Routine prophylactic drugs in normal labour for reducing gastric aspiration and its effects

Abstract

Background: Women in normal labour may sometimes go on to have general anaesthesia if labour becomes abnormal, for example if a caesarean section is required. General anaesthesia carries a very small risk of regurgitation and inhalation of stomach contents into the lungs. This can cause inflammation, particularly if the fluid is acidic, and can lead to severe morbidity and very occasionally mortality. Labour hormones increase the risk of gastric aspiration or Mendelsohn's syndrome, though the exact incidence is unknown. The routine administration of acid prophylaxis drugs to all women in normal labour is commonly practiced worldwide, to reduce gastric aspiration by reducing the volume and acidity of stomach contents. Objectives: To assess the effectiveness of routine prophylaxis drugs for women in normal labour to reduce gastric aspiration and its effects. Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2005), EMBASE (1974 to April 2005) and CINAHL (1982 to April 2005). We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 1 October 2009 and added the results to the awaiting classification section. Selection criteria: Randomised and quasi-randomised controlled trials of women in normal labour assessing the routine administration of drugs (antacids, H2 receptor antagonists, dopamine antagonists and proton-pump inhibitors) compared with placebo/no treatment, and compared with other drugs for reducing gastric aspiration. Data collection and analysis: Two review authors independently assessed eligibility, quality, extracted data and performed double-data entry. Main results: Three trials were included, involving 2465 women, assessing the effects of antacids, H2 receptor antagonists and dopamine antagonists. There were no trials on proton-pump inhibitors. None of the trials were of good quality, and none assessed the incidence of gastric aspiration, Mendelsohn's syndrome or their consequences. All the studies assessed vomiting, and there was limited evidence that vomiting may be reduced by antacids (relative risk (RR) 0.46, 95% confidence interval (CI) 0.27 to 0.77, n = 578, one trial) or by dopamine antagonists given alongside pethidine (RR 0.40, 95% CI 0.23 to 0.68, n = 584, one trial). Comparisons between different drugs showed no significant differences, though the number of participants was small. There was no evidence that H2 receptor antagonists improved outcomes compared with antacids, though only one trial addressed this issue. Authors' conclusions: There is no good evidence to support the routine administration of acid prophylaxis drugs in normal labour to prevent gastric aspiration and its consequences. Giving such drugs to women once a decision to give general anaesthesia is made, is assessed in another Cochrane review. [Note: The four citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.].