FIRST STAGE OF LABOR UCSF AIM conference for the invitation to - - PowerPoint PPT Presentation

▶

Feb 15, 2023 404 likes •582 views

6/14/2019 Acknowledgements FIRST STAGE OF LABOR UCSF AIM conference for the invitation to present Oregon Health & Science University mentors, collaborators, patients, students, and community HOW DO WE MANAGE IN 2019? Special

SLIDE 1

6/14/2019 1

FIRST STAGE OF LABOR

HOW DO WE MANAGE IN 2019?

Ellen Tilden, CNM, PhD, FACNM Oregon Health and Science University School of Nursing, Midwifery Department School of Medicine, Department of Obstetrics & Gynecology

Acknowledgements

UCSF AIM conference for the invitation to present
Oregon Health & Science University mentors, collaborators, patients,

students, and community

Special thanks to the OHSU CNM patients whose data contributed to
ur latent labor analyses and to the OHSU CNMs who entered this

data in addition to completing EMR!

No financial disclosures

#1- regarding cervical dilation associated with active phase onset, 6 is the…

A. New 2
B. New 4
C. New 8
D. 2-4-6-8, who do we appreciate?

N e w 2 N e w 4 N e w 8 2

, w h

e a p p r e c i a t e ?

0% 3% 1% 96%

#2- A healthy woman G1P0 has been at 7 cms for 2

hours. FHT are category 1 and there are no other

concerns about her well-being or fetal well-being. You should:

A. Start oxytocin
B. Cesarean
C. Not intervene

S t a r t

y t

i n C e s a r e a n N

i n t e r v e n e

33% 67% 1%

SLIDE 2

6/14/2019 2

Since we already know 2019 management…

1. HOW DO WE KNOW ABOUT FIRST STAGE LABOR

PROGRESS?

2. WHAT ABOUT LATENT LABOR?
3. HOW ARE WE CURRENTLY USING THIS

INFORMATION?

4. WHAT MIGHT BE NEXT?

THE SUN SHOULD NOT RISE OR SET TWICE ON A WOMAN IN LABOR

African proverb

THE SUN SHOULD NOT RISE OR SET TWICE ON A WOMAN IN LABOR

African proverb

1821

Labor that is too long can hurt women + newborns

SLIDE 3

6/14/2019 3

RESEARCH CLINICAL

1930 CALKINS (US), FREY (Germany), GEISENDORF (France) No clinical implementation recommended 1940 WOLF (Germany), ZIMMER (Germany), KOLLER (Switzerland) No clinical implementation recommended 1950 FRIEDMAN 1960 FRIEDMAN 1970 FRIEDMAN 1980 1990 2000 < 5% quick labors 68% most labors >95% tedious labors Duration of time in the first stage of labor < 5% quick labors 68% most labors >95% tedious labors Duration of time in the first stage of labor < 5% quick labors 68% most labors >95% tedious labors = risk Duration of time in the first stage of labor

SLIDE 4

6/14/2019 4

< 5% quick labors 68% most labors >95% tedious labors = risk Duration of time in the first stage of labor

YES

Maternal: 1) Urinary retention 2) Postpartum hemorrhage 3) Chorioamnionitis Fetal/neonatal/infant: 1) Apgar < 7 at 5 m 2) NICU admit

NO or not yet established

No long-term infant/child morbidity No maternal or child mortality

RESEARCH CLINICAL

FRIEDMAN- 1950s: ‘ABERRATIONS’ ‘PROLONGATION’ PHILPOTT- 1970s: ‘ALERT LINE’ ‘ACTION LINE’

RESEARCH CLINICAL

1930 CALKINS (US), FREY (Germany), GEISENDORF (France) No clinical implementation recommended 1940 WOLF (Germany), ZIMMER (Germany), KOLLER (Switzerland) No clinical implementation recommended 1950 FRIEDMAN 1960 FRIEDMAN 1970 FRIEDMAN PHILPOTT & CASTLE CERVICOGRAPH 1980 ALBERS DUBLIN TRIAL / O’DRISCOLL ACTIVE MANAGEMENT 1990 ALBERS DUBLIN TRIAL / O’DRISCOLL ACTIVE MANAGEMENT 2000 ZHANG 6 IS THE NEW 4

SLIDE 5

6/14/2019 5

TEAM ZHANG TEAM FRIEDMAN TEAM ZHANG TEAM FRIEDMAN

You used the wrong statistical approach You are a bunch of statistics-obsessed eggheads You also used the wrong sample Your results are different because birthing women now are older and heavier And, BTW, your work has led to unnecessary intervention during normal labors all over the world You are so inexperienced with the many markers of normal labor progress that you can’t understand the ‘dynamic beauty and logic’ of birth

‘Outcome[s] vary from one woman to another. Our findings

question the rigid limits currently applied in clinical practice’ Abalos 2018 ‘Our findings call into question the universal application of clinical standards that are conceptually based on linear labour progression in all women’ –Oladapo 2018

SLIDE 6

6/14/2019 6

HUMBLE

and

CURIOUS

SLIDE 7

6/14/2019 7

Since we already know 2019 management…

1. HOW DO WE KNOW ABOUT FIRST STAGE LABOR

PROGRESS?

2. WHAT ABOUT LATENT LABOR?
3. HOW ARE WE CURRENTLY USING THIS

INFORMATION?

4. WHAT MIGHT BE NEXT?

When does latent labor start?

4 latent labor studies in the US… Of these 1) Friedman EA. 1955 2) Friedman EA. 1956 3) Chelmow D, et al 1993 4) Peisner DB, et al 1985

Don’t clearly define latent onset

When does latent labor start?

4 latent labor studies in the US… Of these 1) Friedman EA. 1955 2) Friedman EA. 1956 3) Chelmow D, et al 1993 4) Peisner DB, et al 1985

Don’t clearly define latent onset Defines latent onset as time of hospital admission

When does latent labor start?

4 latent labor studies in the US… Of these 1) Friedman EA. 1955 2) Friedman EA. 1956 3) Chelmow D, et al 1993 4) Peisner DB, et al 1985

Don’t clearly define latent onset Defines latent onset as time of hospital admission Defines latent onset by start of symptoms

SLIDE 8

6/14/2019 8

665 nulliparous and 616 multiparous >21 years, term singleton vertex The objectives of this study were to: 1) characterize latent phase duration among low-risk U.S. women in spontaneous labor using the women’s self-identified onset; and 2) quantify associations between demographic and maternal/newborn health characteristics and the latent phase duration. Study Nulliparous Multiparous mean median mean median Peisner 1985 7.5 hours * 5.2 hours * Friedman 1955-56 8.6 hours 7.5 hours 5.3 hours 4.5 hours Tilden 2019 11.8 hours 9.0 hours 9.3 hours 6.8 hours

* = not reported FRIEDMAN 1950s – 1970s

SLIDE 9

6/14/2019 9

LATENT ACTIVE ZHANG TILDEN LATENT ACTIVE ZHANG

Tilden, Phillippi, Carlson, Dissanayake, Lee, Caughey, Snowden, under review at AJOG Same sample The objective of this study was to evaluate the association between the duration of the latent phase at five points of distribution (mean, median, 80th, 90th, and 95th percentiles) and perinatal processes and outcomes that occurred during active labor, second stage, birth, and the immediate postpartum.

Longer Latent Labor

LABOR DYSTOCIA IN ACTIVE OR 2nd STAGE AUGMENTATION, EPIDURAL LONGER ACTIVE AND 2nd STAGE MULTIPS >80% = NICU * but 2/3 for observation

SLIDE 10

6/14/2019 10

Since we already know 2019 management…

1. HOW DO WE KNOW ABOUT FIRST STAGE LABOR

PROGRESS?

2. WHAT ABOUT LATENT LABOR?
3. HOW ARE WE CURRENTLY USING THIS

INFORMATION?

4. WHAT MIGHT BE NEXT?

QUALITY IMPROVEMENT

2018 6351 nullips France CD decreased from 9.4% to 6.6% No increase adverse outcomes

QUALITY IMPROVEMENT

2018 6351 nullips France CD decreased from 9.4% to 6.6% No increase adverse outcomes 2018 Maternal care consensus bundles ACOG, ACNM, AWHONN

QUALITY IMPROVEMENT

2018 6351 nullips France CD decreased from 9.4% to 6.6% No increase adverse outcomes 2018 Maternal care consensus bundles ACOG, ACNM, AWHONN 2019 119,000 nullips CA CD decreased from 29.3% to 25% Decreased adverse outcomes

SLIDE 11

6/14/2019 11

Dublin Trial / O’Driscoll Active Management of Labor

1. Amniotomy within one hour of dx active labor
2. CVX exams Q2 hours
3. Insufficient progress = oxytocin started at 4 mu and increased by 4 Q 15
4. Midwife in charge diagnoses active labor
5. Continuous nursing care and support

O’Driscoll et al 1969 ‘Prevention of Prolonged Labour’ British Medical Journal, 2

Dublin Trial / O’Driscoll Active Management of Labor

1. Amniotomy within one hour of dx active labor
2. CVX exams Q2 hours
3. Insufficient progress = oxytocin started at 4 mu and increased by 4 Q 15
4. Midwife in charge diagnoses active labor
5. Continuous nursing care and support

O’Driscoll et al 1969 ‘Prevention of Prolonged Labour’ British Medical Journal, 2

Dublin Trial / O’Driscoll Active Management of Labor

1. Amniotomy within one hour of dx active labor
2. CVX exams Q2 hours
3. Insufficient progress = oxytocin started at 4 mu and increased by 4 Q 15
4. Midwife in charge diagnoses active labor
5. Continuous nursing care and support

O’Driscoll et al 1969 ‘Prevention of Prolonged Labour’ British Medical Journal, 2

PARTOGRAMS

2018 27,077 nullips US Latent admit: CD = 18.0% Active admit: CD = 7.2% Adverse outcomes more common if admitted in latent

SLIDE 12

6/14/2019 12

PARTOGRAMS

2018 27,077 nullips US Latent admit: CD = 18.0% Active admit: CD = 7.2% Adverse outcomes more common if admitted in latent 2019 7,277 nullips Norway Friedman/WHO partogram = 9.5% CD → 5.9% CD Zhang partogram = 9.3% CD → 6.8% CD

PARTOGRAMS

Since we already know 2019 management…

1. HOW DO WE KNOW ABOUT FIRST STAGE LABOR

PROGRESS?

2. WHAT ABOUT LATENT LABOR?
3. HOW ARE WE CURRENTLY USING THIS INFORMATION?
4. WHAT MIGHT BE NEXT?

+

HIGH TOUCH and HIGH TECH?

SLIDE 13

6/14/2019 13

‘In trying to address [the question of progress during labor] it is important to understand that [labor] curves were based on and confirmed by direct experimental observations made on women in labor. The primacy of direct observation over theoretical conceptualization or indirect analysis of data in hypothesis testing has been a central tenant of the scientific method since the Enlightenment.’ Cohen & Friedman 2018 ‘Management of Labor: Are the New Guidelines Justified?’ CAN DYSTOCIA BE TREATED WITH SODIUM BICARBONATE? Musaba et al 2019 ‘Effect of preoperative bicarbonate infusion on maternal and perinatal outcomes of obstructed labor’ BMJ Wiberg-Itzel et al 2018 ‘A randomized controlled trial of a new treatment for labor dystocia’ J of Maternal- Fetal & Neonatal Medicine

SLIDE 14

6/14/2019 14

Katherine Kissler, CNM. Doctoral student at U of Colorado F31 Title- Two Novel Biomarkers for Labor Dystocia: Developing a Physiologic Understanding to Facilitate Precision in Diagnosis and Individualized Management DOES A FATIGUED UTERUS NEED SYNTHETIC OXYTOCIN…OR SLEEP?

1. What is the relationship between the duration of the first

stage of labor and risk? Not yet well-defined

2. Latent labor may be longer than we previously understood
3. Can partograms help? We are not yet sure
4. How about QI? Promising but please implement the entire

model

5. What might be next? High-touch + high-tech?

THANK YOU

SLIDE 15

6/14/2019 15

REFERENCES Abalos, E., Oladapo, O. T., Chamillard, M., Diaz, V., Pasquale, J., Bonet, M., . . . Gulmezoglu, A. M. (2018). Duration of spontaneous labour in 'low-risk' women with 'normal' perinatal outcomes: A systematic review. Eur J ObstetGynecol Reprod Biol, 223, 123-132. doi:10.1016/j.ejogrb.2018.02.026 Albers, L. L. (1999). The duration of labor in healthy women. Journal of Perinatology, 19(2), 114-119. Albers, L. L., Schiff, M., & Gorwoda, J. (1996). The length of active labor in normal pregnancies. ObstetGynecol, 87(3), 355-359. Altman, M., Sandström, A., Petersson, G., Frisell, T., Cnattingius, S., & Stephansson, O. (2015). Prolonged second stage

f labor is associated with low Apgar score. European Journal of Epidemiology, 30(11), 1209-1215. Retrieved from

https://www.scopus.com/inward/record.uri?eid=2-s2.0-84951566737&doi=10.1007%2fs10654-015-0043- 4&partnerID=40&md5=a20230bfdd32a28b4ef70b29f7b050ec. doi:10.1007/s10654-015-0043-4 Bernitz, S., Dalbye, R., Zhang, J., Eggebo, T. M., Froslie, K. F., Olsen, I. C., . . . Oian, P. (2019). The frequency of intrapartum caesarean section use with the WHO partograph versus Zhang's guideline in the Labour Progression Study (LaPS): a multicentre, cluster-randomised controlled trial. Lancet, 393(10169), 340-348. doi:10.1016/s0140- 6736(18)31991-3 Campbell, O. M., & Graham, W. J. (2006). Strategies for reducing maternal mortality: getting on with what works. Lancet, 368(9543), 1284-1299. doi:10.1016/s0140-6736(06)69381-1 Chelmow, D., Kilpatrick, S. J., & Laros, R. K. (1993). Maternal and neonatal outcomes after prolonged latent phase. Obstetrics and Gynecology, 81(4), 486-491. Retrieved from https://www.scopus.com/inward/record.uri?eid=2-s2.0- 0027524410&partnerID=40&md5=aa443dfbc90e6f765bcac8fff0aaa81f. REFERENCES Cohen, W., & Friedman, E. (2015). Perils of the new labor management guidelines. American Journal of Obstetrics & Gynecology, 98, 420-427. Cohen, W. R., & Friedman, E. A. (2015). Misguided guidelines for managing labor. Am J ObstetGynecol, 212(6), 753.e751-

753. doi:10.1016/j.ajog.2015.04.012

Cohen, W. R., & Friedman, E. A. (2018). The assessment of labor: a brief history. J Perinat Med, 46(1), 1-8. doi:10.1515/jpm-2017-0018 Cohen, W. R., Sumersille, M., & Friedman, E. A. (2018). Management of Labor: Are the New Guidelines Justified? J Midwifery Womens Health, 63(1), 10-13. doi:10.1111/jmwh.12712 Ferrazzi, E., Milani, S., Cirilla, F., Livio, S., Piola, C., Brusati, V., & Paganelli, A. (2015). Progression of cervical dilatation in normal human labor is unpredictable. Acta ObstetGynecol Scand, 94, 1136-1144. Friedman, E. (1955). Primigravidlabor: A graphicostatisticalanalysis. Obstetrics & Gynecology, 567-589. Friedman, E. A. (1956). Labor in Multiparas: A graphicostatisticalanalysis. Obstetrics and Gynecology, 8(6), 686-703. Retrieved from https://www.scopus.com/inward/record.uri?eid=2-s2.0- 84934739762&partnerID=40&md5=2f98cdccdffc5901b8fc6441e3c2c0b2. Hadar, E., Biron-Shental, T., Gavish, O., Raban, O., & Yogev, Y. (2015). A comparison between electrical uterine monitor, tocodynamometer and intra uterine pressure catheter for uterine activity in labor. J Matern Fetal Neonatal Med, 28(12), 1367-1374. doi:10.3109/14767058.2014.954539 Hamilton, E., Warick, P., Collins, K., Smith, S., & Garite, T. J. (2016). Assessing first-stage labor progression and its relationship to complications. American Journal of Obstetrics & Gynecology, 214(358), e.1-8. REFERENCES King, T. L. (2012). A new era in intrapartum care: moving beyond the Friedman Curve. J Midwifery Womens Health, 57(4), 313-314. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22758353. doi:10.1111/j.1542-2011.2012.00204.x Lagrew, D. C., Kane Low, L., Brennan, R., Corry, M. P., Edmonds, J. K., Gilpin, B. G., . . . Jaffer, S. (2018). National Partnership for Maternal Safety: Consensus Bundle on Safe Reduction of Primary Cesarean Births—Supporting Intended Vaginal Births. JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing, 47(2), 214-226. Retrieved from https://www.scopus.com/inward/record.uri?eid=2-s2.0- 85042377516&doi=10.1016%2fj.jogn.2018.01.008&partnerID=40&md5=c145f91aaffdbdc1195fae176d63d61b. doi:10.1016/j.jogn.2018.01.008 Lavender, T., Cuthbert, A., & Smyth, R. M. (2018). Effect of partograph use on outcomes for women in spontaneous labour at term and their babies. Cochrane Database Syst Rev, 8, Cd005461. doi:10.1002/14651858.CD005461.pub5 Main, E. K., Chang, S. C., Cape, V., Sakowski, C., Smith, H., & Vasher, J. (2019). Safety Assessment of a Large-Scale Improvement Collaborative to Reduce Nulliparous Cesarean Delivery Rates. ObstetGynecol, 133(4), 613-623. doi:10.1097/aog.0000000000003109 Miller, S., Abalos, E., Chamillard, M., Ciapponi, A., Colaci, D., Comandé, D., . . . Althabe, F. (2016). Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. The Lancet, 388(10056), 2176-2192. Retrieved from https://www.scopus.com/inward/record.uri?eid=2-s2.0- 84991296147&partnerID=40&md5=8ab4b86d57555e4b3af02f92e06cc794. doi:10.1016/S0140-6736(16)31472-6 Murphy, M., Butler, M., Coughlan, B., Brennan, D., O'Herlihy, C., & Robson, M. (2015). Elevated amniotic fluid lactate predicts labor disorders and cesarean delivery in nulliparous women at term. Am J ObstetGynecol, 213(5), 673.e671-678. doi:10.1016/j.ajog.2015.06.035 REFERENCES Musaba, M. W., Barageine, J. K., Ndeezi, G., Wandabwa, J. N., & Weeks, A. (2019). Effect of preoperative bicarbonate infusion on maternal and perinatal outcomes of obstructed labour in Mbale Regional Referral Hospital: a study protocol for a randomised controlled trial. BMJ Open, 9(4), e026675. doi:10.1136/bmjopen-2018-026675 Neal, J. L., Lowe, N. K., Caughey, A. B., Bennett, K. A., Tilden, E. L., Carlson, N. S., . . . Dietrich, M. S. (2018). Applying a physiologic partograph to Consortium on Safe Labor data to identify opportunities for safely decreasing cesarean births among nulliparous women. Birth, 45(4), 358-367. Retrieved from https://www.scopus.com/inward/record.uri?eid=2- s2.0-85047786458&doi=10.1111%2fbirt.12358&partnerID=40&md5=51b5d79aa5c0a9196d316922e28c079b. doi:10.1111/birt.12358 O'Driscoll, K., Meagher, D., & Boylan, P. (1993). Active Management of Labor the Dublin Experience (Third ed.): Mosby. Oladapo, O. T., Diaz, V., Bonet, M., Abalos, E., Thwin, S. S., Souza, H., . . . Gülmezoglu, A. M. (2018). Cervical dilatation patterns of ‘low-risk’ women with spontaneous labour and normal perinatal outcomes: a systematic review. BJOG: An International Journal of Obstetrics and Gynaecology, 125(8), 944-954. Retrieved from https://www.scopus.com/inward/record.uri?eid=2-s2.0-85032900569&doi=10.1111%2f1471- 0528.14930&partnerID=40&md5=bdad90eb25dc039257e6c402b75acdda. doi:10.1111/1471-0528.14930 Peisner, D. B., & Rosen, M. G. (1985). Latent phase of labor in normal patients: A reassessment. Obstetrics and Gynecology, 66(5), 644-648. Retrieved from https://www.scopus.com/inward/record.uri?eid=2-s2.0- 0022354628&partnerID=40&md5=794e97c919ae960d4bd90272c0aba607.

SLIDE 16

6/14/2019 16

REFERENCES Philpott, R. H., & Castle, W. M. (1972). Cervicographs in the management of labour in primigravidae I. The alert line for detecting abnormal labour. Journal of Obstetrics and Gynaecology of the British Commonwealth, 79(7), 592-598. Retrieved from https://www.scopus.com/inward/record.uri?eid=2-s2.0- 0015371502&partnerID=40&md5=4befd1b0d60d412394b91930f984365b. Thuillier, C., Roy, S., Peyronnet, V., Quibel, T., Nlandu, A., & Rozenberg, P. (2018). Impact of recommended changes in labor management for prevention of the primary cesarean delivery. Am J ObstetGynecol, 218(3), 341.e341-341.e349. doi:10.1016/j.ajog.2017.12.228 Tilden, E. L., Phillippi, J. C., Ahlberg, M., King, T. L., Dissanayake, M., Lee, C. S., . . . Caughey, A. B. (2019). Describing latent phase duration and associated characteristics among 1281 low-risk women in spontaneous labor. Birth. Retrieved from https://www.scopus.com/inward/record.uri?eid=2-s2.0- 85063645087&doi=10.1111%2fbirt.12428&partnerID=40&md5=5c51dc4c55b30b5bfce60833bdbc9af9. doi:10.1111/birt.12428 Wiberg-Itzel, E., Pettersson, H., Andolf, E., Hansson, A., Winbladh, B., & Akerud, H. (2010). Lactate concentration in amniotic fluid: a good predictor of labor outcome. EurJ ObstetGynecol Reprod Biol, 152(1), 34-38. doi:10.1016/j.ejogrb.2010.05.005 Wiberg-Itzel, E., Wray, S., & Åkerud, H. (2018). A randomized controlled trial of a new treatment for labor dystocia. Journal of Maternal-Fetal and Neonatal Medicine, 31(17), 2237-2244. Retrieved from https://www.scopus.com/inward/record.uri?eid=2-s2.0- 85021205604&doi=10.1080%2f14767058.2017.1339268&partnerID=40&md5=b4b72eba3eb0ff9ff42e4dc2471d572d. doi:10.1080/14767058.2017.1339268 REFERENCES Ye, J., Betrán, A. P., Guerrero Vela, M., Souza, J. P., & Zhang, J. (2014). Searching for the optimal rate of medically necessary cesarean delivery. Birth (Berkeley, Calif.), 41(3), 237-244. Retrieved from https://www.scopus.com/inward/record.uri?eid=2-s2.0- 84940397408&partnerID=40&md5=c14bac590f557baaf297ee022a7e8c31. doi:10.1111/birt.12104 Zhang, J., Troendle, J., Grantz, K., & Reddy, U. (2015). Statistical aspects of modeling the labor curve. American Journal

f Obstetrics and Gynecology, 750-752.

Zhang, J., Troendle, J., Mikolajczyk, R., Sundaram, R., Beaver, J., & Fraser, W. (2010). The natural history of the normal first stage of labor. ObstetGynecol, 115(4), 705-710.