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Contemporary patterns of spontaneous labor with normal neonatal outcomes. Consortium on Safe Labor. How should abnormally progressing first-stage labor be managed?
Management of Abnormal First-Stage Labor Although labor management strategies predicated on the recent Consortium on Safe Labor information have not been assessed yet, some insight into how management of abnormal first-stage labor might be optimized can be deduced from prior studies.
The definitions of a prolonged latent phase are still based Research paper mid term data from Friedman and modern investigators have not particularly focused on the latent phase of labor.
Most women with a prolonged latent phase ultimately will enter the active phase with expectant management. With few exceptions, the remainder either will cease contracting or, with amniotomy or oxytocin or bothachieve the active phase Thus, a prolonged latent phase eg, greater than 20 hours in nulliparous women and greater than 14 hours in multiparous women should not be an indication for cesarean delivery Table 3.
When the first stage of labor is protracted or arrested, oxytocin is commonly recommended. Several studies have evaluated the optimal duration of oxytocin augmentation in the face of labor protraction or arrest.
A prospective study of the progress of labor in nulliparous women and 99 multiparous women who spontaneously entered labor evaluated the benefit of prolonging oxytocin augmentation for an additional 4 hours for a total of 8 hours in patients who were dilated at least 3 cm and had unsatisfactory progress either protraction or arrest after an initial 4-hour augmentation period Thus, slow but progressive labor in the first stage of labor should not be an indication for cesarean delivery Table 3.
More than or equal to 6 cm dilation with membrane rupture and one of the following: The researchers defined active phase labor arrest as 1 cm or less of labor progress over 2 hours in women who entered labor spontaneously and were at least 4 cm dilated at the time arrest was diagnosed.
Subsequently, the researchers validated these results in a different cohort of prospectively managed women An additional study of 1, women conducted by different authors demonstrated that using the same criteria in women with spontaneous labor or induced labor would lead to a significantly higher proportion of women achieving vaginal delivery with no increase in neonatal complications Of note, prolonged first stage of labor has been associated with an increased Research paper mid term of chorioamnionitis in the studies listed, but whether this relationship is causal is unclear ie, evolving chorioamnionitis may predispose to longer labors.
Thus, although this relationship needs further elucidation, neither chorioamnionitis nor its duration should be an indication for cesarean delivery Given these data, as long as fetal and maternal status are reassuring, cervical dilation of 6 cm should be considered the threshold for the active phase of most women in labor Box 1.
Thus, before 6 cm of dilation is achieved, standards of active phase progress should not be applied Table 3.
Further, cesarean delivery for active phase arrest in the first stage of labor should be reserved for women at or beyond 6 cm of dilation with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity, or at least 6 hours of oxytocin administration with inadequate uterine activity and no cervical change Table 3 Recommendations for the Safe Prevention of the Primary Cesarean Delivery Recommendations Grade of Recommendations First stage of labor A prolonged latent phase eg, greater than 20 hours in nulliparous women and greater than 14 hours in multiparous women should not be an indication for cesarean delivery.
Thus, before 6 cm of dilation is achieved, standards of active phase progress should not be applied. At least 2 hours of pushing in multiparous women 1B At least 3 hours of pushing in nulliparous women 1B Longer durations may be appropriate on an individualized basis eg, with the use of epidural analgesia or with fetal malposition as long as progress is being documented.
Training in, and ongoing maintenance of, practical skills related to operative vaginal delivery should be encouraged. In order to safely prevent cesarean deliveries in the setting of malposition, it is important to assess the fetal position in the second stage of labor, particularly in the setting of abnormal fetal descent.
The prevalence of birth weight of 5, g or more is rare, and patients should be counseled that estimates of fetal weight, particularly late in gestation, are imprecise.
IOM, Institute of Medicine. What is the appropriate definition of abnormal second-stage labor? The second stage of labor begins when the cervix becomes fully dilated and ends with delivery of the neonate. Parity, delayed pushing, use of epidural analgesia, maternal body mass index, birth weight, occiput posterior position, and fetal station at complete dilation all have been shown to affect the length of the second stage of labor Further, it is important to consider not just the mean or median duration of the second stage of labor but also the 95th percentile duration.
In the Consortium on Safe Labor study discussed earlier, although the mean and median duration of the second stage differed by 30 minutes, the 95th percentile threshold was approximately 1 hour longer in women who received epidural analgesia than in those who did not Defining what constitutes an appropriate duration of the second stage is not straightforward because it involves a consideration of multiple short-term and long-term maternal and neonatal outcomes——some of them competing.
In the era of electronic fetal monitoring, among neonates born to nulliparous women, adverse neonatal outcomes generally have not been associated with the duration of the second stage of labor. In a secondary analysis of a multicenter randomized study of fetal pulse oximetry, of 4, nulliparous women who reached the second stage of labor, none of the following neonatal outcomes was found to be related to the duration of the second stage, which in some cases was 5 hours or more: Similarly, in a secondary analysis of 1, women enrolled in an early versus delayed pushing trial, a longer duration of active pushing was not associated with adverse neonatal outcomes, even in women who pushed for more than 3 hours This also was found in a large, retrospective cohort study of 15, nulliparous women even in a group of women whose second stage progressed beyond 4 hours The duration of the second stage of labor and its relationship to neonatal outcomes has been less extensively studied in multiparous women.
In one retrospective study of 5, multiparous women, when the duration of the second stage of labor exceeded 3 hours, the risk of a 5-minute Apgar score of less than 7, admission to the neonatal intensive care unit, and a composite of neonatal morbidity were all significantly increased A population-based study of 58, multiparous women yielded similar results when the duration of the second stage was greater than 2 hours A longer duration of the second stage of labor is associated with adverse maternal outcomes, such as higher rates of puerperal infection, third-degree and fourth-degree perineal lacerations, and postpartum hemorrhage Moreover, for each hour of the second stage, the chance for spontaneous vaginal delivery decreases progressively.Term paper help from field experts.
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