaps supplemental glucose is of intravenous fluids, have a reduced duration of labour and a
required to maintain endurance and muscle efficiency during the reduced need for caesarean section delivery for prolonged labour
process of labour and parturition, but is the routine administra- (Eslamian 2006; Garite 2000). This theory raises several ques-
tion of intravenous fluids entirely necessary? tions: can intravenous fluids be proven to reduce the duration of
The labouring uterine smooth muscle may be compared to periods labour and caesarean section delivery for prolonged labour? If so,
of prolonged exertion as is seen with prolonged exercise, for exam- what is the optimal rate and optimal type of intravenous fluid to
ple, in distance runners. Several prospective randomised trials in be administered to labouring women? Are there any associated risk
the field of sports medicine have demonstrated that regular fluid factors with routine intravenous fluid administration?
replacement during exercise improved performance and prevented Indeed the benefits of routine administration of intravenous flu-
dehydration in long-distance runners (Barr 1991; Maughan 1996; ids to low-risk labouring women have not been properly evalu-
Montain 1992). Some researchers believe that extrapolating data ated. Despite the lack of evidence, many institutions have adopted
from exercise physiology to uterine smooth muscle, may provide the policy of restricting women from food and drink in labour
some insight as to why some women who may be inadequately and replacing oral intake with intravenous fluids instead. Another
hydrated undergo prolonged labours (Saltin 1998). During exer- purported reason for enforcing a policy of nil by mouth is that
cise, fluid loss is poorly regulated and moreover, the rate of fluid it is a protective measure against aspiration of gastric contents in
loss by sweating and respiration is not reduced in a state of de- the event of general anaesthesia. However, the advent of epidural
hydration (Garite 2000). More specifically, uterine blood flow is anaesthesia and antacids has greatly reduced the risk of pulmonary
not autoregulated and in the presence of decreased intravascular complications and the attendant morbidity from the aspiration of
volume (which may occur secondary to dehydration), fluid may pulmonary contents has virtually disappeared (O’Sullivan 2003).
be redistributed away from the uterus potentially aggravating the The likelihood of mortality from aspiration during caesarean sec-
problem (Eslamian 2006). Optimal uterine perfusion is not only
tion has been quoted as 1.8 per 100,000 (Schuitemaker 1997), consider the use of intravenous fluids for women with a febrile
and adjusted for the vastly reduced number of general anaesthet- illness or pyrexia during labour.
ics, the actual risk is even lower at 1 in 1.2 million. (Romano There are different types of intravenous fluids that may be em-
2009). Despite a revision of guidelines from the American Society ployed and there are side-effects that are associated with some. For
of Anesthesiologists (ASA 2007) to encourage the oral intake of example, although high-dose glucose solutions may correct ma-
clear fluids in labour, almost 83% of women in America are rou- ternal ketosis, the administration thereof may be associated with
tinely given intravenous fluids instead, even if they were deemed an increased incidence of neonatal hyponatraemia (Tarnow-Mordi
low risk (Romano 2009). 1981). Dextrose-only solutions may also cause maternal hypona-
Practices vary amongst different countries. Many midwifery-led traemia and affect serum osmolality (Keppler 1988).
units in the UK at least, do not routinely administer intravenous Different volumes of fluids may also be used. Excessive amounts
fluids for low-risk women and neither is it a common practice of fluids may lead to fluid overload (Montain 2008) in the mother.
in home births and some birth centres (Michael 1991). A survey There are also concerns over newborn weight loss during the first
that was conducted in around 350 units in England and Wales three days following birth that occurs when mothers have received
revealed that a third allowed some food or drink and well over large volumes of intravenous fluids (Chantry 2011; Noel-Weiss
90% allowed some oral intake (Michael 1991). In the Netherlands 2011).
too, women have been allowed unrestricted oral intake (Scheepers While intravenous fluids may seem a simple and benign interven-
1998). While it is acknowledged that labour is a demanding event, tion to healthcare professionals, routine intravenous fluids may
and in some cases may be prolonged, should women be routinely adversely affect the perception of labour for women and negatively
supplemented with intravenous fluids or could this be simply impact on the normality of labour. We therefore also planned to
avoided by allowing women to eat and drink according to their evaluate the qualitative disadvantages of routine intravenous flu-
own feelings of hunger or thirst? Whether or not restricting oral ids which include women being less mobile in labour, maternal
food intake is justifiable is the subject of another review (Singata discomfort, fear and pain and overall negative feelings.
2010).
Besides medicalising a normal labour, women may find intra-
venous fluids uncomfortable and being attached to an intravenous How the intervention might work
line limits mobility. Furthermore, intravenous infusions can lead
As already discussed above, some women may become very de-
to elevated central venous pressure after the administration of only
hydrated during labour as the uterine muscle has to contract and
one to two litres of fluid. Fluid overload has also been associ-
relax continuously and this may be required for a prolonged pe-
ated with increased cardiovascular work and pulmonary oedema
riod of time. The intense exertion that may be required may lead
(Carvalho 1994).There are also concerns that excessive fluids ad-
to dehydration. Adequate fluid replacement enhances muscle per-
ministered to the mother, may affect the newborn as well. More
formance in long-distance runners. The administration of intra-
recent studies found that if mothers received more than 200 mL/
venous fluids to keep women adequately hydrated during labour
hour of fluids, their babies were 3.2 times more likely to experience
may reduce the period of contraction and relaxation of the uterine
excess weight loss at three days compared to mothers who had less
muscle and may ultimately reduce the duration of the labour.
than 100 mL/hour of fluids (Chantry 2011; Noel-Weiss 2011).
It has been postulated that dehydration may contribute to pro-
The aim of this review was to evaluate the impact of routine ad-
longed and inefficient labour and it can be hypothesised that ade-
ministration of intravenous fluids to low-risk nulliparous labour-
quate maternal hydration will be important for optimum oxygena-
ing women. We also aimed to explore the safety of the mother and
tion, delivery of nutrients and elimination of waste products from
the baby.
the contracting myometrium. It has also been suggested that ad-
equate intravenous fluid replacement regimens may even obviate
the need for caesarean sections that are performed solely for “fail-
ure to progress” in labour, or prolonged labour (Eslamian 2006)
Description of the intervention that may result from inadequate hydration. Some types of intra-
The intervention that we reviewed is the routine administration venous fluids (dextrose-containing solutions), may also provide a
of fluids through an intravenous line (drip) to low-risk nulliparous calorific supplementation for labouring women.
women in labour. This review focuses specifically on the routine However, the notion that the administration of routine intra-
use of intravenous administration of fluids during labour for the venous fluids may prevent operative deliveries by preventing de-
purpose of fluid and nutritional support/management and not for hydration is largely theoretical as operative deliveries may result
clinical conditions where intravenous fluids are medically indi- from various factors. However, even if there is a partial benefit of
cated, for example, as preload prior to epidural analgesia, or for intravenous fluids in the reduction of unnecessary caesarean sec-
any other medical interventions such as cardio-respiratory conditions then it is important to evaluate this as there are wider cost
tions, diabetes, haematological or renal disease. Neither did we implications as well as the impact on future pregnancies.
Why it is important to do this review • Randomised and quasi-randomised studies comparing the
administration of different volumes of the same intravenous
As outlined above, in many centres, the use of routine intravenous
fluids
fluids administration is widespread and pervasive without a cogent
• Randomised and quasi-randomised studies comparing the
body of evidence. Furthermore, little cognisance has been noted
administration of different intravenous fluids
regarding the safety and efficacy of routine intravenous fluids, and
indeed the potential dangers of some types of fluids. Although oral
fluids are the simplest and easiest way of replenishing lost fluids, it Since this review aims to determine whether the routine use of
is thought that amounts of more than 500 mL/hour are required intravenous fluids shortens the duration of labour or minimises
in prolonged exertion (Noakes 1993) such as labour. Thus, there the need for augmentation of labour, women who subsequently
may be some justification for the routine use of intravenous fluids require oxytocin augmentation have not been excluded. However,
for labouring women, however, the volumes and types of fluids women who require oxytocin primarily for induction of labour
need further clarification. The main aim of this review is to deter- were excluded. Therefore, we included caesarean sections, other
mine the impact (if any) on the use of routine intravenous fluid operative deliveries and the need for augmentation as outcome
administration on the duration of labour. Different types of intra- measures.
venous fluid regimens may produce different results for women in We have not included cross-over trials; this research design is not
labour. The type and volume of intravenous fluid that is adminis- suitable for this intervention during labour.
tered during labour need to be elucidated. Moreover, this review
is important as it may assist in providing evidence that routine in-
travenous fluid administration is not superior to unrestricted oral Types of participants
intake in low-risk women.
• Nulliparous women
We intentionally restricted the review to nulliparous women as we

felt that the inclusion of multiparous women would introduce a
OBJECTIVES
considerable bias as this would include women in their second,
third or fourth labours. The main aim of the review is to determine
• To assess the impact of early or routine intravenous fluid
whether intravenous fluids reduce the duration of labour. It is gen-
administration on the duration and course of labour.
erally accepted that women tend to labour quicker in subsequent
• To determine the risks and benefits of early or routine labours and this would have introduced a bias. It would have been
intravenous fluid administration during labour. difficult to determine the influence that a woman’s parity had on
the duration of labour. Therefore, to exclude this bias and for the
• To determine the risks and benefits of different fluid
sake of uniformity, we only included low-risk nulliparous women.
regimens (i.e. different volumes or different types of fluids, or
• Spontaneous active labour
both) used in labour.
• Singleton presentations
• To compare the course of labour when intravenous fluids • Cephalic presentation
are compared with oral intake. • Term pregnancies (greater than 36 weeks)
• Low-risk pregnancies (i.e. no medical conditions such as
• To compare the course of labour when oral intake is
diabetes, pre-eclampsia etc and no obstetric problems such as
supplemented by routine intravenous fluids versus oral intake
antepartum haemorrhage or chorioamnionitis)
only.
METHODS Types of interventions

• Intravenous fluid versus no intravenous fluids (restricted
oral intake)
Criteria for considering studies for this review • Intravenous fluids versus no intravenous fluids (oral intake
not restricted)
• Intravenous fluids + oral intake versus intravenous fluids
Types of studies alone
• Randomised and quasi-randomised studies comparing the • Intravenous fluids + oral intake versus oral intake alone
administration of routine intravenous fluids compared with non- • Comparison of different rates of intravenous fluids
administration of intravenous fluids • Comparison of different types of intravenous fluids
Types of outcome measures 4. handsearches of 30 journals and the proceedings of major
The outcomes were divided into maternal and fetal outcomes. conferences;
5. weekly current awareness alerts for a further 44 journals
plus monthly BioMed Central email alerts.
Primary outcomes Details of the search strategies for CENTRAL, MEDLINE and
EMBASE, the list of handsearched journals and conference pro-
ceedings, and the list of journals reviewed via the current aware-
Maternal ness service can be found in the ‘Specialized Register’ section
within the editorial information about the Cochrane Pregnancy
1. Duration of labour (in minutes)
and Childbirth Group.
2. Fluid overload
Trials identified through the searching activities described above
3. Caesarean section
are each assigned to a review topic (or topics). The Trials Search
4. Assisted delivery
Co-ordinator searches the register for each review using the topic
list rather than keywords.
Fetal We will not apply any language restrictions.
1. Admission to neonatal intensive care unit (NICU)/special
care baby unit
2. Low Apgar scores (less than seven at five minutes) Data collection and analysis
3. Cord pH < 7.0
4. Newborn weight loss (first three days)
Selection of studies
All review authors (Feroza Dawood (FD), Therese Dowsell (TD)
Secondary outcomes and Siobhan Quenby (SQ)) independently assessed for inclusion
all the potential studies identified as a result of the search strategy.
Disagreement was resolved through discussion.
Maternal
1. Maternal comfort
2. Maternal satisfaction Data extraction and management
3. Subjective feelings of thirst We designed a data extraction form to capture data. For eligible
4. Ketoacidosis studies, FD ,TD and SQ extracted the data using the agreed form.
We resolved discrepancies through discussion. We entered data
into Review Manager software (RevMan 2011) and checked for
Fetal and neonatal accuracy.
1. Hyponatraemia
2. Hyperbilirubinaemia
Assessment of risk of bias in included studies
Two review authors independently assessed risk of bias for each
study using the criteria outlined in the Cochrane Handbook for
Search methods for identification of studies
Systematic Reviews of Interventions (Higgins 2011). We resolved
any disagreement by discussion.
Electronic searches
We contacted the Trials Search Co-ordinator to search the (1) Random sequence generation (checking for possible
Cochrane Pregnancy and Childbirth Group’s Trials Register (13 selection bias)
February 2013). We have described for each included study the method used to
The Cochrane Pregnancy and Childbirth Group’s Trials Register generate the allocation sequence in sufficient detail to allow an
is maintained by the Trials Search Co-ordinator and contains trials assessment of whether it should produce comparable groups.
identified from: We assessed the method as:
1. monthly searches of the Cochrane Central Register of • low risk of bias (any truly random process, e.g. random
Controlled Trials (CENTRAL); number table; computer random number generator);
2. weekly searches of MEDLINE; • high risk of bias (any non-random process, e.g. odd or even
3. weekly searches of EMBASE; date of birth; hospital or clinic record number);
• unclear risk of bias. We assessed methods as:
• low risk of bias (e.g. no missing outcome data; missing
outcome data balanced across groups);
(2) Allocation concealment (checking for possible selection • high risk of bias (e.g. numbers or reasons for missing data
bias) imbalanced across groups; ‘as treated’ analysis done with
We have described for each included study the method used to substantial departure of intervention received from that assigned
conceal allocation to interventions prior to assignment and assess at randomisation);
whether intervention allocation could have been foreseen in ad- • unclear risk of bias.
vance of, or during recruitment, or changed after assignment.
We assessed the methods as:
• low risk of bias (e.g. telephone or central randomisation; (5) Selective reporting (checking for reporting bias)
consecutively numbered sealed opaque envelopes); We have described for each included study how we investigated
• high risk of bias (open random allocation; unsealed or non- the possibility of selective outcome reporting bias and what we
opaque envelopes, alternation; date of birth); found.
• unclear risk of bias. We assessed the methods as:
• low risk of bias (where it is clear that all of the study’s pre-
specified outcomes and all expected outcomes of interest to the
(3.1) Blinding of participants and personnel (checking for
review have been reported);
possible performance bias)
• high risk of bias (where not all the study’s pre-specified
We have described for each included study the methods used, if outcomes have been reported; one or more reported primary
any, to blind study participants and personnel from knowledge of outcomes were not pre-specified; outcomes of interest are
which intervention a participant received. We considered studies reported incompletely and so cannot be used; study fails to
to be at low risk of bias if they were blinded, or if we judged that include results of a key outcome that would have been expected
the lack of blinding would be unlikely to affect results. We assessed to have been reported);
blinding separately for different outcomes or classes of outcomes. • unclear risk of bias.
We assessed the methods as:
• low, high or unclear risk of bias for participants;
• low, high or unclear risk of bias for personnel; (6) Other bias (checking for bias due to problems not
covered by (1) to (5) above)
(3.2) Blinding of outcome assessment (checking for possible We have described for each included study any important concerns
detection bias) we had about other possible sources of bias.
We assessed whether each study was free of other problems that
We have described for each included study the methods used, if
could put it at risk of bias:
any, to blind outcome assessors from knowledge of which inter-
• low risk of other bias;
vention a participant received. We assessed blinding separately for
• high risk of other bias;
different outcomes or classes of outcomes.
• unclear whether there is risk of other bias.
We assessed the methods used to blind outcome assessment as:
• low, high or unclear risk of bias.
(7) Overall risk of bias
(4) Incomplete outcome data (checking for possible attrition We made explicit judgements about whether studies are at high risk
bias due to the amount, nature and handling of incomplete of bias, according to the criteria given in the Handbook (Higgins
outcome data) 2011). With reference to (1) to (6) above, we assessed the likely
We have described for each included study, and for each outcome magnitude and direction of the bias and whether we considered
or class of outcomes, the completeness of data including attrition it was likely to impact on the findings. We explored the impact
and exclusions from the analysis. We have stated whether attrition of the level of bias through undertaking sensitivity analyses - see
and exclusions were reported and the numbers included in the Sensitivity analysis.
analysis at each stage (compared with the total randomised par-
ticipants), reasons for attrition or exclusion where reported, and
whether missing data were balanced across groups or were related Measures of treatment effect
to outcomes. Where sufficient information was reported, or was
supplied by the trial authors, we re-included missing data in the
analyses which we undertook. Dichotomous data
For dichotomous data, we have presented results as summary risk
ratio with 95% confidence intervals. We analysed data on all participants with available data in the
group to which they were allocated, regardless of whether or not
they received the allocated intervention. If in the original reports
Continuous data participants were not analysed in the group to which they were ran-
For continuous data, we used the mean difference if outcomes domised, and there was sufficient information in the trial report,
were measured in the same way between trials. We planned to use we would have attempted to restore them to the correct group.
the standardised mean difference to combine trials that measured
the same outcome, but used different methods.
Assessment of heterogeneity
We examined statistical heterogeneity in each meta-analysis using
Unit of analysis issues the T², I² and Chi² statistics. We regarded heterogeneity as sub-
stantial if the T² was greater than zero and either an I² was greater
than 30% or there was a low P value (less than 0.10) in the Chi²
Cluster-randomised trials
test for heterogeneity. In the presence of heterogeneity, we have
We did not anticipate any cluster-randomised trials on this topic. used a random-effects meta-analysis as an overall summary if cal-
However, if we identify any cluster-randomised trials in future culating an average treatment effect was considered appropriate.
updates of this review they will be included in the analyses along
with individually-randomised trials. We will adjust their sample
sizes using the methods described in the Handbook (Higgins 2011) Assessment of reporting biases
using an estimate of the intracluster correlation co-efficient (ICC) In future updates of this review, if there are 10 or more studies
derived from the trial (if possible), from a similar trial or from a in the meta-analysis we will investigate reporting biases (such as
study of a similar population. If we use ICCs from other sources, publication bias) using funnel plots. We will assess funnel plot
we will report this and conduct sensitivity analyses to investigate asymmetry visually, and use formal tests for funnel plot asymmetry.
the effect of variation in the ICC. If we identify both cluster- For continuous outcomes we will use the test proposed by Egger
randomised trials and individually-randomised trials, we plan to 1997, and for dichotomous outcomes we will use the test proposed
synthesise the relevant information. We will consider it reasonable by Harbord 2006. If asymmetry is detected in any of these tests
to combine the results from both if there is little heterogeneity or is suggested by a visual assessment, we will perform exploratory
between the study designs and the interaction between the effect analyses to investigate it.
of intervention and the choice of randomisation unit is considered
to be unlikely.
We will also acknowledge heterogeneity in the randomisation unit Data synthesis
and perform a subgroup analysis to investigate the effects of the We carried out statistical analysis using the Review Manager soft-
randomisation unit. ware (RevMan 2011). We used fixed-effect meta-analysis for com-
bining data where trials examined the same intervention, and the
trials’ populations and methods were judged sufficiently similar.
Cross-over trials Where we suspected clinical or methodological heterogeneity be-
We did not include cross-over trials. tween studies sufficient to suggest that treatment effects may differ
among trials, we used random-effects meta-analysis.
Dealing with missing data If we identified substantial heterogeneity in a fixed-effect meta-

For included studies, we noted levels of attrition. We planned to analysis we noted this and repeated the analysis using a random-
explore the impact of including studies with high levels of missing effects method, when appropriate. Where we used random-effects
data in the overall assessment of treatment effect by using sensitiv- analyses, the results are presented as the average treatment effect
ity analysis; however, in this version of the review most of the trials with its 95% confidence interval, along with the estimates of I².
had low levels of attrition and we did not carry out this planned
analysis.
For all outcomes, we carried out analyses, as far as possible, on an Subgroup analysis and investigation of heterogeneity
intention-to-treat basis, i.e. we attempted to include all partici- If we had identified substantial heterogeneity, we planned to in-
pants randomised to each group in the analyses. The denominator vestigate it using subgroup analyses and sensitivity analyses.
for each outcome in each trial was the number randomised mi- We planned to assess differences between subgroups by interaction
nus any participants whose outcomes were known to be missing tests. In this version of the review too few studies contributed data
(’available case’ analysis). to allow this additional analysis.
Sensitivity analysis Shrivastava 2009; Stratton 1995) were included in this review. Col-
We planned to carry out sensitivity analyses to explore the effect lectively, a total of 1781 women were initially recruited, however
of trial quality for important outcomes in the review. Where there due to attrition and exclusion, the final analysis is based on 1617
was risk of bias associated with a particular aspect of study quality women. For full details, see Characteristics of included studies.
(e.g. quasi-randomisation or high risk of bias for allocation con-
cealment), we planned to explore this by sensitivity analyses using
the primary outcomes. However, in this version of the review only Participants
a very limited number of studies contributed data for each out- All women were spontaneously labouring low-risk nulliparous
come and so we did not carry out this planned analysis. In future women with a singleton pregnancy at term, i.e. at least 36 weeks’
updates, as more data become available, we will carry out these completed gestation. We excluded trials that solely studied women
additional analyses. whose labours were induced.
Interventions
RESULTS
Various different intravenous fluids in different volumes (see
Effects of interventions below).
Description of studies
We included nine trials that collectively recruited 1781 women. Excluded studies
However, due to attrition and various exclusion factors, the final
analysis in this review is based on 1617 women. We excluded 26 trials. For details, see Characteristics of excluded
studies. In addition, we identified one trial that is still ongoing
(Salim 2011) and two that are awaiting assessment (Amir 2004;
Results of the search Rad 2012).
We included nine trials and excluded 26 trials.
Included studies Risk of bias in included studies

Nine trials (Alavi 2005; Coco 2010; Direkvand-Moghadam 2012; Summaries of risk of bias assessments have been set out in Figure
Eslamian 2006; Garite 2000; Kavitha 2012; Maderia 2007; 1 and Figure 2.
Figure 1. ’Risk of bias’ graph: review authors’ judgements about each risk of bias item presented as
percentages across all included studies.
Figure 2. ’Risk of bias’ summary: review authors’ judgements about each risk of bias item for each included
study.
Allocation Comparison 1: Intravenous fluid alone versus no
intravenous fluids (restricted oral intake)
Adequate and secure concealment of allocation was described in
seven trials (Coco 2010; Direkvand-Moghadam 2012; Eslamian None of the included studies analysed this comparison.
2006; Garite 2000; Kavitha 2012; Shrivastava 2009; Stratton
1995). We classified as unclear allocation risk in the Alavi 2005 Comparison 2: Intravenous fluids alone versus no
trial, as although sealed envelopes were used there was unclear intravenous fluids (unrestricted oral intake)
information on the method of randomisation. There was also an
unclear risk of allocation concealment in the study by Maderia None of the included trials analysed this comparison.
2007 as it was published as an abstract with limited information.
Comparison 3: Intravenous fluids alone versus
intravenous fluids and oral intake
Blinding
None of the included studies studied this comparison
Where intravenous fluids were compared with no intravenous flu-
ids, masking women and staff would not be feasible, and staff
would also be likely to be aware of treatment group when women Comparison 4: Intravenous fluids (up to 250
were randomised to have different rates of infusion. Lack of blind- mL/hour) + oral intake versus oral intake alone
ing may have had an effect on outcomes in five of the included Two trials were included in this comparison (Direkvand-
studies (Alavi 2005; Coco 2010; Direkvand-Moghadam 2012; Moghadam 2012; Kavitha 2012).
Garite 2000; Kavitha 2012). In one study it was stated that in- In the study by Direkvand-Moghadam 2012, 120 women were
fusion rates were masked (Eslamian 2006), and in one study re- divided into four groups; the control group was allowed free oral
ported in a brief abstract, it was not clear whether there had been intake of water and/or, soft drinks, in three intervention arms
any attempt at blinding women and staff. Where different intra- women received intravenous Ringer lactate solution at rates of
venous fluids were compared women and staff were blinded in 60 mL, 120 mL or 250 mL per hour throughout active labour
Shrivastava 2009, but it was not clear whether there was blinding and were also allowed free oral fluids. To allow a single pair-wise
or not in Stratton 1995. comparison for this study, in the data and analysis tables for this
comparison, we combined the results for the three groups receiving
intravenous fluids. The mean total amount of oral or intravenous
Incomplete outcome data intake for the four groups was not stated.
In most of our included studies all women were accounted for In Kavitha 2012, 96 women were randomised to receive 250 mL/
in the analysis, or rates of attrition were low, reasons for loss to hour of Ringer’s lactate solution as well as oral intake, and 99
follow-up were explained, and were balanced across groups. In the women received oral intake only. The mean amount of oral fluid
Coco 2010 study, women were recruited during pregnancy and intake was 1325 mL in the intravenous fluid group and 896 mL
there was a high rate of loss to follow- up, putting this study at in the oral intake group. Oral intake included both plain water
high risk of bias for this domain. and coconut water.
Effects of interventions Primary outcomes

For the sake of clarity we have used the following comparisons.
• Intravenous fluid versus no intravenous fluids (restricted
Maternal outcomes
oral intake)
• Intravenous fluids versus no intravenous fluids (unrestricted Duration of labour in minutes (vaginal deliveries): Both studies re-
oral intake) ported on the duration of labour although Direkvand-Moghadam
• Intravenous fluids + oral intake versus intravenous fluids 2012 reported separate results for each stage of labour and in the
alone analysis we used the duration of the active first stage of labour.
• Intravenous fluids + oral intake versus oral intake alone There was a reduction in the duration of labour in the intravenous
• Different rates of intravenous fluids + oral intake fluids + oral intake group of 29 minutes (mean difference (MD) -
• Comparison of different rates of intravenous fluids 28.86, 95% confidence interval (CI) -47.41 to -10.30, two stud-
• Comparison of different types of intravenous fluids ies, 241 women) (Analysis 4.1). Direkvand-Moghadam 2012 re-
ported that the duration of the 2nd and the 3rd stages of labour
Three trials with more than two arms are included in more than were reduced for women receiving intravenous fluids, although
one comparison (Direkvand-Moghadam 2012; Kavitha 2012; the difference between groups for the third stage was not statisti-
Shrivastava 2009). cally significant (data not shown).
Mode of delivery: There was no statistically significant reduction deliveries in both groups in this study (RR 0.47, 95% CI 0.27 to
in the number of caesarean sections (CS) in the intravenous fluid 0.81) (Analysis 5.3).
group (risk ratio (RR) 0.73, 95% CI 0.49 to1.08, two studies, Fluid overload: There were no cases of fluid overload in either
315 women) (Analysis 4.2). Neither study reported the number group in the two studies reporting this outcome.
of assisted vaginal deliveries.
Fluid overload: There were no cases of fluid overload in either
Neonatal outcomes
group in the Kavitha 2012 trial.
NICU admission: There was no strong evidence of a difference
between groups in admission to the neonatal unit in the two trials
Neonatal outcomes reporting this outcome; overall, there were a total of eight admis-
NICU admission: There was no evidence of a statistically significant sions from the pooled sample of 274 (RR 0.56, 95% CI 0.15 to
difference in admission to the neonatal unit in the Kavitha 2012 2.06) (Analysis 5.5).
trial (RR 0.52, 95% CI 0.05 to 5.59) (Analysis 4.5). Apgar score > seven at five minutes: This was reported by Coco 2010
Apgar score > seven at five minutes: This was reported by Direkvand- and Direkvand-Moghadam 2012; there were no infants with a low
Moghadam 2012; there were no infants with a low Apgar score at Apgar score at five minutes in either study (Analysis 5.6).
five minutes in either group (Analysis 4.6). Other primary outcomes: None of the studies included in this com-
Other primary outcomes: Neither of the two studies included in parison reported on cord pH or newborn weight loss.
this comparison reported on cord pH or newborn weight loss.
Secondary outcomes
Secondary outcomes There were no data reported for any of our maternal or infant
There were no data reported for any of our maternal or infant secondary outcomes (maternal hyponatraemia, maternal comfort/
secondary outcomes (maternal hyponatraemia, maternal comfort/ discomfort, maternal feelings of thirst, neonatal hyponatraemia,
discomfort, maternal feelings of thirst, neonatal hyponatraemia, neonatal hypoglycaemia or hyperbilirubinaemia).
neonatal hypoglycaemia or hyperbilirubinaemia).
Comparison 6: Comparison of different rates of
Comparison 5: Intravenous fluids 125 mL/hour + oral intravenous fluids (125 mL/hour versus 250 mL/hour)
intake versus intravenous fluids 250 mL/hour + oral with restricted oral intake
intake Four trials (Alavi 2005; Eslamian 2006; Garite 2000; Maderia
Three studies were included in this comparison (Coco 2010; 2007 ) were included in this comparison with a total number of
Direkvand-Moghadam 2012; Kavitha 2012). 808 women. Two trials (Eslamian 2006; Garite 2000 ) compared
different rates of Ringer’s lactate solution. The Alavi 2005 trial
compared different rates of normal saline in dextrose water, while
Primary outcomes
there was no further information on the type of fluid used in the
Maderia 2007 trial.
Maternal outcomes
Duration of labour in minutes (vaginal deliveries): All three studies Primary outcomes
included in this comparison reported on the duration of labour.
(Direkvand-Moghadam 2012 reported separate results for each
stage of labour and in the analysis we have used the length of Maternal outcomes
the active first stage of labour). Women receiving a greater hourly Duration of labour in minutes (vaginal deliveries): There was a sig-
volume of intravenous fluids (250 mL) plus free oral fluids had nificant reduction in the duration of labour in women who re-
shorter labours than those receiving 125 mL (MD 23.87, 95% CI ceived a higher infusion rate of intravenous fluids (MD 105.61,
3.72 to 44.02, three studies, 256 women) (Analysis 5.1). 95% CI 53.19 to 158.02 (P < 0.0001) four studies, 632 women.
Mode of delivery: There was no statistically significant reduction However, findings must be interpreted with caution as results in
in the number of caesarean sections (CS) in the 250 mL hourly the four trials were not consistent. There was fairly high statistical
intravenous fluid group (average RR 1.00, 95% CI 0.54 to1.87, heterogeneity amongst trials and results have been pooled using a
three studies, 334 women (random-effects analysis)) (Analysis random-effects model (heterogeneity within this comparison I2 =
5.2). One study reported results for 80 women and the number 53%) (Analysis 6.1).
of assisted vaginal deliveries was lower in the group receiving 125 Mode of delivery: There was a significant reduction in the caesarean
mL hourly plus free oral fluids compared with the group receiving section rate in women receiving a higher rate of intravenous fluid
250 mL although there were relatively high numbers of assisted infusion without any significant heterogeneity between trials (RR
1.56, 95% CI 1.10 to 2.21; (P = 0.01) four trials, 748 women, I2 Primary outcomes
= 0%) (Analysis 6.2).
Only two trials reported on assisted delivery (Eslamian 2006;
Garite 2000). There was no evidence of any difference between Maternal outcomes
groups in the assisted delivery rate (RR 0.78, 95% CI 0.44 to 1.40 Duration of labour in minutes: Both studies included in this com-
(Analysis 6.3). parison reported duration of labour. Stratton 1995 reported the
Fluid overload: Only one trial reported on fluid overload (Garite mean duration of labour and there was no strong evidence of a
2000). Only one woman in the 125 mL/hour group was reported difference in the duration of labour for women receiving normal
to have developed fluid overload, while no women suffered this in saline versus a 5% dextrose solution (MD of -12.00, 95% CI -
the 250 mL/hour group (RR 3.22 and wide 95% CI of 0.13 to 30.09 to 6.09) (Analysis 8.1). Shrivastava 2009 reported the me-
78.11) (Analysis 6.4). dian time from fluid initiation to delivery and reported shorter
duration in the 5% dextrose group (median 392 minutes) versus
the normal saline group (median 464 minutes) and this difference
Neonatal outcomes
between groups was reported to be statistically significant (P =
NICU admission: There was no strong evidence that the rate of 0.02) (data not shown in the data and analysis tables).
infusion affected admission to NICU in 3 studies with data for 689 Mode of delivery: There was no significant difference in the need
babies, overall the number of admissions was relatively low and for caesarean section or assisted delivery (RR 0.77, 95% CI 0.41
results in different studies were not consistent. We used a random- to 1.43, two studies, 284 women) and (RR 0.59, 95% CI 0.21 to
effects model for this analyses and the 95% confidence intervals 1.63, one study, 93 women) respectively. (Analysis 8.2; Analysis
for this outcome are wide (average RR 0.48, 95% CI 0.07 to 3.17, 8.3).
I2 47%). (Analysis 6.5). Fluid overload: There were no cases of fluid overload in either
Apgar score < seven at five minutes: More babies had low Apgar group in the single study reporting this outcome (Analysis 8.4.)
scores in the 125 mL/hour group compared to the 250 mL/hour
group although the difference between groups was not statistically
significant (RR 4.35, 95% CI 0.97 to 19.51, three studies, 689 Neonatal outcomes
babies) (Analysis 6.6). NICU admission: There was no evidence of a difference between
Other primary outcomes: Neither of the studies included in this groups in admissions to the neonatal unit (RR 1.11, 95% CI 0.42
comparison reported on cord pH or newborn weight loss. to 2.93, two studies, 284 babies) (Analysis 8.5).
Apgar score < seven at five minutes: There was no difference in the
number of babies with low Apgar scores (RR 0.48, 95% CI 0.04,
Secondary outcomes 5.25, two studies, 284 babies) (Analysis 8.6).
None of the trials reported on maternal feelings of thirst, maternal Other primary outcomes: Neither of the two studies included in
comfort or satisfaction/dissatisfaction of being attached to intra- this comparison reported on cord pH or newborn weight loss.
venous fluids. None of the trials reported on low cord pH, neona-
tal hyponatraemia, hypoglycaemia, fetal hyperbilirubinaemia or
Secondary outcomes
newborn weight loss.
As far as maternal complications are concerned, only the Stratton
1995 trial reported on maternal hyponatraemia (serum sodium
Comparison 7: 125 mL/hour Ringer’s lactate versus levels < 135 mmol/L ). While none of the women in the normal
125 mL/hour 5% dextrose saline group developed hyponatraemia, nine women in the dex-
None of the trials included in this version of the review analysed trose groups did (RR 0.06, 95% CI 0.00, 0.94) (Analysis 8.9). The
this comparison. Shrivastava 2009 trial did not conduct any assessment of maternal
hyponatraemia. (This was not a pre-specified review outcome.)
In the Stratton 1995 trial, one-third of babies (33.3%) developed
Comparison 8: 125 mL/hour normal saline versus 125 hyponatraemia in the dextrose group compared to 13.3 % in the
mL/hour 5% dextrose normal saline group (RR 0.40, 95% CI 0.17 to 0.93; P = 0.03)
Two trials ( Shrivastava 2009) and Stratton 1995 analysed this (Analysis 8.12). It is noteworthy that the Shrivastava 2009 trial
comparison involving 284 women. In the Shrivastava 2009 trial, did not conduct any testing for neonatal hyponatraemia. The
a total of 191 women were randomised to two groups: 97 women Shrivastava 2009 trial did report neonatal hyperbilirubinaemia,
were randomised to receive 125 mL/hour normal saline and 94 and although there were more babies in the dextrose group of
women were randomised to receive 125 mL/hour of 5% dextrose babies with hyperbilirubinaemia the difference between groups
solution. In the Stratton 1995 trial, 45 women received normal was not statistically significant (RR 0.39, 95% CI 0.08 to 1.95) (
saline and 48 women received 5% dextrose solution. Analysis 8.13). There was no difference in neonatal hypoglycaemic
episodes between the two groups with a RR of 0.97, (95% CI 0.20 excluded from the final analysis, which was based on only 80
to 4.68) (Analysis 8.14). participants.
The main drive for routine intravenous fluid administration, was as
Comparison 9: 125 mL/hour normal saline versus 125 a consequence of the pervasive ’nil by mouth’ policy for labouring
mL/hour Ringer’s lactate women. The justification and arguments against this has been
None of the included trials so far have analysed this comparison. addressed above. As such, intravenous fluids are administered to
women in labour without robust scientific evidence that they are
required, or if they are required, what volumes or which types of
fluids are to be used. An arbitrary rate of 125 mL/hour seems to
be employed by many centres. Hence, our next question was to
DISCUSSION
determine whether when women are restricted in their oral intake,
We reviewed nine trials that collectively recruited 1781 women. and intravenous fluids are administered, is the rate of 125 mL/
However, due to attrition and various exclusion factors, the final hour sufficient?
analysis is based on 1617 women.
Four trials (Alavi 2005; Eslamian 2006; Garite 2000; Maderia
One of the underlining objectives of this review was to determine, 2007), in which women were restricted in their oral intake, com-
in the first instance whether or not, the routine administration of pared 125 mL/hour versus 250 mL/hour of intravenous fluids.The
intravenous fluids conferred any benefit to nulliparous labouring type of fluid in the Alavi 2005 trial was normal saline in dextrose
women, particularly in reducing the duration of labour. Therefore, water. Both the Eslamian 2006 and Garite 2000 trials adminis-
we searched for trials that compared “usual care” of unrestricted tered Ringer’s lactate solution. There was insufficient information
oral fluids with intravenous fluid administration. Only two trials on the type of fluid that was used in the Maderia 2007 trial as it
analysed this comparison (Direkvand-Moghadam 2012; Kavitha was published as an abstract only. The meta-analysis of the four
2012). Pooled results from these trials showed a reduction in mean trials revealed that the mean duration of labour was significantly
duration of labour for women receiving intravenous fluids com- reduced (by approximately one and half hours) in the group that
pared with oral intake only. However, it is worth noting that in one received the increased rate of 250 mL/hour of fluid, however there
of the trials (Kavitha 2012), the mean oral intake in the women in was considerable heterogeneity between trials which makes this re-
the intravenous fluids + oral intake group was much higher than in sult more difficult to interpret. In addition, there was a statistically
the oral intake group only (1325 versus 896 mL). There were no significant reduction in the number of caesarean sections in the
significant maternal or neonatal complications in the intravenous 250 mL/hour group. There was insufficient information about the
fluids group. As these findings are based on just two trials, they indication for CS in the Maderia 2007 trial, however, the remain-
need to be interpreted with caution. ing three trials (Alavi 2005; Eslamian 2006; Garite 2000) describe
the indication for CS, and the majority of CS were for failure to
In the Coco 2010 trial, women were divided into two groups, i.e.
progress in the first stage. What was not standardised however,
intravenous fluids and oral intake versus “usual care”, the “usual
is how “failure to progress” was diagnosed in each of the trials.
care” that was referred to was not confined solely to oral intake. In
None of the trials was able to demonstrate conclusively that in-
fact, women in the “usual care” group had received a mean volume
creased hydration directly prevented caesarean sections for failure
of 1627 mL of intravenous fluid (approximating to a rate of 125
to progress.There was no significant difference in the rates of as-
mL/hour). The intravenous fluid that was administered in both
sisted delivery between the two groups. As far as neonatal compli-
groups was Ringer’s lactate. The findings of the Coco 2010 trial
cations were concerned, more babies were admitted to the neona-
were therefore grouped with the comparison of 125 mL/hour of
tal unit in the 250 mL/hour group, although the difference be-
intravenous fluid and oral intake versus 250 mL/hour intravenous
tween groups was not statistically significant. However, there was
fluid and oral intake. Two groups from the Kavitha 2012 and
a statistically higher risk of low Apgar scores in the 250 mL/hour
Direkvand-Moghadam 2012 trials also compared these different
group. None of the trials reported on neonatal hyponatraemia,
rates. The findings from these trials showed a reduction in the
hypoglycaemia or newborn weight loss in the first three days of
duration of labour in the 250 mL/hour intravenous fluid + oral
life.
intake group.There was a difference in the types of oral fluids that
were consumed in two of these trials. In the Kavitha 2012 trial The impact on maternal and neonatal safety of different types of
the oral fluid intake consisted of plain water and coconut water, intravenous fluids has not been rigorously evaluated. The three
while in the Coco 2010 trial, oral intake included water, juices most common solutions that are used are normal saline, Ringer’s
and carbonated drinks, and these may have influenced calorific lactate and dextrose solutions. None of the trials directly compared
content. The quality of the Coco 2010 trial needs to be taken normal saline versus Ringer’s lactate, or Ringers’ lactate versus dex-
into account as although the trial initially recruited 220 women, trose solutions. Two trials Shrivastava 2009; Stratton 1995 com-
there was a very high attrition rate with more than 60% of women pared normal saline versus 5% dextrose solution. The Shrivastava
2009 trial administered the same rate of 125 mL/hour for both Quality of the evidence
solutions. Although the Stratton 1995 trial also administered the
Overall, the quality of evidence in this review is limited: firstly, for
same rate of fluids in their two groups, the rate was not the same
any one outcome few studies contributed results, and for many
as the Shrivastava 2009 trial. The results of these two trials were
outcomes evidence was derived from only one or two relatively
not consistent in Stratton 1995 there were no clear differences in
small trials. Furthermore, for our primary outcome results were
the mean duration of labour, whereas Shrivastava 2009 reported
not simple to interpret. Duration of labour was not measured
shorter duration in the 5% dextrose group (reported as median).
in a consistent way between trials; in some studies duration was
There was no difference in the rates of caesarean section or as-
from the initiation of study fluids to delivery, while in others it
sisted delivery between the two groups. Regarding maternal com-
was for a specific stage of labour and the total duration was not
plications, the Shrivastava 2009 trial did not assess for maternal
stated. One study reported the median (Shrivastava 2009), and
hyponatraemia. Based on just the Stratton 1995 trial, there was a
for studies reporting the mean the standard deviation (SD) was
statistically significant increased risk of maternal hyponatraemia
frequently not reported. For these studies, to allow us to include
noted in the dextrose group. There was no assessment of fluid
the data, we calculated the SD from other information in the
overload in the Shrivastava 2009 trial, and there were no cases
paper. As the mean was reported in most studies, we assumed that
of fluid overload in either group in the Stratton 1995 trial. Re-
the distribution was normal and that the SD was similar in both
garding neonatal welfare, there was no difference in the admis-
arms of the trials, but this was not always clear. In addition, not
sion to SCBU or low Apgar scores between the groups. While the
all studies made it clear that the duration of labour related only
Shrivastava 2009 trial did not report on neonatal hyponatraemia,
to those women having vaginal deliveries; in the studies by Alavi
the Stratton 1995 trial found a statistically higher incidence of
2005 and Kavitha 2012 for example, this was not explicitly stated.
neonatal hyponatraemia in the dextrose arm of the trial.
In the data and analysis we have used the number of women having
vaginal deliveries as the denominators. The findings of the review
In summary, the routine administration of intravenous fluids com- also need to be interpreted in the light of our assessments of risk
pared with oral intake alone demonstrated that intravenous flu- of bias; overall, the methodological quality of studies was assessed
ids conferred a reduction in the duration of labour, however, this as moderate or good, but for some bias domains we were unable
was based on limited evidence. The findings of the other trials in to make judgements about bias due to unclear descriptions, or
this review suggest that if a policy of strictly no oral intake is to limited descriptions of the methods used.
be employed, 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. The caesarean
section rate may also be reduced. However, is it justifiable to sub-
AUTHORS’ CONCLUSIONS
ject women to routine intravenous fluids for a reduction in the
labour when it is not clear that this would have a positive effect
Implications for practice
on other maternal and neonatal outcomes? There are inconsisten-
cies across the trials with regard to maternal and neonatal adverse In the first instance, taking into account the potential maternal
outcome and several trials have simply not reported on the safety and neonatal morbidity that may arise from the unnecessary ad-
of increased intravenous fluids. ministration of intravenous fluids, we need to justify why the pol-
icy of ’nil by mouth’ still permeates current practice. This is espe-
Of concern too, is the increased attendant maternal and neonatal cially so since the dangers of gastric aspiration have been shown to
morbidity that is associated with intravenous 5% dextrose solu- be virtually eliminated and a concern of the past. Therefore, given
tions. Both maternal and neonatal hyponatraemia are increased, that there is no clear evidence of harm associated with unrestricted
and although these results are based on just one trial, perhaps 5% oral intake perhaps it is time to abandon this policy altogether and
dextrose should be avoided until a larger trial can demonstrate to allow women to self-regulate their oral intake during labour.
better safety. Rather than routine administration of intravenous fluids, it may
be more appropriate for intravenous fluids to be administered for
clinical reasons, or if a labouring women becomes ketotic.
None of the trials that were included in this review reported on
the evaluation of maternal views of comfort, satisfaction or dis- The evidence gleaned from this review does not provide evidence
satisfaction of being attached to a drip during their entire labour. that is robust enough to recommend routine administration of
Furthermore, there was no subjective or objective evaluation of intravenous fluids. Interpreting findings relating to duration of
maternal thirst. There was no objective assessment of dehydration labour was not straightforward as there was considerable hetero-
either (no measurements of ketosis). None of the trials elicited geneity in terms of the mean length of labour and in the variability
whether or not there is any associated newborn weight loss with in length of labour (SDs) in different trials. It is unclear why dura-
intravenous fluids. tion of labour was so different in the various settings but this may
partly be explained by different definitions of the start of active may cause newborn weight loss in the first 72 hours, future trials
labour. There was also variation in the rates of CS and assisted should attempt to elicit this. More high quality trials need to be
deliveries in different settings. conducted that address whether there is even a need for intravenous
fluids at all.
In addition, interpreting the results from trials was hampered by
the low number of trials contributing data to each comparison
and in variation between trials. In trials where oral fluids were not
restricted there was considerable variation in the amount of oral
fluid women consumed in different arms of the same trial as well ACKNOWLEDGEMENTS
as between different trials. In addition, results from trials were
not consistent and the risk of bias in trials varied. Some of the Sincere gratitude to Lynn Hampson and Frances Kellie for their
important research questions were addressed by single trials only guidance and assistance in trial searches and methodology.
and important outcomes relating to maternal and infant morbidity As part of the pre-publication editorial process, this review has
were frequently not reported. been commented on by three peers (an editor and two referees
who are external to the editorial team) and the Group’s Statistical
Implications for research Adviser.
The findings of these trials do have clinical implications for labour
The National Institute for Health Research (NIHR) is the largest
management, however, more studies are needed to validate these
single funder of the Cochrane Pregnancy and Childbirth Group.
findings and to elicit a scientific evaluation to quantify levels of
The views and opinions expressed therein are those of the authors
hydration in labouring women. Perhaps an objective assessment of
and do not necessarily reflect those of the NIHR, NHS or the
maternal dehydration may improve the quality of future studies.
Department of Health.
Further trials are also required to evaluate whether additional in-
The final version of this systematic review was financially sup-
travenous fluids in women with unlimited access to oral fluids
ported by the UNDP-UNFPA-UNICEF-WHO-World Bank
confers any reduction in the length of labour, without potentially
Special Programme of Research, Development and Research
harming the neonate. Future trials should definitely also include
Training in Human Reproduction (HRP) and the Department of
an evaluation of maternal perceptions, comfort and mobility dur-
Reproductive Health and Research (RHR), World Health Orga-
ing labour.
nization. The named authors alone are responsible for the views
Since there is emerging evidence that excessive intravenous fluids expressed in this publication.
REFERENCES
References to studies included in this review Garite 2000 {published data only}
Garite TJ, Weeks J, Peters-Phair K. A randomized trial on
Alavi 2005 {published data only} the influence of increased intravenous hydration on the
Alavi MH, Talaei Rad Z, Dadgar SR. Assessment of the course of nulliparous labor. American Journal of Obstetrics
effects of increased intravenous hydration on the course of and Gynecology 2000;182(1 Pt 2):S37.
labor in nulliparous term pregnancies. Medical Journal of ∗
Garite TJ, Weeks J, Peters-Phair K, Pattilo C, Brewster
the Islamic Republic of Iran 2005;18(4):289–92. WR. A randomized controlled trial of the effect of increased
Coco 2010 {published data only} intravenous hydration on the course of labor in nulliparous
Coco A, Derksen-Schrock A, Coco K, Raff T, Horst M, women. American Journal of Obstetrics and Gynecology 2000;
Hussar E. A randomized trial of increased intravenous 183:1544–8.
hydration in labor when oral fluid is unrestricted. Family Hausman N, Garite T, Rumney P. The influence of
Medicine 2010;42(1):52–6. increased intravenous hydration on the incidence of
Direkvand-Moghadam 2012 {published data only} nonreassuring fetal heart rate patterns in nulliparous labor
Direkvand-Moghadam A, Rezaeian M. Increased [abstract]. American Journal of Obstetrics and Gynecology
intravenous hydration of nulliparas in labor. International 2001;184(1):S6.
Journal of Gynecology and Obstetrics 2012;118(3):213–5. Kavitha 2012 {published data only}
Eslamian 2006 {published data only} Kavitha A, Chacko KP, Thomas E, Rathore S, Christoper
Eslamian L, Marsoosi V, Pakneeyat Y. Increased intravenous S, Biswas B, et al. A randomized controlled trial to study
fluid intake and the course of labor in nulliparous women. the effect of IV hydration on the duration of labor in
International Journal of Gynecology & Obstetrics 2006;93(2): nulliparous women. Archives of Gynecology and Obstetrics
102–5. 2012;285(2):343–6.
Maderia 2007 {published data only} Haesslein 1975 {published data only}
Maderia LM, Hoffman MK, Wilson S, Chichester ML. Haesslein HC, Goodlin RC. Intrapartum hypertension and
Effect of intravenous hydration on labor length and delivery intravenous saline. Journal of Reproductive Medicine 1975;
mode [abstract]. Obstetrics & Gynecology 2007;109(4 14:8–9.
Suppl):90S. Higgins 1996 {published data only}
Higgins J, Gleeson R, Holohan M, Cooney C, Darling
Shrivastava 2009 {published data only}
M. Maternal and neonatal hyponatraemia: a comparison
Shrivastava V, Garite T, Jenkins S, Saul L, Rumney P,
of Hartmanns solution with 5% dextrose for the delivery
Preslicka C, et al. A double-blinded randomized controlled
of oxytocin in labour. European Journal of Obstetrics &
trial comparing normal saline with and without dextrose
Gynecology and Reproductive Biology 1996;68:47–8.
on the course of labor in nulliparas. American Journal
of Obstetrics and Gynecology 2007;197(6 Suppl 1):S18, Hofmann 2001 {published data only}
Abstract no: 36. Hofmann J, Schrod L, Schleelein O, Springer S, Steck T.
∗
Shrivastava VK, Garite TJ, Jenkins SM, Saul L, Rumney P, Effects of prepartum infusion solutions on glucose and
Preslicka C, et al. A randomized, double-blinded, controlled bilirubin metabolism of mother and child in the prepartum
trial comparing parenteral normal saline with and without and postpartum period [Auswirkungen von prapartal
dextrose on the course of labor in nulliparas. American verabreichten Infusionslosungen auf den Zucker– und
Journal of Obstetrics and Gynecology 2009;200(4):379.e1–6. Bilirubinstoffwechsel von Mutter und Kind peri– und
postpartal]. Zeitschrift fur Geburtshilfe und Neonatologie
Stratton 1995 {published data only} 2001;205(2):60–4.
Stratton JF, Stronge J, Boylan P. Non-electrolyte solutions in Jamal 2007 {published data only}
labouring primigravida. 27th British Congress of Obstetrics Jamal A, Choobak N, Tabassomi F. Intrapartum maternal
and Gynaecology; 1995 July 4-7; Dublin, Ireland. 1995: glucose infusion and fetal acid-base status. International
Abstract no: 490. Journal of Gynecology & Obstetrics 2007;97(3):187–9.
∗
Stratton JF, Stronge J, Boylan PC. Hyponatraemia
Kenepp 1985 {published data only}
and non-electrolyte solutions in labouring primigravida.
Kenepp NB, Cheek TC, Gabbe SG, Gutsche BB.
European Journal of Obstetrics & Gynecology and Reproductive
Intrapartum maternal intravenous dextrose administration.
Biology 1995;59:149–51.
Anesthesiology 1985;63:436.
References to studies excluded from this review Loong 1987 {published data only}
Loong EPL, Lao TTH, Chin RKH. Effects of intrapartum
intravenous infusion of 5% dextrose or Hartmann’s solution
Boylan 1980 {published data only} on maternal and cord blood glucose. Acta Obstetricia et
Boylan P, Lewis PJ. Fetal breathing in labor. Obstetrics & Gynecologica Scandinavica 1987;66(3):241–3.
Gynecology 1980;56:35–8.
Menigaux 1993 {published data only}
Caspi 1979 {published data only} Menigaux C, Hamza J, Bougnieres P, Saint-Maurice C.
Caspi E, Ron-El R, Modai D. Controlled intravenous Neonatal glycemia: does the maternal iv fluid regimen
bicarbonate and fetal-maternal acid-base balance. I. The during labor make a difference?. Regional Anesthesia 1993;
primipara. Obstetrics & Gynecology 1979;54:615–23. 18:91.
Navarette,1982 {published data only}
Cerri 2000 {published data only} Navarrete L, Ratinoff I, Clavero P, Sabatel R, Herrera R.
Cerri V, Tarantini M, Zuliani G, Schena V, Redaelli C, Maternal metabolic control in the intrapartum management
Nicolini U. Intravenous glucose infusion in labor does [Control metabólico materno intraparto]. Acta Obstétrica y
not affect maternal and fetal acid-base balance. Journal of Ginecológica Hispano-Lusitana 1982;30(2):121–30.
Maternal-Fetal Medicine 2000;9:204–8.
Nordstrom 1995 {published data only}
Cheek 1996 {published data only} Nordstrom L, Arulkumaran S, Chua S, Ratnam S,
∗
Cheek TG, Samuels P, Miller F, Tobin M, Gutsche BB. Ingemarsson I, Kublickas M, et al. Continuous maternal
Normal saline i.v. fluid load decreases uterine activity in glucose infusion during labor: effects on maternal and fetal
active labour. British Journal of Anaesthesia 1996;77:632–5. glucose and lactate levels. American Journal of Perinatology
Cheek TG, Samuels P, Tobin M, Gutsche BB. Rapid 1995;12:357–62.
intravenous saline infusion decreases uterine activity in Omigbodun 1989 {published data only}
labor, epidural analgesia does not. Anesthesiology 1989;71: Omigbodun AO. Choice of intravenous fluid infusion in
A884. labour and maternal postpartum blood pressure. Tropical
Fisher 1997 {published data only} and Geographical Medicine 1989;41:227–9.
Fisher AJ, Huddleston JF. Intrapartum maternal d-glucose Omigbodun 1991 {published data only}
infusion reduces the risk of umbilical cord acidemia. Omigbodun AO, Fajimi JL, Adeleye JA. Effects of using
American Journal of Obstetrics and Gynecology 1997;176(1 either saline or glucose as a vehicle for infusion in labour.
Pt 2):S20. East African Medical Journal 1991;68:88–92.
Omigbodun 1993 {published data only} Wright 2000 {published data only}
Omigbodun AO, Akindele JA, Osotimehin BO, Fatinikun Wright TE, Martin D, Qualls C, Curet LB. Effects of
T, Fajimi JL, Adeleye JA. Effect of saline and glucose intrapartum administration of invert sugar and D5LR on
infusions of oxytocin on neonatal bilirubin levels. neonatal blood glucose levels. Journal of Perinatology 2000;
International Journal of Gynecology & Obstetrics 1993;40: 20:217–8.
235–9.
References to studies awaiting assessment
Oral 2003 {published data only}
Oral E, Gezer A, Cagdas A, Pakkal N. Oxytocin infusion Amir 2004 {published data only}
in labor: the effect different indications and the use of Amir AliAkbari S, Dabiri F, Bakhshori Z, Alavii Majd H.
different diluents on neonatal bilirubin levels. Archives of Effects of increased intravenous hydration on the outcome
Gynecology & Obstetrics 2003;267:117–20. of labor in nulliparous women at Shariati hospital in Bandar
Rooth 1967 {published data only} Abbas, 2003. Journal of Faculty of Nursing & Midwifery of
Rooth G, Jacobson L. Interrelationship between maternal Shaheed Beheshti University of Medical Sciences And Health
and foetal acid-base and electrolyte balance during labour. Services 2004;14(46):49.
5th World Congress of Gynecology and Obstetrics; 1967; Rad 2012 {published data only}
Sydney, Australia. 1967:187. Rad RH, Najar S, Hekmat K. Effects of intravenous normal
saline with and without dextrose on labour duration and
Rosenberg 2006 {published data only} delivery outcomes in nulliparous women. Koomesh 2012;13
Rosenberg V, Rauch E, Eglinton G, Skupski D. Intrapartum (4):434–9.
maternal glycemic control in women with insulin requiring
diabetes: a randomized clinical trial of rotating fluids vs. References to ongoing studies
insulin drip [abstract]. American Journal of Obstetrics and
Gynecology 2005;193(6 Suppl):S93. Salim 2011 {unpublished data only}
∗
Rosenberg VA, Eglinton GS, Rauch ER, Skupski DW. Salim R. Intrapartum hydration. http://www.controlled-
Intrapartum maternal glycemic control in women with trials.com/mrct/trial/1276843/nct01242293 (accessed
insulin requiring diabetes: a randomized clinical trial of 2011).
rotating fluids versus insulin drip. American Journal of
Obstetrics and Gynecology 2006;195(4):1095–9. Additional references
Simpson 2005 {published data only} ASA 2007
Simpson KR, James DC. Efficacy of intrauterine American Society of Anesthesiologists Task Force on
resuscitation techniques in improving fetal oxygen status Obstetric Anesthesia. Practice guidelines for obstetric
during labor. Obstetrics & Gynecology 2005;105:1362–8. anesthesia: An updated report by the American Society of
Anesthesiologists. Anesthesiology 2007;106(4):843–63.
Singhi 1982 {published data only}
Singhi S, Choo Kang E, Hall JS. Hazards of maternal Barr 1991
hydration with 5% dextrose. Lancet 1982;2:335–6. Barr SI, Costill DL, Fink WJ. Fluid replacement during
prolonged exercise: effects of water, saline, or no fluid.
Thaler 2007 {published data only} Medicine and Science in Sports and Exercise 1991;23(7):
Thaler I. Maternal glucose infusion during labor increases 811–7.
fetal lactate production and modifies fetal acid-base balance. Carvalho 1994
American Journal of Obstetrics and Gynecology 2007;197(6 Carvalho JC, Mathias RS. Intravenous hydration in
Suppl 1):S182, Abstract no: 629. obstetrics. International Anesthesiology Clinics 1994;32(2):
Watson 2012 {published data only} 10–15.
Watson J. The effect of intrapartum intravenous fluid Chantry 2011
management on breastfed newborn weight loss. JOGNN: Chantry CJ, Nommsen-Rivers LA. Excess weight loss
Journal of Obstetric, Gynecologic & Neonatal Nursing 2011; in first-born breastfed newborns relates to maternal
40:S97. intrapartum fluid balance. Pediatrics 2011;127(1):171–9.
∗
Watson J, Hodnett E, Armson BA, Davies B, Watt- Egger 1997
Watson J. A randomized controlled trial of the effect of Egger M, Davey Smith G, Schneider M, Minder C. Bias
intrapartum intravenous fluid management on breastfed in meta-analysis detected by a simple, graphical test. BMJ
newborn weight loss. Journal of Obstetric, Gynecologic, & 1997;315(7109):629–34.
Neonatal Nursing 2012;41(1):24–32.
Harbord 2006
Wells-Brooks 2001 {published data only} Harbord RM, Egger M, Sterne JA. A modified test for
Wells-Brooks NY. Uterine contraction frequency changes small-study effects in meta-analyses of controlled trials
following crystalloid infusion [thesis]. Tennessee: University with binary endpoints. Statistics in Medicine 2006;25(20):
of Tennessee, 2001. 3443–57.
Higgins 2011 Pierce 2003
Higgins JPT, Green S, editors. Cochrane Handbook for Pierce SJ, Kupittayanant S, Shmigol A, Wray S. The effects
Systematic Reviews of Interventions Version 5.1.0 [updated of pH change on calcium signalling and force in pregnant
March 2011]. The Cochrane Collaboration, 2011. human myometrium. American Journal of Obstetrics and
Available from www.cochrane-handbook.org. Gynecology 2003;188:1031–8.
Keppler 1988 RevMan 2011 [Computer program]
Keppler AB. The use of intravenous fluids during labour. The Nordic Cochrane Centre, The Cochrane Collaboration.
Birth 1988;15(2):75–9. Review Manager (RevMan). Version 5.1. Copenhagen:
Maughan 1996 The Nordic Cochrane Centre, The Cochrane Collaboration,
Maughan RJ, Bethell LR, Leiper JB. Effects of ingested 2011.
fluids on exercise capacity and on cardiovascular and Romano 2009
metabolic responses to prolonged exercise in man. Romano AM. First, do no harm: How routine interventions,
Experimental Physiology 1996;81(5):847–59. common restrictions, and the organisation of our health-
Michael 1991 care system affect the health of mothers and newborns. J
Michael S, Reilly C, Caunt J. Policies for oral intake during perinatal Educ 2009;18(3):58–62.
labour. A survey of maternity units in England and Wales.
Saltin 1998
Anaesthesia 1991;46(12):1071–3.
Saltin S, Costill DL. Fluid and electrolyte balance during
Montain 1992 prolonged exercise. In: Horton ES, Terjung RL editor(s).
Montain SJ, Coyle EF. The effect of graded dehydration Exercise, Nutrition and Metabolism. New York: MacMillan,
on hyperthermia and cardiovascular drift during exercise. 1988:150–8.
Journal of Applied Physiology 1992;73:1340–50.
Scheepers 1998
Montain 2008
Scheepers H, Essed G, Brouns F. Aspects of fodd and fluid
Montain SJ. Hydration recommendations for sport 2008.
intake during labour. Policies of midwives and obstetricians
Current Sports Medical Reports 2008;7(4):187–92.
in the Netherlands. European Journal of Obstetrics &
Morton 1985 Gynecology and Reproductive Biology 1998;78(1):37–40.
Morton KE, Jackson MC, Gillmer MD. A comparison of
the effects of four intravenous solutions for the treatment Schuitemaker 1997
of ketonuria during labour. British Journal of Obstetrics and Schuitemaker N, van Roosmalen J, Dekker G, van Dongen
Gynaecology 1985;92(5):473–9. P, van Geijn H, Gravenhorst JB. Maternal mortality after
cesarean scetion in the Netherlands. Acta Obstetricia et
Noakes 1993
Gynecologica Scandinavia 1997;76(4):332–4.
Noakes TD. Fluid replacement during exercise. Exercise and
Sport Sciences Reviews 1993;21:297–330. Singata 2010
Noel-Weiss 2011 Singata M, Tranmer J, Gyte GML. Restricting oral
Noel-Weiss J, Woodend AK, Peterson WE, Gibb W, Groll fluid and food intake during labour. Cochrane Database
D. An observational study of associations among maternal of Systematic Reviews 2010, Issue 1. [DOI: 10.1002/
fluids during parturition,neonatal output,and breastfed 14651858.CD003930.pub2]
newborn weight loss. International Breatsfeeding Journal Tarnow-Mordi 1981
2011;6(9):1–10. Tarnow-Mordi WO, Shaw JC, Liu D, Gardner DA, Flynn
O’Sullivan 2003 FV. Iatrogenic hyponatraemia of the newborn due to
O’Sullivan G, Scrutton M. NPO during labor. Is there any maternal fluid overload: a prospective study. British Medical
scientific validation?. Anesthesiology Clinics of North America Journal 1981;283(6292):639–42.
2003;21(1):87–98. ∗
Indicates the major publication for the study
CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
Alavi 2005
Methods Prospective randomised clinical trial.
Participants 194 nulliparous women in term spontaneous labours with a singleton pregnancy, cephalic
presentation
112 women received 125 mL/hour; 82 women received 250 mL/hour
Interventions 125 mL/hour vs 250 mL/hour of normal saline in dextrose water
Outcomes Duration of labour in minutes; CS due to failure to progress
Notes No other oral intake; no food.

No epidurals.
Risk of bias
Bias Authors’ judgement Support for judgement
Random sequence generation (selection Unclear risk Women were randomised but the study does not
bias) specify method of randomisation
Allocation concealment (selection bias) Unclear risk Possible selection bias. Unclear details.
Incomplete outcome data (attrition bias) Low risk No attrition reported.

All outcomes
Selective reporting (reporting bias) Low risk Fairly transparent results.
Other bias Unclear risk No details about duration of study.
Blinding of participants and personnel High risk Not mentioned.

(performance bias)
All outcomes
Blinding of outcome assessment (detection Low risk Detailed reporting of outcome assessment.
bias)
All outcomes
Coco 2010
Methods Prospective randomised trial.
Participants Nulliparous women in spontaneous active labour with a singleton, vertex presentation
≥ 37 weeks’ gestation were included. Women were eligible for inclusion if dilatation was
between 2 and 5 cm, with or without ruptured membranes
220 women were recruited.
116 women excluded due to preterm delivery, pre-eclampsia or scheduled CS
11 women excluded as fluids were delayed.
4 women did not have consent forms.
9 women delivered elsewhere so were lost to follow-up.
80 women fulfilled criteria for inclusion and were analysed.
Interventions 37 women received 250 mL of lactated Ringer’s solution IV per hour (IV fluid group)
and 43 women received “usual care”
Usual care consisted of lactated Ringer’s solution IV for medical indications at the dis-
cretion of the provider. The women in this group received a mean volume of 1627 mL
of fluid
Both groups were allowed unrestricted oral intake of fluids.
Outcomes Duration of labour; first, second stage and total duration.
Notes Unrestricted oral fluids (water, juice, carbonated drinks) amounts recorded in both groups
Risk of bias
Random sequence generation (selection Low risk Random number chart.

bias)
Allocation concealment (selection bias) Low risk Consecutively numbered opaque sealed envelopes.
Incomplete outcome data (attrition bias) High risk Large attrition due to recruitment taking place antena-
All outcomes tally rather than at the onset of labour
Clear explanatory notes when attrition occurred.
220 women were recruited.
116 women excluded due to preterm delivery, pre-
eclampsia or scheduled CS
11 women excluded as fluids were delayed.
4 women did not have consent forms.
9 women delivered elsewhere so were lost to follow-up.
80 women fulfilled criteria for inclusion and were anal-
ysed.
Selective reporting (reporting bias) Low risk Prospective data capture.
Other bias Unclear risk No restriction on oral fluid intake may have influenced
results; inherent bias of women drinking as much as pos-
sible, although similar mean oral intake in both groups
Coco 2010 (Continued)
Women recruited from 4 hospitals including 3 private

practices
Blinding of participants and personnel High risk Unclear as to whether measures were taken to blind per-
(performance bias) sonnel
All outcomes Participants: potential bias in that they were informed
about increased fluids in labour and allowed to drink
Potential bias as participants recruited antenatally and
could have influenced the amount of fluids ingested
orally
Blinding of outcome assessment (detection Low risk Prospective analysis by nursing staff.
bias)
All outcomes
Direkvand-Moghadam 2012
Methods Prospective randomised controlled trial. 4 arms with individual randomisation
Participants 120 women in labour at a hospital in Ilam, Iran in 2010.

Inclusion criteria: nulliparity, aged between 18-35 years, singleton pregnancy, sponta-
neous active labour (defined as cervical dilatation of 4 to 5 cm), gestational age 38-40
weeks, normal fetal heart tracings, intact membranes and vertex presentation. Labour
analgesia was not used
Exclusion criteria: elective labour induction, emergency CS, known cephalopelvic dis-
proportion, diagnosed pre-eclampsia, chorioamnionitis, pyelonephritis, maternal cardiac
or renal disease, IUGR, cervix dilated > 5 cm
Interventions 4 groups: 30 women in each group

1. Control. Free oral fluids (no IV fluids).
2. Free oral fluids + IV Ringer lactate solution at infusion rate of 60 mL/hour.
In all groups partograms were used to monitor progress in labour. Amniotomy was
performed by a midwife when cervical dilatation reached 5 cm if membranes had not
ruptured spontaneously. At one hour after amniotomy, if uterine contractions were less
than 3 in ten minutes, or dilation was less than 1.2 cm per hour, oxytocin was used for
labour augmentation
Outcomes Duration of active phase of first stage of labour, duration of 2nd and 3rd stages of labour,
need for oxytocin augmentation, mode of delivery, Apgar scores at 1 and 5 minutes
Notes In the data and analyses in this review for comparison 4 (IV fluids plus oral intake vs
oral intake alone) we have combined results for the three groups receiving IV fluids to
allow a single pair-wise comparison between women receiving IV fluids plus oral fluids
vs oral fluids alone. This study is also included in comparison 5 where different hourly
rates of infusion are compared
Direkvand-Moghadam 2012 (Continued)
Risk of bias
Random sequence generation (selection Low risk Random number tables.

bias)
Allocation concealment (selection bias) Low risk Opaque, sealed, consecutively numbered
envelopes.
Incomplete outcome data (attrition bias) Low risk 120 women were randomised and all
All outcomes seemed to be accounted for in the analysis.
There was no mention of missing data for
any outcome
Selective reporting (reporting bias) Unclear risk Assessment from published study report.
Other bias Unclear risk In the methods section it was stated that
the 4 groups were “matched” for inclusion
criteria. It was not clear what this meant
Blinding of participants and personnel High risk Blinding women or staff to this interven-
(performance bias) tion was not mentioned. Lack of blinding
All outcomes may have affected staff behaviour and out-
come assessment
Blinding of outcome assessment (detection High risk It was not mentioned whether any out-
bias) come data were collected by blind outcome
All outcomes assessors. Lack of blinding may have af-
fected staff behaviour and outcome assess-
ment
Eslamian 2006
Methods Prospective double-blind randomised trial.
Participants 300 nulliparous women enrolled; all women went in to spontaneous labour at term;
singleton pregnancies; cephalic presentation
153 randomised to 125 mL/hour; 147 women randomised to 250 mL/hour
Interventions 2 different volumes of Ringer’s lactate solution (125 mL/hour vs 250 mL/hour)
Outcomes Duration of labour in minutes; CS due to failure to progress; assisted delivery
Notes Nil by mouth; no epidurals.
Risk of bias
Eslamian 2006 (Continued)
Random sequence generation (selection Low risk Random computer-generated numbers.

bias)
Allocation concealment (selection bias) Low risk Consecutively numbered opaque sealed en-
velopes.
Incomplete outcome data (attrition bias) Low risk Detailed outcome data available for all 300
All outcomes recruited women.
Selective reporting (reporting bias) Low risk No evidence of selective reporting.
Other bias Unclear risk Authors acknowledge the following: no

measurements of inherent maternal dehy-
dration; no measurements of skin turgor,
osmolality
Blinding of participants and personnel Low risk Double-blinded study with clear evidence
(performance bias) of double-blinding measures
All outcomes
Blinding of outcome assessment (detection Low risk None apparent.

bias)
All outcomes
Garite 2000
Participants 195 nulliparous women in term spontaneous labour with a singleton pregnancy, cephalic
presentation
Interventions 125 mL/hour vs 250 mL/hour of Ringer’s lactate solution.

94 women received 125 mL/hour while 101 women received the higher volume of 250
mL/hour
Outcomes Maternal: duration of labour in minutes

Maternal/fetal: need for CS or assisted delivery/Apgar < 7; admission to SCBU
Notes No food; no oral fluid intake; sips of water only; ice chips allowed
Risk of bias
Random sequence generation (selection Low risk Random computer-generated sequence.

bias)
Garite 2000 (Continued)
Allocation concealment (selection bias) Low risk Consecutively numbered opaque sealed envelopes.
Incomplete outcome data (attrition bias) Low risk None of the women randomised needed to be excluded.
All outcomes
Selective reporting (reporting bias) Low risk None apparent.
Other bias Unclear risk No measurement of inherent maternal dehydration; no

assessment of serum/urine osmolality
Blinding of participants and personnel High risk No masking of interventions.

(performance bias)
All outcomes

bias)
All outcomes
Kavitha 2012
Methods Randomised controlled trial.
Participants 293 nulliparous women with term spontaneous labours between 3- 6 cm dilatation,
singleton pregnancy, cephalic presentation
Interventions 99 women received oral hydration.

98 women were randomised to receive 125 mL/hour of Ringer’s lactate and oral fluids
96 women were randomised to receiving 250 mL/hour of Ringer’s lactate and oral fluids
Outcomes Maternal: duration of labour, mode of delivery, CS delivery for failure to progress,
vomiting
Fetal: admission to NICU.
Notes Oral fluids was allowed in all study groups (no quantification of volumes required)
Risk of bias
Random sequence generation (selection Low risk Computerised block randomisation.

bias)
Allocation concealment (selection bias) Low risk Sequential opaque envelopes.
Incomplete outcome data (attrition bias) Low risk Complete outcomes for all participants; no attrition.
All outcomes
Selective reporting (reporting bias) Low risk None apparent.
Kavitha 2012 (Continued)
Other bias High risk Women in control group (oral fluids) were allowed either
plain fluids or coconut water (no clear discussion about
possible bias with coconut water)
In IV fluid groups, maximum quantity of IV fluids was
restricted to 3 litres “to prevent fluid overload”
Blinding of participants and personnel High risk No masking of interventions.

(performance bias)
All outcomes

bias)
All outcomes
Maderia 2007
Participants 59 nulliparous women in term spontaneous labours with a singleton pregnancy, cephalic
presentation
30 women received 125 mL/hour; 29 women received 250 mL/hour
Interventions 125 mL/hour vs 250 mL/hour of unspecified IV fluid.
Outcomes Duration of labour in minutes; CS due to failure to progress
Notes Nil by mouth; only ice-chips.
Risk of bias
Random sequence generation (selection Unclear risk No information (abstract only).

bias)
Allocation concealment (selection bias) High risk No information (abstract only); does not specify what
type of IV fluid administered
Incomplete outcome data (attrition bias) Unclear risk No information (abstract only).
All outcomes
Selective reporting (reporting bias) Unclear risk No information (abstract only).
Other bias Unclear risk No information (abstract only).
Blinding of participants and personnel Unclear risk No information (abstract only).

(performance bias)
All outcomes
Maderia 2007 (Continued)
Blinding of outcome assessment (detection Unclear risk No information (abstract only).

bias)
All outcomes
Shrivastava 2009
Methods Prospective double-blinded randomised controlled trial.
Participants 300 nulliparous women in term spontaneous labour with a singleton pregnancy, cephalic
presentation enrolled
5 women were withdrawn by their physician.
3 women did not meet inclusion criteria.
3 women had incomplete data collection.
11 women were not included in data analysis.
2 women were excluded (1 with diabetes mellitus 1 who developed pre-eclampsia)
289 women completed the study.
Interventions 3 different groups:

97 women randomised to receive normal saline 125 mL/hour.
94 women randomised to receive 5% dextrose 125 mL/hour.
98 women randomised to receive 10% dextrose 125 mL/hour.
Outcomes Maternal: duration of first, second stages of labour and total duration of labour, CS
Fetal/neonatal: admission to neonatal unit, Apgar scores < 7 at 5 minutes, hyperbiliru-
binaemia requiring therapy, cord pH < 7.20, arterial cord glucose, hypoglycaemia at 1
and 2 hours
Notes Nil by mouth; ice chips only.
Risk of bias
Random sequence generation (selection Low risk Computer-generated randomisation.

bias)
Allocation concealment (selection bias) Low risk Consecutively numbered opaque sealed en-
velopes by pharmacy staff
Incomplete outcome data (attrition bias) Low risk Clear documentation of excluded women
All outcomes when incomplete data collection and clear
documentation of reasons for attrition:
300 nulliparous women in term sponta-
neous labours with a singleton pregnancy,
cephalic presentation enrolled
5 women were withdrawn by their physi-
cian.
3 women did not meet inclusion criteria
Shrivastava 2009 (Continued)
(1 with diabetes mellitus, 1 who developed

pre-eclampsia and 1 woman < 18 years)
3 women had incomplete data collection.
11 women were not included in data anal-
ysis.
289 women completed the study.
Selective reporting (reporting bias) Low risk Clear flow-diagrams and different tables for
maternal and neonatal outcomes
Other bias Unclear risk Insufficiently powered for neonatal out-

comes.
Blinding of participants and personnel Low risk Double-blinded study; blinding by phar-
(performance bias) macy personnel; each group assigned A, B,
All outcomes C and changed after every 80 women to
minimise observer bias; IV bags were cov-
ered with non-transparent adhesive tapes to
ensure double-blinding
Blinding of outcome assessment (detection Low risk Adequate measures as above to ensure dou-
bias) ble-blinding.
All outcomes
Stratton 1995
Participants 100 primigravid women in spontaneous labour.

7 women randomised but no blood taken so excluded from analysis
4 other women declined consent.
2 other women excluded as no consent obtained by medical staff
Interventions 5% dextrose vs normal saline for oxytocin augmentation.
Outcomes Maternal : delivery outcomes, mean duration of labour, CS, maternal hyponatraemia,
fluid overload
Fetal: neonatal hyponatraemia. admission to NICU.
Notes Subgroup of women with epidurals.
Risk of bias
Random sequence generation (selection Low risk Random allocation.

bias)
Stratton 1995 (Continued)
Allocation concealment (selection bias) Low risk Sealed envelopes.
Incomplete outcome data (attrition bias) Low risk Clear explanations for attrition due to omission of ob-
All outcomes taining blood samples; failure to obtain consent
Selective reporting (reporting bias) Low risk Detailed explanations for all outcomes.
Other bias High risk A subgroup of women were given additional fluids as
part of their epidurals
Blinding of participants and personnel Unclear risk Not clearly apparent that study was double-blind.
(performance bias)
All outcomes
Blinding of outcome assessment (detection Unclear risk Outcomes not blinded.

bias)
All outcomes
CS: caesarean section

IUGR: intrauterine growth restriction
IV: intravenous
NICU: neonatal intensive care unit
SCBU: special care baby unit
vs: versus
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Boylan 1980 Open and double-blind study.

Participants: unclear whether nullips or multips; also in a subgroup, labour was induced
Interventions: intravenous bolus of glucose versus Hartmann’s
Outcome: fetal breathing; no maternal outcomes.
Caspi 1979 Method: appears to be a case-controlled study.

There is no evidence that women were randomly assigned to the 2 groups
Participants: 22 primips.
Intervention: sodium bicarbonate infusion.
Cerri 2000 Participants: 81 women but no distinction between nullips and multips
Intervention: 43 women received 5% glucose and 38 women did not receive any fluids
Cheek 1996 Prospective randomised controlled trial.

Participants: 34 labouring women (no clear distinction in outcomes between nullips and multips)
(Continued)
Interventions: extradural normal saline and glucose.
Fisher 1997 Abstract only, so limited information.

Participants: multips and nullips.
Haesslein 1975 Participants: all low-risk labouring women (nullips and multips)
Interventions: 5% dextrose in water versus 5% dextrose in saline
Outcome: maternal hypertension.
Higgins 1996 Randomised controlled trial.

Interventions; oxytocin in Hartmann’s solution compared with the standard 5% dextrose regimen for induction
or augmentation in labour.
Outcomes: maternal serum sodium.
Good study with clear randomisation method; reason for exclusion was non-spontaneous labour
Hofmann 2001 Participants: labouring women in their first or second pregnancy (no distinction between nullips and multips)
Interventions: glucose was compared with a glucose substitute treatment (Xylit) and an electrolyte treatment
(Sterofundin)
Jamal 2007 Randomised controlled trial.

Participants: 178 women but all were multiparous (at least para 1)
Intervention: 120 mL/hour of 5% dextrose was compared with the same volume of Ringer’s lactate
Outcomes: primary outcome was fetal acid-base status.
Kenepp 1985 Randomised trial.

Participants: 31 term labourers; unclear whether nullips or multips or both
Intervention: different concentrations of dextrose solutions
Outcomes; ketoacidosis.
Limited information about duration of labour and other outcomes as published as abstract only
Loong 1987 Prospective randomised trial.

Participants: 48 women (nullips and multips).
Interventions: 5% dextrose solution or Hartmann’s solution.
Outcomes: maternal and cord blood glucose.
Reason for exclusion: although there was a distinction between nullips and multips in the demographics, there
was no distinction in the outcomes in terms of parity
Menigaux 1993 Randomised controlled trial.

Participants: 20 labouring women having epidurals (study does not specify whether nullips or multips)
Interventions: 50% dextrose versus Ringer’s lactate in women who were given a basal infusion of 100 mL/hour
Ringer’s lactate before an epidural
Outcome: maternal and neonatal hypoglycaemia.
Abstract only.
Navarette,1982 Randomised controlled trial.

Participants: insufficient information on parity.
Outcome: intrapartum metabolic control.
(Continued)
Nordstrom 1995 All participants were on average para 1 therefore excluded.
Omigbodun 1989 Participants: all women who required oxytocin for induction of labour or augmentation (so non-spontaneous
labours). Furthermore, no distinction regarding parity
Intervention: normal saline or 5% glucose with oxytocin.
Outcomes: maternal postpartum blood pressure.
Omigbodun 1991 Participants: all women who required oxytocin for induction of labour or augmentation (so non-spontaneous
labours). Furthermore, no distinction regarding parity
Intervention: normal saline or 5% glucose with oxytocin.
Outcomes: maternal postpartum sodium levels; cord sodium levels
Omigbodun 1993 Interventions: all women received oxytocin.
Oral 2003 Participants: nullips and multips included; control group comprised entirely of multiparous women
Interventions: oxytocin for augmentation.
Outcomes: neonatal bilirubin levels.
Rooth 1967 Limited information available, published as abstract only.

Participants: 60 labouring women; unclear whether nulliparous or not; no details of randomisation
Interventions: sodium bicarbonate given to half the participants
Rosenberg 2006 Participants: all women in this study were insulin requiring gestational diabetics therefore excluded
Simpson 2005 Participants: 42 women were randomised to either a 500 mL or 1000 mL intravenous fluid bolus over 20
minutes. All women were either being induced or having this bolus as a preload for epidurals.
51 women were randomised to 1 of 6 position sequences including supine with the head elevated 30°, left
lateral and right lateral for 15 minutes each in succession
Singhi 1982 Study published as part of Letter-to-the Editor.

Participants: no mention of parity; so difficult to interpret results
Thaler 2007 Participants: 85 women; unclear whether nullips or multips.

Interventions: 10% glucose versus Ringer’s lactate.
Abstract only; limited information.
Watson 2012 Randomised controlled trial.

Participants: nulliparous or multiparous women requesting epidurals and who intended to breastfeed
Interventions: different volumes of epidural preload.
Outcome measures: effect on weight loss on the newborn.
Wells-Brooks 2001 Methods: quasi-experimental research design.

Participants: labouring women receiving combined spinal epidural anaesthesia
Interventions: different volumes of intravenous fluids in women receiving combined spinal epidural anaesthesia
Outcome measures: frequency of uterine contractions.
(Continued)
Wright 2000 Prospective randomised double-blind study.

Participants: 32 insulin requiring diabetic women randomised to 2 different dextrose infusions
multip: (multipara) a woman who has delivered two or more babies

nullip: (nulligravida) a woman who has never been pregnant
primip: (primigravida) a women who has given birth once
Characteristics of studies awaiting assessment [ordered by study ID]
Amir 2004
Methods This study was identified by the search, but we have not yet been able to locate a copy of the paper
Participants
Interventions
Outcomes
Notes
Rad 2012
Methods Described as a “randomized clinical trial”.
Participants 97 primiparous women.
Interventions Group 1. IV normal saline 120 mL/minute.

Group 2. IV dextrose 5% in normal saline 120 mL/minute.
Outcomes Cervical dilatation, duration of 2nd stage of labour, need for oxytocin, caesarean section, Apgar score at 1 and 5
minutes, neonatal hypoxia
Notes This study was reported in a paper published in Iranian. We are awaiting full translation in order to assess risk of bias
and to carry out data extraction. (Brief abstract in English.)
IV: intravenous
Characteristics of ongoing studies [ordered by study ID]
Salim 2011
Trial name or title Intrapartum Hydration
Methods Randomised controlled trial.
Participants Nulliparous women in spontaneous labour; singleton pregnancy, gestational age 37-41 weeks
Interventions Intravenous fluids: 0.9 % saline with 5% glucose solution at rate of 125 mL/hour versus 250 mL/hour Ringer’s
lactate
Outcomes • Duration of labour

• Mode of delivery
Starting date November 2010.
Contact information Raed Salim

salim ra @clalit.org.il
Notes Status of study: still recruiting.
DATA AND ANALYSES
Comparison 1. Intravenous fluids versus no fluids (restricted oral intake)
No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size
1 Mean duration of labour in 0 0 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
minutes
2 Caesarean section 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
3 Assisted delivery 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
4 Maternal hyponatraemia 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
(sodium level < 135 mmol/L)
5 Fluid overload 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
6 Subjective feelings of thirst 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
7 Maternal comfort/satisfaction 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
8 Admission to neonatal unit 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
9 Low Apgar scores (< 7 at 5 mins) 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
10 Cord pH < 7.0 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
11 Neonatal hyponatraemia (cord 0 0 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
sodium level < 135 mmol/L)
12 Neonatal hypoglycaemia 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
13 Fetal hyperbilirubinaemia 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
14 Newborn weight loss( first 72 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
hours)
Comparison 2. Intravenous fluids alone versus no intravenous fluids (unrestricted oral intake
No. of No. of
1 Mean duration of labour 0 0 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]
4 Fluid overload or pulmonary 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
oedema
14 Newborn weight loss( first 72 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
hours)
Comparison 3. Intravenous fluids alone versus intravenous fluids and oral intake
No. of No. of
minutes
14 Newborn weight loss (first 72 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
hours)
Comparison 4. Intravenous fluids + oral intake versus oral intake alone
No. of No. of
1 Mean duration of labour 2 241 Mean Difference (IV, Fixed, 95% CI) -28.86 [-47.41, -10.
30]
hours)
Comparison 5. 125 mL/hour intravenous fluids + oral intake versus 250 mL/hour intravenous fluids + oral intake
No. of No. of
minutes
2 Caesarean section 3 334 Risk Ratio (M-H, Random, 95% CI) 1.00 [0.54, 1.87]
hours)
Comparison 6. 125 mL/hour fluids versus 250 mL/hour fluids (restricted oral intake in both arms)
No. of No. of
1 Mean duration of labour in 4 632 Mean Difference (IV, Random, 95% CI) 105.61 [53.19, 158.
minutes 02]
5 Admission to neonatal unit 3 689 Risk Ratio (M-H, Random, 95% CI) 0.48 [0.07, 3.17]
hours)
Comparison 7. 125 mL/hour Ringer’s lactate versus 125 mL/hour versus 5% dextrose
No. of No. of
minutes
hours)
Comparison 8. Normal saline versus 5% dextrose solutions
No. of No. of
1 Mean duration of labour in 1 91 Mean Difference (IV, Random, 95% CI) -12.0 [-30.09, 6.09]
minutes
6 Low Apgar scores (< 7 at 5 mins) 2 284 Risk Ratio (M-H, Random, 95% CI) 0.48 [0.04, 5.25]
hours)
12 Neonatal hyponatraemia (cord 1 93 Risk Ratio (M-H, Fixed, 95% CI) 0.4 [0.17, 0.93]
13 Neonatal hyperbilirubinaemia 1 191 Risk Ratio (M-H, Fixed, 95% CI) 0.39 [0.08, 1.95]
14 Neonatal hypoglycaemia (< 40 1 191 Risk Ratio (M-H, Fixed, 95% CI) 0.97 [0.20, 4.68]
mg/dL)
Comparison 9. 125 mL normal saline versus 125 mL Ringer’s lactate
No. of No. of
minutes
hours)
Analysis 4.1. Comparison 4 Intravenous fluids + oral intake versus oral intake alone, Outcome 1 Mean
duration of labour.
Review: Intravenous fluids for reducing the duration of labour in low risk nulliparous women
Comparison: 4 Intravenous fluids + oral intake versus oral intake alone
Outcome: 1 Mean duration of labour
Mean Mean
Study or subgroup iv fluids + oral intake oral intake alone Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Direkvand-Moghadam 2012 (1) 78 225.23 (41.42) 22 252.3 (40.9) 91.5 % -27.07 [ -46.48, -7.66 ]
Kavitha 2012 (2) 72 343 (171) 69 391 (211) 8.5 % -48.00 [ -111.55, 15.55 ]
Total (95% CI) 150 91 100.0 % -28.86 [ -47.41, -10.30 ]

Heterogeneity: Chi2 = 0.38, df = 1 (P = 0.54); I2 =0.0%
Test for overall effect: Z = 3.05 (P = 0.0023)
Test for subgroup differences: Not applicable
-200 -100 0 100 200

iv fluids + oral intake oral intake alone
(1) Duration of active 1st stage (all IV doses combined)
(2) Not clear that reported duration was for vaginal deliveries only
Analysis 4.2. Comparison 4 Intravenous fluids + oral intake versus oral intake alone, Outcome 2 Caesarean
section.
Outcome: 2 Caesarean section
Study or subgroup iv fluids + oral intake oral intake alone Risk Ratio Weight Risk Ratio
n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI
Direkvand-Moghadam 2012 12/90 8/30 28.9 % 0.50 [ 0.23, 1.11 ]
Kavitha 2012 24/96 30/99 71.1 % 0.83 [ 0.52, 1.30 ]
Total (95% CI) 186 129 100.0 % 0.73 [ 0.49, 1.08 ]

Total events: 36 (iv fluids + oral intake), 38 (oral intake alone)
Heterogeneity: Chi2 = 1.15, df = 1 (P = 0.28); I2 =13%
0.01 0.1 1 10 100

Analysis 4.4. Comparison 4 Intravenous fluids + oral intake versus oral intake alone, Outcome 4 Fluid
overload.
Outcome: 4 Fluid overload
Kavitha 2012 0/96 0/99 Not estimable
Total (95% CI) 96 99 Not estimable

Heterogeneity: not applicable
Test for overall effect: not applicable
0.5 0.7 1 1.5 2

Analysis 4.5. Comparison 4 Intravenous fluids + oral intake versus oral intake alone, Outcome 5 Admission
to neonatal unit.
Outcome: 5 Admission to neonatal unit
Kavitha 2012 1/96 2/99 100.0 % 0.52 [ 0.05, 5.59 ]
Total (95% CI) 96 99 100.0 % 0.52 [ 0.05, 5.59 ]

0.01 0.1 1 10 100

Analysis 4.6. Comparison 4 Intravenous fluids + oral intake versus oral intake alone, Outcome 6 Low Apgar
scores (< 7 at 5 mins).
Outcome: 6 Low Apgar scores (< 7 at 5 mins)
Direkvand-Moghadam 2012 0/90 0/30 Not estimable

0.5 0.7 1 1.5 2

Analysis 5.1. Comparison 5 125 mL/hour intravenous fluids + oral intake versus 250 mL/hour intravenous
fluids + oral intake, Outcome 1 Mean duration of labour in minutes.
Comparison: 5 125 mL/hour intravenous fluids + oral intake versus 250 mL/hour intravenous fluids + oral intake
Outcome: 1 Mean duration of labour in minutes
125mls/hr
+oral 250mls/hr+ Mean Mean
Study or subgroup intake oral intake Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Coco 2010 (1) 36 564 (231) 26 570 (231) 3.0 % -6.00 [ -122.52, 110.52 ]
Direkvand-Moghadam 2012 (2) 26 231.7 (43.5) 28 206.2 (38.3) 84.4 % 25.50 [ 3.57, 47.43 ]
Kavitha 2012 (3) 68 363 (172) 72 343 (171) 12.6 % 20.00 [ -36.85, 76.85 ]
Total (95% CI) 130 126 100.0 % 23.87 [ 3.72, 44.02 ]

-100 -50 0 50 100

125mls shorter 250mls shorter
(1) SD not stated. Calculated from P value (0.92) reported
(2) Duration of active 1st stage 240 vs 120mls
(3) Not clear that this is for vaginal deliveries only
fluids + oral intake, Outcome 2 Caesarean section.
Study or subgroup 125 ml/hour 250 ml/hour Risk Ratio Weight Risk Ratio
M- M-
H,Random,95% H,Random,95%
n/N n/N CI CI
Coco 2010 7/43 11/37 32.3 % 0.55 [ 0.24, 1.27 ]
Direkvand-Moghadam 2012 (1) 4/30 2/30 12.4 % 2.00 [ 0.40, 10.11 ]
Kavitha 2012 30/98 24/96 55.3 % 1.22 [ 0.78, 1.93 ]
Total (95% CI) 171 163 100.0 % 1.00 [ 0.54, 1.87 ]

Total events: 41 (125 ml/hour), 37 (250 ml/hour)
Heterogeneity: Tau2 = 0.13; Chi2 = 3.35, df = 2 (P = 0.19); I2 =40%
0.01 0.1 1 10 100

125 ml/hour 250 ml/hour
(1) 120mls vs 240mls
fluids + oral intake, Outcome 3 Assisted delivery.
Outcome: 3 Assisted delivery
Coco 2010 12/43 22/37 100.0 % 0.47 [ 0.27, 0.81 ]
Total (95% CI) 43 37 100.0 % 0.47 [ 0.27, 0.81 ]

0.01 0.1 1 10 100

fluids + oral intake, Outcome 4 Fluid overload.
Coco 2010 0/43 0/37 Not estimable
Kavitha 2012 0/98 0/96 Not estimable

0.01 0.1 1 10 100

fluids + oral intake, Outcome 5 Admission to neonatal unit.
Coco 2010 3/43 4/37 73.9 % 0.65 [ 0.15, 2.70 ]
Kavitha 2012 0/98 1/96 26.1 % 0.33 [ 0.01, 7.92 ]
Total (95% CI) 141 133 100.0 % 0.56 [ 0.15, 2.06 ]

0.01 0.1 1 10 100

fluids + oral intake, Outcome 6 Low Apgar scores (< 7 at 5 mins).
Coco 2010 0/43 0/37 Not estimable
Direkvand-Moghadam 2012 0/30 0/30 Not estimable

0.01 0.1 1 10 100

Analysis 6.1. Comparison 6 125 mL/hour fluids versus 250 mL/hour fluids (restricted oral intake in both
arms), Outcome 1 Mean duration of labour in minutes.
Comparison: 6 125 mL/hour fluids versus 250 mL/hour fluids (restricted oral intake in both arms)
Mean Mean
Study or subgroup 125 ml/hour 250 ml/hour Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Alavi 2005 (1) 97 451 (213) 78 312 (297) 23.8 % 139.00 [ 60.64, 217.36 ]
Eslamian 2006 118 386 (110) 123 253 (97) 45.0 % 133.00 [ 106.77, 159.23 ]
Garite 2000 (2) 78 552 (248) 91 484 (248) 24.9 % 68.00 [ -7.00, 143.00 ]
Maderia 2007 (3) 23 560 (340) 24 626 (340) 6.4 % -66.00 [ -260.45, 128.45 ]
Total (95% CI) 316 316 100.0 % 105.61 [ 53.19, 158.02 ]

-200 -100 0 100 200

(1) Not clear that duration was for vaginal deliveries only
(2) SD calculated from P value given in paper (0.06)
(3) Sd calculated from P value given in paper (0.51)
arms), Outcome 2 Caesarean section.
Alavi 2005 15/112 4/82 10.3 % 2.75 [ 0.95, 7.97 ]
Eslamian 2006 35/153 24/147 54.8 % 1.40 [ 0.88, 2.24 ]
Garite 2000 16/94 10/101 21.6 % 1.72 [ 0.82, 3.60 ]
Maderia 2007 6/29 6/30 13.2 % 1.03 [ 0.38, 2.84 ]
Total (95% CI) 388 360 100.0 % 1.56 [ 1.10, 2.21 ]

0.2 0.5 1 2 5
arms), Outcome 3 Assisted delivery.
Eslamian 2006 1/153 0/147 2.3 % 2.88 [ 0.12, 70.21 ]
Garite 2000 15/94 22/101 97.7 % 0.73 [ 0.40, 1.33 ]
Total (95% CI) 247 248 100.0 % 0.78 [ 0.44, 1.40 ]

0.01 0.1 1 10 100

arms), Outcome 4 Fluid overload.
Garite 2000 1/94 0/101 100.0 % 3.22 [ 0.13, 78.11 ]
Total (95% CI) 94 101 100.0 % 3.22 [ 0.13, 78.11 ]

0.01 0.1 1 10 100

arms), Outcome 5 Admission to neonatal unit.
M- M-
n/N n/N CI CI
Alavi 2005 0/112 3/82 27.8 % 0.10 [ 0.01, 2.00 ]
Eslamian 2006 0/153 0/147 Not estimable
Garite 2000 8/94 10/101 72.2 % 0.86 [ 0.35, 2.09 ]
Total (95% CI) 359 330 100.0 % 0.48 [ 0.07, 3.17 ]

0.01 0.1 1 10 100

arms), Outcome 6 Low Apgar scores (< 7 at 5 mins).
Alavi 2005 4/112 1/82 53.8 % 2.93 [ 0.33, 25.72 ]
Eslamian 2006 4/153 0/147 23.8 % 8.65 [ 0.47, 159.25 ]
Garite 2000 1/94 0/101 22.5 % 3.22 [ 0.13, 78.11 ]
Total (95% CI) 359 330 100.0 % 4.35 [ 0.97, 19.51 ]

0.01 0.1 1 10 100

Analysis 8.1. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 1 Mean duration of
labour in minutes.
Comparison: 8 Normal saline versus 5% dextrose solutions
Mean Mean
Study or subgroup Normal saline Dextrose solutions Difference Weight Difference
N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI
Stratton 1995 44 384 (44) 47 396 (44) 100.0 % -12.00 [ -30.09, 6.09 ]
Total (95% CI) 44 47 100.0 % -12.00 [ -30.09, 6.09 ]

-200 -100 0 100 200

Normal saline Dextrose solutions
Analysis 8.2. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 2 Caesarean section.
Study or subgroup Normal saline Dextrose solutions Risk Ratio Weight Risk Ratio
Shrivastava 2009 14/97 18/94 95.0 % 0.75 [ 0.40, 1.43 ]
Stratton 1995 1/45 1/48 5.0 % 1.07 [ 0.07, 16.55 ]
Total (95% CI) 142 142 100.0 % 0.77 [ 0.41, 1.43 ]

Total events: 15 (Normal saline), 19 (Dextrose solutions)
0.01 0.1 1 10 100

Analysis 8.3. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 3 Assisted delivery.
Stratton 1995 5/45 9/48 100.0 % 0.59 [ 0.21, 1.63 ]
Total (95% CI) 45 48 100.0 % 0.59 [ 0.21, 1.63 ]

0.01 0.1 1 10 100

Analysis 8.4. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 4 Fluid overload.
Stratton 1995 0/45 0/48 Not estimable

0.01 0.1 1 10 100

Analysis 8.5. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 5 Admission to neonatal
unit.
Shrivastava 2009 8/97 7/94 100.0 % 1.11 [ 0.42, 2.93 ]
Total (95% CI) 142 142 100.0 % 1.11 [ 0.42, 2.93 ]

0.01 0.1 1 10 100

Analysis 8.6. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 6 Low Apgar scores (< 7
at 5 mins).
M- M-
n/N n/N CI CI
Shrivastava 2009 1/97 2/94 100.0 % 0.48 [ 0.04, 5.25 ]
Total (95% CI) 142 142 100.0 % 0.48 [ 0.04, 5.25 ]

0.01 0.1 1 10 100

Analysis 8.9. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 9 Maternal
hyponatraemia (sodium level < 135 mmol/L).
Outcome: 9 Maternal hyponatraemia (sodium level < 135 mmol/L)
Study or subgroup Normal saline Dextrose Risk Ratio Weight Risk Ratio
Stratton 1995 0/44 9/47 100.0 % 0.06 [ 0.00, 0.94 ]
Total (95% CI) 44 47 100.0 % 0.06 [ 0.00, 0.94 ]

Total events: 0 (Normal saline), 9 (Dextrose)
0.005 0.1 1 10 200

Analysis 8.12. Comparison 8 Normal saline versus 5% dextrose solutions, Outcome 12 Neonatal
hyponatraemia (cord sodium level < 135 mmol/L).
Outcome: 12 Neonatal hyponatraemia (cord sodium level < 135 mmol/L)
Study or subgroup Normal saline Dextrose Risk Ratio Weight Risk Ratio
Stratton 1995 6/45 16/48 100.0 % 0.40 [ 0.17, 0.93 ]
Total (95% CI) 45 48 100.0 % 0.40 [ 0.17, 0.93 ]

Total events: 6 (Normal saline), 16 (Dextrose)
0.01 0.1 1 10 100

Favours normal saline Favours dextrose
hyperbilirubinaemia.
Outcome: 13 Neonatal hyperbilirubinaemia
Shrivastava 2009 2/97 5/94 100.0 % 0.39 [ 0.08, 1.95 ]
Total (95% CI) 97 94 100.0 % 0.39 [ 0.08, 1.95 ]

0.01 0.1 1 10 100

hypoglycaemia (< 40 mg/dL).
Outcome: 14 Neonatal hypoglycaemia (< 40 mg/dL)
Shrivastava 2009 3/97 3/94 100.0 % 0.97 [ 0.20, 4.68 ]
Total (95% CI) 97 94 100.0 % 0.97 [ 0.20, 4.68 ]

0.5 0.7 1 1.5 2

CONTRIBUTIONS OF AUTHORS
Feroza Dawood (FD) created the first draft of the protocol and Siobhan Quenby (SQ) commented on the draft and suggested changes.
FD, Therese Dowswell (TD) and SQ then analysed the data and drew up the final results. FD wrote the initial draft of the review and
TD and SQ edited the review.
DECLARATIONS OF INTEREST
None known.
SOURCES OF SUPPORT
Internal sources
• The University of Liverpool, UK.
External sources
• UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human
Reproduction (HRP) and the Department of Reproductive Health and Research (RHR), World Health Organization, Switzerland.
DIFFERENCES BETWEEN PROTOCOL AND REVIEW

’Apgar score less than seven at five minutes’ has been added as a fetal and neonatal secondary outcome.
’Early newborn weight loss’ has been removed from the list of fetal and neonatal secondary outcomes.
INDEX TERMS
Medical Subject Headings (MeSH)

Cesarean Section [utilization]; Drinking Water [administration & dosage]; Fluid Therapy [∗ methods]; Isotonic Solutions [administra-
tion & dosage]; Labor, Obstetric [∗ physiology]; Parity; Randomized Controlled Trials as Topic; Risk; Sodium Chloride [administration
& dosage]; Time Factors
MeSH check words

Female; Humans; Infant, Newborn; Pregnancy

CD007715 PDF

Uploaded by

Copyright:

Available Formats

You might also like

CD007715 PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

CD007715 PDF

Uploaded by

Copyright:

Available Formats

Cochrane Database of Systematic Reviews

Intravenous fluids for reducing the duration of labour in low

Dawood F, Dowswell T, Quenby S

Dawood F, Dowswell T, Quenby S.

Intravenous fluids for reducing the duration of labour in low

Feroza Dawood1 , Therese Dowswell2 , Siobhan Quenby3

Editorial group: Cochrane Pregnancy and Childbirth Group.

Data collection and analysis

PLAIN LANGUAGE SUMMARY

We intentionally restricted the review to nulliparous women as we

METHODS Types of interventions

Dealing with missing data If we identified substantial heterogeneity in a fixed-effect meta-

Included studies Risk of bias in included studies

Effects of interventions Primary outcomes

Characteristics of included studies [ordered by study ID]

Methods Prospective randomised clinical trial.

Interventions 125 mL/hour vs 250 mL/hour of normal saline in dextrose water

Outcomes Duration of labour in minutes; CS due to failure to progress

Notes No other oral intake; no food.

Bias Authors’ judgement Support for judgement

Incomplete outcome data (attrition bias) Low risk No attrition reported.

Selective reporting (reporting bias) Low risk Fairly transparent results.

Other bias Unclear risk No details about duration of study.

Blinding of participants and personnel High risk Not mentioned.

Methods Prospective randomised trial.

Outcomes Duration of labour; first, second stage and total duration.

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Random number chart.

Selective reporting (reporting bias) Low risk Prospective data capture.

Women recruited from 4 hospitals including 3 private

Methods Prospective randomised controlled trial. 4 arms with individual randomisation

Participants 120 women in labour at a hospital in Ilam, Iran in 2010.

Interventions 4 groups: 30 women in each group

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Random number tables.

Methods Prospective double-blind randomised trial.

Outcomes Duration of labour in minutes; CS due to failure to progress; assisted delivery

Notes Nil by mouth; no epidurals.

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Random computer-generated numbers.

Selective reporting (reporting bias) Low risk No evidence of selective reporting.

Other bias Unclear risk Authors acknowledge the following: no

Blinding of outcome assessment (detection Low risk None apparent.

Methods Prospective randomised trial.

Interventions 125 mL/hour vs 250 mL/hour of Ringer’s lactate solution.

Outcomes Maternal: duration of labour in minutes

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Random computer-generated sequence.

Selective reporting (reporting bias) Low risk None apparent.

Other bias Unclear risk No measurement of inherent maternal dehydration; no

Blinding of participants and personnel High risk No masking of interventions.

Blinding of outcome assessment (detection Low risk None apparent.

Methods Randomised controlled trial.

Interventions 99 women received oral hydration.

Bias Authors’ judgement Support for judgement

Random sequence generation (selection Low risk Computerised block randomisation.

Allocation concealment (selection bias) Low risk Sequential opaque envelopes.

Selective reporting (reporting bias) Low risk None apparent.