how long is too long? defining and preventing labor dystocia

How long is too long? Defining and preventing labor dystocia

Rebecca Amirault, CNMProfessor Department of Obstetrics, Gynecology and Reproductive SciencesUniversity of California, San Francisco

A short lecture on long labors

I have nothing to disclose

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Question 1

32 y/o G1P0 at 39w1 comes to triage. She reports that she has been contracting painfully for 12 hours. Denies LOF, reports +FM. Reactive NST and DVP of 4.1. SVE 2/1.5/-2.

What do you recommend for her:

1. Admission to labor and delivery if she is is amenable to augmentation

2. Walk for 1-2 hours and then return for exam

3. Discharge home with return precautions

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Question 2

36 year old G2P0 at 39w6 was admitted at 4/.5/-1 with intact membranes and a reactive NST. 4 hours later her contractions have spread out and she is unchanged. What do you recommend?

1. AROM and Pitocin

2. Arom alone

3. Pitocin alone

4. Movement and nipple stimulation

5. Expectant management for 2 more hours and then a cesarean for labor arrest

6. Discharge home with return precautions

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Objectives

Review normal spontaneous labor length

Review definitions of labor dystocia

How to prevent labor dystocia?

How to treat labor dystocia?

Ultimately the question is:

How do we decrease unnecessary cesareans in 1st stage of labor?

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Ehrenthal DB, Jiang X, Strobino DM. Labor induction and the risk of a cesarean delivery among nulliparous women at term. ObstetGynecol. 2010 Jul;116(1):35-42. doi: 10.1097/AOG.0b013e3181e10c5c. PMID: 20567165.7

This is not ARRIVE

Induction of labor does have a higher cesarean rate when compared to spontaneous labor by about 2 fold.

This is not a comparison of induction of labor to expectant management, these patient are in labor already and will likely deliver in the next 24-48 hours.

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Common causes of Cesareans

Labor arrest34%

Macrosomia 4%

Malpresentation17%

Maternal-fetal5%

Maternal request3%

Multiple Gestation7%

Non-reassuring Fetal Tracing

23%

Other Obstetrical indication

4%

Preeclampsia3%

American College of Obstetricians and Gynecologists (College); Society for Maternal-Fetal Medicine, Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol. 2014 Mar;210(3):179-93. doi: 10.1016/j.ajog.2014.01.026. PMID: 24565430.

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Zhang J, Landy HJ, Ware Branch D, Burkman R, Haberman S, Gregory KD, Hatjis CG, Ramirez MM, Bailit JL, Gonzalez-Quintero VH, Hibbard JU, Hoffman MK, Kominiarek M, Learman LA, Van Veldhuisen P, Troendle J, Reddy UM; Consortium on Safe Labor. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol. 2010 Dec;116(6):1281-1287. doi: 10.1097/AOG.0b013e3181fdef6e. PMID: 21099592; PMCID: PMC3660040.

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Normal labor progress

Lets stop talking about Friedman!

American College of Obstetricians and Gynecologists (College); Society for Maternal‐Fetal Medicine, Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol. 2014 Mar;210(3):179‐93. doi: 10.1016/j.ajog.2014.01.026. PMID: 24565430.

https://www.nichd.nih.gov/about/org/diphr/officebranch/eb/safe-labor10

Consortium on Safe Labor

Latent phase

Most patients with prolonged latent phase ultimately enter the active phase with expectant management

Labor may take over 6 hours to progress from 4 to 5 cm and over 3 hours to progress from 5-6cm dilation

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Active phase begins at 6 cm dilation

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Active phase arrest in the 1st stage of labor

At or beyond 6cm with Ruptured membranes

Adequate contractions, no cervical change in 4 hours

orInadequate uterine activity with oxytocin and no cervical

change in 6 hours

14 https://www.cmqcc.org/,

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15 https://www.cmqcc.org/

Presentation Title16

How do we prevent arrested labor?

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Bailit JL, Dierker L, Blanchard MH, Mercer BM. Outcomes of women presenting in active versus latent phase of spontaneous labor. ObstetGynecol. 2005 Jan;105(1):77-9. doi: 10.1097/01.AOG.0000147843.12196.00. PMID: 15625145.17

Admission in latent labor

Why do we tend to admit patients early?‐ Sooth fear of labor

‐ Relieve pain

‐ Continue to confirm the health of the patient and baby

‐ Concern that they will return “too late”

BUT

Nulliparous and multiparous patients who are admitted in early labor have cesarean rates twice as high as those admitted in active labor.

Neal JL, Lamp JM, Buck JS, Lowe NK, Gillespie SL, Ryan SL. Outcomes of nulliparous women with spontaneous labor onset admitted to hospitals in preactive versus active labor. J Midwifery Womens Health. 2014 Jan-Feb;59(1):28-34. doi: 10.1111/jmwh.12160. Epub2014 Feb 11. PMID: 24512265; PMCID: PMC4104945.

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AND

Nulliparous people admitted before active labor are about twice as likely to be augmented and use epidural anesthesia compared to nulliparous patients admitted in active labor

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19 https://www.cmqcc.org/,

Tilden EL, Lee VR, Allen AJ, Griffin EE, Caughey AB. Cost-Effectiveness Analysis of Latent versus Active Labor Hospital Admission for Medically Low-Risk, Term Women. Birth. 2015 Sep;42(3):219-26. doi: 10.1111/birt.12179. Epub 2015 Jun 22. PMID: 26095829.20

Delayed admission- cost effective model

Delaying admission until > 4 cm decreases epidurals, cesareans and maternal death and would save $694 million annually in the US

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Paul, J.A., Yount, S.M., Breman, R.B., LeClair, M., Keiran, D.M., Landry, N. and Dever, K. (2017), Use of an Early Labor Lounge to Promote Admission in Active Labor. Journal of Midwifery & Women's Health, 62: 204-209. https://doi.org/10.1111/jmwh.1259121

Early labor lounge

• Support stations available• Meditation station, Yoga station, Acupressure, Rebozo, Shower,

Birth balls, Nutrition station• Each station had posters or instructions/ headphones

Paul, J.A., Yount, S.M., Breman, R.B., LeClair, M., Keiran, D.M., Landry, N. and Dever, K. (2017), Use of an Early Labor Lounge to Promote Admission in Active Labor. Journal of Midwifery & Women's Health, 62: 204-209.22

Cesarean rates:

Study group: 7.1%. Control group: 21.2%

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Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2017 Jul 6;7(7):CD003766. doi: 10.1002/14651858.CD003766.pub6. PMID: 28681500; PMCID: PMC6483123.tle

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Continuous emotional support by a trained professional

More likely to have a spontaneous vaginal birth

Less likely to report negative feelings about childbirth experience

Shorter labors

Lawrence A, Lewis L, Hofmeyr GJ, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD003934. DOI: 10.1002/14651858.CD003934.pub3. Accessed 10 September 2021.24

Movement

Patients without regional who ambulate have shorter duration of labor by 4 hours and have decreased rates of operative vaginal delivery and cesarean

Patients without regional anesthesia who sit, stand, squat or kneel have shorter duration of labor by over 1 hour and lower rates of operative delivery, but no change in rates of cesarean

Patients with regional who sit, squat or kneel have similar rates of operative vaginal delivery and cesarean.

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Ehsanipoor RM, Saccone G, Seligman NS, Pierce-Williams RAM, Ciardulli A, Berghella V. Intravenous fluid rate for reduction of cesarean delivery rate in nulliparous women: a systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2017 Jul;96(7):804-811. doi: 10.1111/aogs.13121. Epub 2017 Mar 27. PMID: 28236651.

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IV fluid

Meta-analysis showed IV fluid of 250ml q hour in nulliparous patients who are in spontaneous labor may reduce duration of labor and cesarean compared to 125ml q hour

30% reduction in cesarean compared to 125ml

250ml vs 125ml = 60min shorter duration of labor

Not replicated in induction of labor studies

Ahmadpour P, Mohammad-Alizadeh-Charandabi S, Doosti R, Mirghafourvand M. Use of the peanut ball during labour: A systematic review and meta-analysis. Nurs Open. 2021 Sep;8(5):2345-2353. doi: 10.1002/nop2.844. Epub 2021 Mar 27. PMID: 33773071; PMCID: PMC8363404.

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Peanut ball

Trend towards shorter first stage of labor

Trends towards lower cesarean rate

Low cost and low risk interventions

Photo: Lamaze international

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• Hantoushzadeh S, Alhusseini N, Lebaschi AH. The effects of acupuncture during labour on nulliparous women: a randomisedcontrolled trial. Aust N Z J Obstet Gynaecol. 2007 Feb;47(1):26-30. doi: 10.1111/j.1479-828X.2006.00674.x. PMID: 17261096.27

Acupuncture for augmentation in active labor

Small reduction in active phase duration and augmentation,‐ Reduction of oxytocin dosage used

Decrease in labor duration in 1st stage compared to placebo or no intervention by approximately an hour

More significant reduction of pain experience

A standardized labor induction protocol: impact on racial disparities in obstetrical outcomes Rebecca F. Hamm, MD; Sindhu K. Srinivas, MD, MSCE; Lisa D. Levine, MD, MSCE28

There was a significant reduction in cesarean rate for black patients using the induction protocol compared to those in the observational group

There was no difference in the cesarean rate in nonblack patients in the protocol versus observational group

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Augmentation of labor

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Goals:

Preventing a cesarean

decreasing length of

labor

maternal satisfaction

length of hospital

stay

decreasing neonatal

risk

decreasing maternal

risk

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O'Driscoll K, Stronge JM, Minogue M. Active management of labour. Br Med J. 1973;3(5872):135-137. doi:10.1136/bmj.3.5872.13531

Fetal malposition or

malpresentation

Cephalopelvic disproportion

Psyche/ Fear combination of factors

Inadequate uterine

contractions

What causes Labor Dystocia?

Razgaitis EJ, Lyvers AN. Management of protracted active labor with nipple stimulation: a viable tool for midwives? J Midwifery WomensHealth. 2010 Jan-Feb;55(1):65-9. doi: 10.1016/j.jmwh.2009.05.002. PMID: 20129232.

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Nipple stimulation

Mechanical stimulation of the nipple triggers the release of oxytocin from the posterior pituitary

Can be done with a pump or manually

Time intensive/ person intensive method

Historically popular method

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Curtis P, Resnick JC, Evens S, Thompson CJ. A comparison of breast stimulation and intravenous oxytocin for the augmentation of labor. Birth. 1999 Jun;26(2):115-22. doi: 10.1046/j.1523-536x.1999.00115.x. PMID: 10687576.33

Does it work as well as Pitocin? NO

But, 35% of patients did not need oxytocin after 3 hours of stimulation

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Getting into the “Messy Studies”

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Routine Amniotomy alone

Routine amniotomy alone increases risk of cesarean delivery thought not statistically significant

No statistically significant reduction in length of labor‐ Lower rates of labor dystocia seen in some studies (Frasier et al)

Reduction in use of oxytocin in amniotomy group (more pronounced for multiparous patients)

Many study flaws in each study: 30% of patients in the “no amniotomy group” had an amniotomy, many patients had Pitocin and amniotomy together

• 1)Smyth RM, Alldred SK, Markham C. Amniotomy for shortening spontaneous labour. Cochrane Database Syst Rev. 2013 Jan 31;(1):CD006167. doi: 10.1002/14651858.CD006167.pub3. Update in: Cochrane Database Syst Rev. 2013;(6):CD006167. PMID: 23440804.

• 2)Bugg GJ, Siddiqui F, Thornton JG. Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour. Cochrane Database Syst Rev. 2013 Jun 23;(6):CD007123. doi: 10.1002/14651858.CD007123.pub3. PMID: 23794255.36

Pitocin alone

No significant difference in cesarean rate

Oxytocin group had shorter labor, mean difference about 2 hours.

Increase in hyperstimulation in the oxytocin group, but not statistically significant and no difference in neonatal outcomes

No difference in epidural use

Maternal satisfaction higher in Oxytocin group, but not statistically significant

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American College of Obstetricians and Gynecologists (College); Society for Maternal-Fetal Medicine, Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol. 2014 Mar;210(3):179-93. doi: 10.1016/j.ajog.2014.01.026. PMID: 24565430.Rouse DJ, Owen J, Hauth JC. Active-phase labor arrest: oxytocin augmentation for at least 4 hours. Obstet Gynecol. 1999 Mar;93(3):323-8. doi: 10.1016/s0029-7844(98)00448-7. PMID: 10074971.

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How long to augment with Pitocin?

“Slow but progressive labor progress in the 1st stage should not be an indication for cesarean delivery”

Patients with active phase arrest who were given 4 hours of Pitocin for augmentation had cesarean rate twice as high as those given 8 hours on Pitocin.

Vaginal delivery rate for patients who had not progressed despite 2 hours of Pitocin was 91% for multiparous patients and 74% for nulliparous patients

After 4 hours vaginal delivery rate was 88% for multiparous patients and 56% for nulliparous patients

‐ Giving more time on Pitocin (4-8 hours) = more vaginal births!

3)Dencker A, Berg M, Bergqvist L, Ladfors L, Thorsén LS, Lilja H. Early versus delayed oxytocin augmentation in nulliparous women with prolonged labour--a randomised controlled trial. BJOG. 2009 Mar;116(4):530-6. doi: 10.1111/j.1471-0528.2008.01962.x. PMID: 19250364.

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Nulliparous patients were randomized into 2 groups: augmentation immediately or delayed (3 hours)

Cesarean rate and instrumental vaginal delivery rate are equivalent

Immediate Oxytocin group shortened labor

Patients had amniotomy as well as Oxytocin if they were intact

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5)Nachum, Z. “Comparison Between Amniotomy, Oxytocin or Both for Augmentation of Labor in Prolonged Latent Phase: a Randomized Controlled Trial.” Reprod Biol Endocrinol 8 (2010): n. 39

Prolonged latent defined as– 20 hours for nulliparous patients, 14 hours for multiparous patients

Study had 75% multiparous patients

Amniotomy vs oxytocin vs both vs expectant management (progressing spontaneously)

Labor was shortest in the group with both

Increase in patient satisfaction was in both or expectant management

Cesarean rate equivalent in all groups

See citations 1-540

Amniotomy, Oxytocin or Both

• cesarean and instrumental rates are about equivalent

• cesarean and instrumental rates are about equivalent

• modest reduction in cesarean, Shorter duration of labor

• modest reduction in cesarean, Shorter duration of labor

• no significant difference in cesarean rate

• reduction of time in labor by 2 hours

• no significant difference in cesarean rate

• reduction of time in labor by 2 hours

• equivalent or increased cesarean risk

• No significant difference in length of labor

• equivalent or increased cesarean risk

• No significant difference in length of labor

Amniotomy alone

Oxytocin alone

Delayed Oxytocin

vs Immediate oxytocin

Early oxytocin

and amniotomy

together

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Blix-Lindström S, Christensson K, Johansson E. Women's satisfaction with decision-making related to augmentation of labour. Midwifery. 2004 Mar;20(1):104-12. doi: 10.1016/j.midw.2003.07.001. PMID: 15020032.41

Patient autonomy Individualized vs

standardization of management

2004 qualitative study regarding maternal satisfaction with decision making for augmentation of labor

Patients who did not participate in decision making but wanted to report the most dissatisfaction regarding decisions and labor.

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How to prevent labor dystocia:

Avoid admission to L&D for low risk patients in latent labor

Increase access to professional one on one labor support

Emotional and physical support

Allow for movement (walking or upright positioning in 1st

stage of labor

Hydration

Contemporary guidelines on normal length of labor

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Presentation Title43

Augmentation magic

Use the tools we have

Give it time!

Thank you

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how long is too long? defining and preventing labor dystocia

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