Evidence for Bundles

1. Evidence for Bundles

2. Intermittent Auscultation

3. Summary of RCTs Comparing IA to EFM During Labor1 • Multiple RCTs have been performed since adoption of EFM as the standard of care during labor • 2006 first meta-analysis of 11 RCTs • >33,000 women • 2013 Updated 2013; 13 RCTs > 37,000 women • No change to conclusions Alfirevic, Devane, & Gyte, CDSR, Issue 3, CD006066 (2006) Alfirevic, Devane & Gyte, CDSR, Issue 5, CD006066 (2013)

4. Summary of RCTs Comparing IA to EFM During Labor2 • Compared with IA, EFM: • Showed no significant improvement in overall perinatal death rate • Associated with a halving of neonatal seizures* • No significant difference in the cerebal palsy rates • Showed significant increase in CD rate • Showed slight increase in instrumental delivery rate Alfirevic, Devane & Gyte, CDSR, Issue 5, CD006066 (2013)

5. Studies Comparing cEFM to IA1

6. Studies Comparing EFM to IA2

7. Continuous EFM “Randomized controlled trials of electronic fetal monitoring compared with intermittent auscultation reveal that electronic fetal monitoring statistically significantly increases instrumental and cesarean deliveries for women but provides no long-term benefits for children.” Grimes & Peipert. 2010. Electronic Fetal Monitoring as a Public Health Screening Program The Arithmetic of Failure. Obstetrics and Gynecology 116 (6).

8. Intermittent Auscultation3 • ACNM published Clinical Bulletin on IA based on best available scientific data in 2010, updated in 2015 • Review of evidence and recommendations for use of IA • Emphasis on informed choice • Consideration of patient safety ACNM Clinical Bulletin No. 13, 2015

12. Traditional Friedman curve

13. Freidman’s Curve as a Standard of Care vs Normal Labor Progress Today? • Friedman’s Normals • Included premature deliveries • Frequent use of morphine, sedatives, oxytocin • Vaginal breech and twins included • High use of forceps after 2 hours in 2nd stage • Mothers Today • Epidurals replaced morphine • Vaginal breech rare • Most studies focus on term pregnancy only • Forceps rare • Increased BMI in women

14. Challenges to Friedman • Jun Zhang et al Am Jrn OB/GYN 2002 • Active phase slower dilation than Friedman • 5.5 hours vs 2.5 hours to dilate from 4-10cm • No deceleration phase • Before 7cm no cervical change for greater than 2 hours was normal • The 5th Percentiles rate of dilation were all below 1cm per hour • Greater length of second stage also noted

15. Comparison of Zhang to Friedman

16. When does active labor begin? • 62,415 women with singleton gestation, spontaneous onset of labor, vtx presentation, vaginal birth with healthy outcome • Key Insights: • Active labor progress more consistent at 6cm • Labor may take over 6 hours to progress from 4-5cm • Nulliparous and multiparas are similar before 6cm • Greater time in labor before 6cm reduces c/s Zhang et al 2010

17. Redefines Active Labor Onset and Spontaneous Progress in Labor

19. Timing of Admission to Hospital After Spontaneous Labor Onset • Low-risk, nulliparous at >37 wks with a singleton, cephalic fetus • admitted for spontaneous labor onset by provider (n = 216) • 114 (52.8%) were admitted in pre-active labor • 102 (47.2%) were admitted in active labor • Women in pre-active labor were more likely to undergo: • Oxytocin augmentation (84.2% v. 45.1%, respectively; OR 6.5, 95% CI 3.43-12.27) • Cesarean delivery (15.8% v. 6.9%, respectively; OR 2.6, 95% CI 1.02-6.37) • All cesareans for dystocia (n = 10) were in pre-active group (p < 0.01) (7 of 10 were performed at ≤ 5 cm) • In-hospital labor time >4 hrs longer in pre-active group (p < 0.001) • Neal et al JMWH 2014; 59(1)

20. What contributes to changes in labor progress…over time? • Increased Maternal BMI • Increased Fetal Size • Friedman’s Methodology (Ideal Labor of an Individual vs Aggregate) • No Deceleration Phase: • Other studies support greater time for augmentation and for second stage • Age increases and pain relief**

21. Normal labor progress today • Many women not in active labor until 6 cm • 2 hour threshold for diagnosis of arrest before 6cm is too short • There is a wide variability in cervical dilation between 6-10 cms • The slowest yet normal rate of cervical dilation 1cm/2 hr in primip women in active labor

22. Definitions of Labor Progress per the ACOG/SMFM Consensus Statement • Prolonged latent phase as currently defined not indication for c/s • Slow but progressive labor in the 1st stage should not be indication for c/s • Cervical dilation of 6cm is threshold for active labor and standards of active labor progress should not be applied before then • C/S for active phase arrest in 1st stage should be reserved for women • beyond 6cm with ROM who FTP despite 4 hours of adequate ctx • Or 6 hours of oxytocin administration.

23. ACOG/SMFM Second Stage Labor • Adverse neonatal outcomes have not been associated with the duration of 2nd stage of labor. • Instrument delivery can reduce the need for cesarean.  • Use of manual rotation for posterior presentation

24. Global Focus on TIME TIME as a PROXY for the other types of interventions we see included in management of second stage as the duration of it increases Last 10 years of research…

25. Overall • Greater duration without neonatal morbidity • Consistent focus on maternal morbidity with primary outcomes being inc risk for PPH and chorio • Actual management approaches unclear and effects of various interventions not consistent

26. Summary of Evidence Supporting New Definitions of Labor ProgressSpong et al 2012 NICHD

27. ACOG/SMFM Consensus StatementSecond Stage Labor • At least 2 hours for multiparous women • At least 3 hours for nulliparous women • Longer durations may be appropriate on an individualized basis…e.g. epidural, fetal malposition

28. 2nd Stage of Labor and Epidural Use: A larger effect than previously suggested • Retrospective cohort study of 42,268 women with vaginal births. • Compared medial length and 95th percentiles of second stage duration and epidural use. • Nulliparous women 95%tile 197 min w/o epidural and 336 min with an epidural. • Multiparous women 95%tile 81 minutes w/o epidural and 255 min with epidural. • There were no significant inc in morbidity with inc duration of second stage labor. • Concludes the differences in the presence of the epidural is closer to 2 hours longer vs the 1 hour in general recommendations and current ACOG definitions may be too stringent. • Cheng, Y. et al, ObstetGynecol 2014 123:527-35

29. Inc vaginal delivery rate in delayed group • But…When only “High level studies” included difference was less and no longer significant • No difference in instrument deliveries • Inc duration of second stage total time, dec active • Maternal and Fetal outcomes remain unclear…….

30. Open Glottis, Self Directed Pushing Supported as the Best Practice method of pushing Education regarding strategy in CBE classes QI method of managing second stage labor AWHONN Guidelines for Nursing Care during Second Stage

32. Continuous labor support should be the standard of care for all women in labor

37. “If Doulas were a drug they would be required for all pregnant women” Penny Simkin “Epi-DOULA”