Labor Labor Term, nulliparous women carrying singleton, cephalic - PDF document

10/9/13 ! Presentation Overview Physiologic partograph to improve birth safety and outcomes among low-risk, nulliparous women with spontaneous • Background & Significance ! labor onset • Introduction to Partograph ! • Partograph Use Examples ! Jeremy L. Neal PhD, CNM, RN Assistant Professor The Ohio State University ! To start… ! Birth should be recognized as a normal physiologic process ! Background and Providers should advocate for non-intervention in the Significance absence of complications ! Scientific evidence should be incorporated into clinical practice ! Why Nulliparous Women? Labor Labor • Term, nulliparous women carrying singleton, cephalic • “The presence of uterine contractions of sufficient presenting fetuses are of particular interest when strategizing to improve obstetrical care quality and outcomes (CDC, 2012; frequency, duration, and intensity to cause ACOG, 2000; Boyle et al, 2012; Main et al, 2004, 2006; Cleary et al, 1996) ! demonstrable effacement and dilation of the • 40% of all U.S. births are to nulliparous women; 1.6 million in cervix” (ACOG, 2003) ! 2011 (Martin et al, 2013) ! • ~ 97-98% of the variation in overall cesarean rates between • 1 st Stage = contraction onset → full dilatation ! institutions is d/t variation in cesareans to low-risk, ! Latent phase = contraction onset → ‘active’ dilation onset ! nulliparous women (Brennen et al, 2009, 2011) ! • The course of the 1°labor largely dictates the course and ! ‘Active’ phase = ‘active’ dilation → complete dilatation ! management of subsequent labors ! ! 1 !

10/9/13 ! Nulliparous Labor Curve From Friedman’s Active Phase: Nulliparae ‘Active’ Labor Onset 4.9 ± 3.4 hrs ( mean ) (1955) ! 11.7 hrs ( mean+2 SD ) ! 7.3 hrs ! 4.6 ± 3.6 hrs ( mean ) (1971, 1978) ! (1955, 1971, 1978) ! 13.7 hrs 16.4 hrs (median) ! (90 th %) ! (95 th %) ! 10 10 Deceleration Phase (~9-10 cm) = 0.84-0.9 hr ! 9 9 8 8 Phase of Max Slope (~4-9 cm) = 3.0-3.7 cm/hr ! Phase of Max Slope ! 7 7 [**computes to 1.35-1.67 hrs] ! (~4-9 cm) = 1.2 cm/hr ! cm 6 cm 6 “1 cm/hr rule” ! 5 5 Dilatations associated with ‘active’ 4 labor onset (Cunningham et al, 2010; 4 Acceleration Phase (~2.5-4 cm) ≈ 2.1-2.4 hrs ! Gabbe et al, 2007; Varney et al, 2004) ! 3 3 2 2 5 10 15 0 0 5 10 15 Hrs Hrs (Friedman, 1955, 1971, 1978) ! (Zhang, Troendle et al, 2002) ! (Friedman, 1955, 1978; Friedman & Kroll, 1971) ! (Zhang, Troendle et al, 2010) ! (Zhang, Landy et al, 2010) ! ‘Cer ervicogr icograph’ aph’ (adapt adapted) ed) Nulliparous ‘Active’ Labor • Alert line = dilation expectation of ≥ 1 cm/hr meant to • Peisner & Rosen (1986) (n = 1060) ! represent the slowest 10% (based on Friedman work) ! • Action line = if crossed, consider aggressive interventions (e.g., ! Using Friedman’s 1.2 cm/hr criteria, low-risk, term, nulliparas with intact oxytocin) ! membranes, cephalic presentation, and spontaneous labor were evaluated: ! Alert line Action line 10 • At 3 cm, 75% were not ‘active’ ! • At 4 cm, 50% were not ‘active’ ! 78.2% 10.9% 10.9% • At 5 cm, 25% were not ‘active’ ! 8 (n=488) (n=68) (n=68) • Neal et al (In review) (n = 216) ! cm 0.64 cm/hr 6 ! Using criteria put forth by the SOGC (1995), i.e., at > 3 cm dilatation, Low-risk, Rhodesian adequate labor involves average dilation of > 0.5 cm/hr over any 4 hr time primigravidae at ! 3 cm window: ! 4 at admission (n = 624) • 52.8% did not meet this expectation in the first 4 hrs after admission ! 3 (average dilatation at admission ~3.5 cm) ! 0 2 4 6 8 10 12 14 16 Hrs (Philpott, 1972; Philpott & Castle, 1972a, 1972b) WHO Partograph (adapted) WHO Partograph • Evaluated in large, multicenter trial in 1990s (n = 35,484) ! • Reported on subgroup of low-risk, term, nulliparous women with spontaneous labor onset admitted in ‘active’ labor, i.e., ≥ 3 cm dilatation + contractions (n = 2397) ! Alert line Action line 10 69.1% 19.2% 11.7% 8 (n=1656) (n=460) (n=281) cm 0.64 cm/hr ! 6 4 3 2 4 6 8 10 12 14 0 16 Hrs (WHO, 1994) ! 2 !

10/9/13 ! Nulliparous women assessed via partographs WHO Partograph (adapted) with ‘alert’ and 4-hr ‘action’ lines • In 2007, the WHO changed their definition of active labor onset from 3 cm to 4 cm (WHO, 2007) ! Study ! Country ! Earliest n ! Alert Line Action Line partograph Crossed ! Crossed ! initiation ! (< 1cm/hr) ! (< 0.64 cm/hr) ! Alert line Action line Philpott et al. (1972) ! Zimbabwe ! 3 cm ! 624 ! 21.8% ! 10.9% ! 10 Drouin et al. (1979) ! Cameroon ! 3.4 ± 0.6 cm* ! 480 ! 56.3% ! 32.3% ! WHO (1994) ! Indonesia, 3 cm ! 2397 ! 30.9% ! 11.7% ! Thailand, & 65.3% 16.2% 18.5% 8 Malaysia ! (n=169) (n=42) (n=48) Lavender et al. (1998) ! England ! 3 cm ! 311 ! Not reported ! 38.1% ! cm Lavender et al. (1999) ! England ! 3 cm ! 171 ! Not reported ! 37.4% ! 0.60 cm/hr ! 6 Pattinson et al. (2003) ! South Africa ! 4 cm ! 350 ! 49.7% ! Not reported ! Lavender et al. (2006) ! England ! 3 cm ! 1485 ! Not reported ! 45.3% ! Low-risk, term, Nigerian Mathews et al. (2007)† ! India ! 3 cm ! 175 ! 19.4% ! 10.9% ! nulliparas at ! 4 cm at 4 cm ! 156 ! 17.9% ! 1.3% ! 4 admission (n = 259) Orji (2008) ! Nigeria ! 4 cm ! 259 ! 34.8% ! 18.5% ! ! 3 van Bogaert (2009) ! South Africa ! 3 cm ! 1595 ! 34.4% ! 10.1% ! * ! Mean dilatation at “active phase” onset ! 2 4 6 8 10 12 14 0 16 † 2 partographs with 4-hr action lines were tested in this study ! Hrs (WHO, 2007; Orji, 2008) ! Active Management of Labor (AML) Studies of Spontaneous Nulliparous Labor (Ø oxytocin, Ø anesthesia) • Multifaceted labor management program aimed • Kilpatrick & Laros (1989) (n = 2302) ! ! regular, painful contractions " full dilatation = 8.1 ± 4.3 hrs ! to shorten nulliparous labor (O’Driscoll et al, • Albers, Schiff, & Gorwoda (1996) (n = 347) ! 1973, 1993) ! ! 4 cm " 10 cm = 7.7 ± 5.9 hrs (95 th %ile = 19.4 hrs) ! • Components: ! • Albers (1999) (n = 806) ! ! Antenatal childbirth preparation; strict diagnosis of spontaneous labor ! 4 cm " 10 cm = 7.7 ± 4.9 hrs (95 th %ile = 17.5 hrs) ! onset; 1-on-1 labor support ; routine amniotomy; routine cervical • Jones & Larson (2003) (n = 120) ! assessments; oxytocin if dilation is < 1 cm/hr; peer review of assisted deliveries ! ! 4 cm " 10 cm = 6.2 ± 3.6 hrs (95 th %ile = 13.4 hrs) ! • 55-62% receive oxytocin under AML (O’Driscoll • Average dilation rates in these studies range from: ! et al, 1973; Brown et al, 2008) ! ! 0.8-1.0 cm/hr at the mean ! ! 0.3-0.5 cm/hr at the statistical limit ! ‘Slowest-Yet-Normal’ Dilation Clinical Dilemma Rate for Nulliparous Women • Either many nulliparous women are admitted • Summary: Existing literature indicates that prior to progressive (active) labor yet held to 10-18% of low-risk nulliparous women with dilation expectations of ‘active’ labor ! spontaneous labor onset dilate <0.5-0.64 cm/hr, on average, even after 3 or 4 cm ! and/or ! (Zhang et al, 2002, 2010; Philpott & Castle, 1972a, 1972b; WHO, 1994; Orji, 2008; Perl & Hunter, 1992; Albers et al, 1996; Albers, 1999; Jones & • Common expectations of active labor dilation Larson, 2003) ! rates (e.g. 1 cm/hr) are unrealistically fast ! • The problem: Clinician expectation of ‘active’ labor dilation is often much faster than the above rates ! 3 !