Disclosures � No financial disclosures LEADING THE QUEST FOR HEALTH � No off-label use of medications Nulliparous Term Singleton Vertex (NTSV): Is Healthy People 2020 Goal Possible? Kimberly D. Gregory MD, MPH Vice Chair Women’s Healthcare Quality & Performance improvement Department Obstetrics & Gynecology Cedars Sinai Medical Center Professor, David Geffen School of Medicine & UCLA School of Public Health KD Gregory 5/2014 KD Gregory 5/2014 Objectives Why is this important? � Cesarean delivery is the most commonly performed � Participants will be able to surgical procedure in the United States —Discuss the different strategies for defining normal � Approximately 1/3 of pregnancies are delivered via and abnormal labor cesarean —Describe the risks associated with cesarean � In 2010, 26.4% of low risk women underwent a delivery with an emphasis on nulliparous patients cesarean —Discuss potential interventions which may help —Low risk = nulliparous, term, singleton, vertex reduce the risk of having the ‘first’ cesarean (NTSV) delivery and impact the NTSV rate � Over 90% of women undergoing a primary cesarean in the US will have a repeat cesarean KD Gregory 5/2014 KD Gregory 5/2014 1
After the first cesarean… After the first cesarean… � Risks for abnormal placentation increase � Maternal risk for complications increase — Previa � Intraoperative risks — Accreta — Increta —Hemorrhage — Percreta —Injury to viscera � Risk of uterine rupture increases — Fetal/Maternal jeopardy � Bowel � With all of these, there is an increased risk for: � Bladder — Hysterectomy —Adhesions — Blood transfusion — Wound infection/breakdown — DVT KD Gregory 5/2014 KD Gregory 5/2014 Summary � The decision to undertake the first cesarean has profound implications on a woman’s future reproductive health � Much of labor management in the US relies on information based on Friedman’s curves (1955) � Some of these concepts have been challenged Let’s start with the 1950’s —Review of key concepts introduced throughout the years regarding labor management KD Gregory 5/2014 KD Gregory 5/2014 2
Historical Background Friedman Curve � Friedman curve 1955 � Focused on looking at rate of cervical dilation � 500 patients � Recorded all ‘rectal’ and ‘vaginal’ exams —Ages 13-42 (mostly 20-30) � Dilation plotted over time —SVD in 202 (40.4%) � Noted features such as age, pelvis type, fetal presentation, — Low forceps in 256 (51.2%) fetal station —Mid forceps in 19 (3.8%) — Cesarean delivery 9 (1.8%) � Augmentation / induction —69 patients (13.8%) received pitocin � 22 for ‘induction’ Individually plotted by hand! � 47 for ‘stimulation’ KD Gregory 5/2014 KD Gregory 5/2014 Friedman 1955 Friedman Curve – ‘Ideal Labor’ 95%tile Characteristic Mean Range Stat Maximum ‘Primagravidas whose labors Latent phase (hr) 8.6 1.0-44 20.6 progressed Active phase (hr) 4.9 0.8-34 11.7 normally without Deceleration (hr) 0.9 0.0-14 3.3 Iatrogenic Max slope (cm/hr) 3.0 0.4-12 6.8 tampering.’ First stage (hr) 13.3 2.0-58 28.5 Second stage (hr) 0.95 0.0-5.5 2.5 14.3 hrs 31 hrs Friedman EA. Primagravid Labor: A graphostatistical Analysis. Friedman EA. Primagravid Labor: A graphostatistical Obstet Gynecol 1955 (6): 567-89. Analysis. Obstet Gynecol 1955 (6): 567-89. KD Gregory 5/2014 KD Gregory 5/2014 3
On to the 1970’s… Friedman Curve � ‘Clinical Inertia’ — 46 patients Average of 13 hours in latent phase � Average of 12.2 hours in active phase � Second stage was 1.6 hours � Maximum slope was 1.4 cm / hr � — Primary inertia 21 patients (46%) � — Secondary inertia 20 patients (43%) These people didn’t � — Reasons: fit his curves! Excessive medication (46%) � CPD (28%) � Occiput posterior (28%) � Caudal Anesthesia (22%) � Unknown � KD Gregory 5/2014 KD Gregory 5/2014 Alternate Ways to Monitor Labor Progress Cervicograph � Founded on Friedman’s � Philpott and Castle (1972) work —Cervicograph — Low resource conditions � Composed of alert and action lines — Starts at 3 cm plotted against time (hours) — Alert: close observation — Action: augment/transfer —Partograph Philpott & Castle, J Ob Gyn Brit Comm 1972 KD Gregory 5/2014 KD Gregory 5/2014 4
On to the 1990s…. WHO Partograph � Definition of “active phase” — Shift from “rate of change” (slope) to specific cm — 3 cm KD Gregory 5/2014 KD Gregory 5/2014 Active Phase Labor Arrest Active Phase Arrest � Term, gravid patients � Rouse et al (1999) � Spontaneous labor —Prospectively studied a labor-management � Active phase arrest protocol which mandated at least 4 hours of — 4 cm dilated oxytocin prior to cesarean delivery for active — < 1 cm in 2 hours of cervical change phase arrest � Excluded: —Malpresentation, prior cesarean deliveries, multiple gestation, and nonreassuring fetal heart tracings (NRFHT) KD Gregory 5/2014 KD Gregory 5/2014 5
Active Phase Arrest Active Phase Arrest � After the diagnosis of active phase arrest, oxytocin was initiated to achieve >200 Mv Units (IUPC) Vaginal delivery and infection rate based on labor progress and time after active phase arrest � Cesarean delivery not performed until 4 hours with adequate MVU —Or a minimum of 6 hours (if adequacy not achieved) Rouse DJ et al. Failed Labor Induction . Obstet Gynecol 2011 (117): 267-72. (modified) KD Gregory 5/2014 KD Gregory 5/2014 Rouse’s Take Home Point: A little more time… � 2 hours may not be enough time for some women to progress in labor � A minimum of 4 hours of oxytocin-augmented labor (adequate Mv units) should be allowed � For women who do not achieve adequate mvu, a minimum of 6 hours of augmentation should be allowed for these patients Into the 21 st century… KD Gregory 5/2014 KD Gregory 5/2014 6
Reassessing Friedman in the 21 st century Study populations REASSESSMENT OF THE FRIEDMAN CURVE (2002) Zhang J, Troendle JF, Yancey MK. Reassessing the labor curve in nulliparous women . Am J Obstet Gynecol 2002 (187): 824-8. Comparison of Friedman and Zhang Labor Curves Zhang J, Troendle JF, Yancey MK. Reassessing the labor curve in nulliparous women. Am J Obstet Gynecol 2002 (187): 824-8. (modified) KD Gregory 5/2014 KD Gregory 5/2014 Zhang Conclusions � Labor progress may be more gradual than originally thought (especially for nulliparous 5 cm patients) Rate of change based on cervix exam � Women may enter active labor between 3-5 cm Cervix (cm) dilation � Even the course of the active phase of labor will vary from person to person —May result in a flatter curve � Friedman’s curve likely represents an individual Labor Duration (hrs) patient with an ‘ideal’ curve Zhang J, Troendle JF, Yancey MK. Reassessing the labor curve in nulliparous women. Am J Obstet Gynecol 2002 (187): 824-8. (modified KD Gregory 5/2014 KD Gregory 5/2014 7
Recap Safe Labor � Friedman focused on individual progress, defined � Consortium for Safe Labor* active labor based on maximum slope rate of change � Large multicenter study � Latent phase could be a long time � Contemporary women in spontaneous labor undergoing the ‘usual’ care may: � Philpott & Castle, WHO started curves at 3 cm; ignored latent phase and/or early labor — Take 6 hours to change from 4-5 cm — Take more than 3 hours to change from 5-6 cm � Zhang nulliparous slower, mimics Friedman after — After that point, labor curve is steeper active phase; rate of change occurs around 5 cm � Redefine the starting point of active labor from 4 cm to 6 —Similar population as Friedman; more cm contemporaneous cohort � Does this mean that Friedman’s results are wrong? —Data started at 3 cm *includes patients from CSMC (2002-2008) KD Gregory 5/2014 KD Gregory 5/2014 Demographics Safe Labor Consortium 2002-2008 Cervical Exam on Admission 95%tile of cumulative duration of spontaneous Diverse pop labor from admission to vaginal delivery Zhang et al. Contemp Labor Patterns Obstet Gynecol 2010 KD Gregory 5/2014 KD Gregory 5/2014 8
Duration of Labor by Method of Onset Duration of Labor Based on Exam on Admission “ 6 is the new 4” Median (95%tile) After “active phase” (6 cm) doesn’t matter, all “clinically” the same Zhang et al. Contemp Labor Patterns. Obstet Gynecol 2010 (modified) KD Gregory 5/2014 KD Gregory 5/2014 Implications Duration of Labor by Method of Onset, Parity � If the definition of active labor is shifted to 6 cm —many cesarean deliveries performed prior to Spontaneous Induction Multips Multips that point would be considered “latent phase Nullips Nullips cesareans” � Arrest of labor diagnosis prior to 6 cm of cervical dilation needs to be considered carefully —Zhang et al KD Gregory 5/2014 KD Gregory 5/2014 9
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