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Management of Labor
and Delivery
Editor
AARON B. CAUGHEY
OBSTETRICS AND
GYNECOLOGY
CLINICS OF NORTH AMERICA
www.obgyn.theclinics.com
Consulting Editor
WILLIAM F. RAYBURN
http://www.theclinics.com
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Contributors
CONSULTING EDITOR
EDITOR
AUTHORS
ALLISON J. ALLEN, MD
Maternal-Fetal Medicine Fellow, Department of Obstetrics and Gynecology, Oregon
Health & Science University, Portland, Oregon
NATHAN S. FOX, MD
Maternal-Fetal Medicine Associates, PLLC, Department of Obstetrics, Gynecology, and
Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
ANNESSA KERNBERG, MD
Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland,
Oregon
BETH LEOPOLD, MD
Resident, Department of Obstetrics and Gynecology, Christiana Care Health System,
Newark, Delaware
iv Contributors
STEPHANIE MELKA, MD
Maternal-Fetal Medicine Associates, PLLC, Department of Obstetrics, Gynecology, and
Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
JAMES MILLER, MD
Maternal-Fetal Medicine Associates, PLLC, Department of Obstetrics, Gynecology, and
Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
RACHEL A. PILLIOD, MD
Clinical Fellow, Department of Obstetrics and Gynecology, Division of Maternal-Fetal
Medicine, Oregon Health & Science University, Portland, Oregon
JANINE S. RHOADES, MD
Department of Obstetrics and Gynecology, Washington University School of Medicine in
St. Louis, St Louis, Missouri
BETHANY SABOL, MD
Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland,
Oregon
JAMES SARGENT, MD
Clinical Fellow in Maternal-Fetal Medicine, Department of Obstetrics and Gynecology,
Oregon Health & Science University, Portland, Oregon
ANTHONY SCISCIONE, DO
Director of Maternal-Fetal Medicine and the OB/Gyn Residency Program, Department of
Obstetrics and Gynecology, Christiana Care Health System, Newark, Delaware
Contents
Defining and Managing Normal and Abnormal First Stage of Labor 535
Janine S. Rhoades and Alison G. Cahill
Modern data have redefined the normal first stage of labor. Key differences
include that the latent phase of labor is much slower than was previously
thought and the transition from latent to active labor does not occur until
about 6 cm of cervical dilatation, regardless of parity or whether labor
was spontaneous or induced. Providers should have a low threshold to
use one of the safe and effective interventions to manage abnormal pro-
gression in the first stage of labor, including oxytocin, internal tocodyna-
mometry, and amniotomy.
Defining and Managing Normal and Abnormal Second Stage of Labor 547
Yvonne W. Cheng and Aaron B. Caughey
The American College of Obstetricians and Gynecologists (ACOG) Prac-
tice Bulletin No. 49 on Dystocia and Augmentation of Labor defines a pro-
longed second stage as more than 2 hours without or 3 hours with epidural
analgesia in nulliparous women, and 1 hour without or 2 hours with
epidural in multiparous women. This definition diagnoses 10% to 14% of
nulliparous and 3% to 3.5% of multiparous women as having a prolonged
second stage. Although current labor norms remained largely based on
data established by Friedman in the 1950s, modern obstetric population
and practice have evolved with time.
vi Contents
Vaginal Birth After Cesarean Trends: Which Way Is the Pendulum Swinging? 655
James Sargent and Aaron B. Caughey
The cesarean delivery rate has plateaued at 32%; concurrently, after peak-
ing in the mid-1990s, trial of labor after cesarean (TOLAC) rates have
declined. Less than 25% of women with a prior cesarean delivery attempt
a future TOLAC. This decreasing trend in TOLAC is caused by inadequate
resource availability, malpractice concerns, and lack of knowledge in pa-
tients and providers regarding the perceived risks and benefits. This article
outlines the factors influencing recent vaginal birth after cesarean trends in
addition to reviewing the maternal and neonatal outcomes associated with
TOLAC, specifically in high-risk populations.
Foreword
Addressing Common
M a n a g e m e n t D i l e m m a s in La b o r
and Delivery
This issue of the Obstetrics and Gynecology Clinics of North America deals with key
management decisions undertaken regularly in the Labor and Delivery Unit. Ably edi-
ted by Aaron Caughey, MD, the issue highlights controversies pertaining to induction
of labor, progression during the first and second stages, fetal monitoring interpretation,
reducing cesarean delivery rates, and enhancing quality care and patient safety.
Management during labor and delivery requires two views: (1) acceptance of a
normal physiologic process that most women experience, and (2) anticipation of
complications, often occurring unexpectedly and quickly. Labor onset represents
the culmination of a series of biochemical changes in the cervix and uterus. Preterm
labor, dystocia, and postterm pregnancy may result when labor is abnormal.
Induction of labor affects one in every four pregnancies, although the incidence
varies between practices. Topics covered by the authors pertain to the role of outpa-
tient preinduction cervical ripening, best techniques for labor induction, and impact of
elective induction of labor. Oxytocin for inducing or augmenting labor is common,
affecting half or more of all pregnancies undergoing a trial of labor. Use of oxytocin
for augmentation and active labor is well reviewed in this issue.
Many abnormalities may interfere with the orderly progression of fetal descent and
spontaneous vaginal delivery. Soon after admission, a rational plan for monitoring
labor can be established based on past pregnancies and current needs of the fetus
and mother. Because there are marked variations in labor lengths, precise statements
are unwise as to its anticipated duration.
Electronic measurement of uterine activity permits generalities about certain
contraction patterns and labor outcome. Uterine muscle efficiency to effect delivery
varies greatly. Abnormal progress during the first and second stages of labor is defined
in this issue along with principles of management. Slow progress arises from a single
or combination of several factors: insufficiently strong or coordinated uterine contrac-
tions; fetal malpresentations or malpositioning; abnormalities of the maternal pelvis
creating a contracted pelvis; soft tissue restrictions in the lower reproductive tract;
and inadequate maternal pushing during the second stage. These abnormalities are
addressed categorically in this issue.
Electronic fetal monitoring was introduced into practice 50 years ago. The continu-
ously recorded fetal heart rate pattern is potentially diagnostic in assessing patho-
physiologic events. Accurate information provided by this monitoring remains a
matter of debate, however, despite most American women now being monitored elec-
tronically during labor. The authors focus on category II tracings, which include those
characterized as being neither normal (category I) nor abnormal (category III). A sys-
tematic analysis of the baseline rate, baseline variability, accelerations, and periodic
or episodic decelerations is described.
Also, over the past 50 years, the cesarean delivery rate in the United States rose from
5% to 33%. This rate declined temporarily, mostly from a significant increase of vaginal
births after cesarean (VBAC), and to a closely mirrored decrease in primary cesareans.
Reasons for this high cesarean rate relate to the following conditions: common perfor-
mance of a repeat cesarean; use of electronic monitoring with a resultant higher
suspicion of “fetal distress”; breech-presenting fetus delivered by cesarean; operative
vaginal deliveries being performed less; labor induction being more common, espe-
cially among nulliparas; maternal obesity being observed frequently; more cesareans
being performed for women with preeclampsia; lower VBAC rates; elective cesarean
deliveries to avoid pelvic floor injury or reduce fetal risk or upon maternal request;
and fear of litigation. Many of these conditions are covered in this issue.
The authors emphasize the growing need for quality improvement and patient safety
on labor and delivery and how it may be measured for a variety of conditions. This
trend was accompanied by the evolution of the laborist movement in the United
States. Much of this has arisen to provide care that is more standard and accessible.
The American College of Obstetricians and Gynecologists and the American Academy
of Pediatrics continue to collaborate in the development of guidelines for optimal care
in labor and delivery. These efforts are intended to improve interdisciplinary commu-
nication, increase team-based effort with clarified expectations, and increase engage-
ment in decision-making with the patient and family. While these guidelines apply to all
pregnancies, they are especially relevant to twin pregnancies as covered in this issue.
Management strategies addressed here should be helpful to the obstetrician during
labor and delivery. Dr Caughey did well in selecting an accomplished group of authors
with proven clinical and research experience in their field. Evidence-based
approaches imparted in this collection are greatly appreciated for immediate use
and future direction.
Preface
Evidence-Based Management of
L a b o r a n d D e l i v e r y : W h a t D o We
Still Need to Know?
In the United States, there are four million births each year, and the large majority of
them occur in hospitals on labor and delivery units.1 These specialized locations are
so specific that really only pregnant women can use this space, and an enormous
amount of resources is dedicated to the care of pregnant women going through the
birth process. Why would we have women who are experiencing a normal physiologic
event in the majority of cases, do so in the hospital? Predominantly this is because of
the small, but specific, inherent risk that accompanies childbirth, both to mothers and
to babies. Over the twentieth century, a number of interventions were developed and
refined to reduce the morbidity and mortality for mothers and babies, including blood
banking, antibiotics, and more specifically, fetal heart rate monitoring and operative
obstetrics, notably the cesarean delivery.
At this point in the twenty-first century, there are more than 1.2 million cesarean
deliveries each year in the United States.2 While a cesarean rate above 15% to 20%
appears to be associated with lower maternal and neonatal mortality, a benefit by
increasing the cesarean rate up to the current 32% in the United States has not
been demonstrated.3 The divide between these two thresholds has been a focus for
the past decade. One of the drivers identified to safely reduce the primary cesarean
rate is the use of more evidence-based labor and delivery management.4
The collection of articles in this issue of Obstetrics and Gynecology Clinics of North
America deals with just that, the evidence-based management of labor and delivery.
While many are framed with the focus on mode of delivery and the potential for
reducing the cesarean rate, the intent is to provide the most up-to-date evidence to
guide practice, research, and contemplation of obstetric management. The articles
include more general management of labor and fetal heart rate monitoring as well as
more specific articles on twins, malposition, and malpresentation. There are also
pieces on laborist models and quality improvement on labor and delivery. Throughout
them all, I think you will see that while there has been an increasing amount of evi-
dence produced over the past several decades, there is a great need for much
more evidence to be accumulated on specifics of labor and delivery care.
So, if you have a passion for labor and delivery as I do, I hope you enjoy this collec-
tion of pieces and will be inspired after reading to identify some holes in the existing
research and start a research project to address a question or begin a quality improve-
ment project to improve outcomes. Enjoy, and I hope to see you on L&D!
REFERENCES
KEYWORDS
Evidence-based Labor Delivery Management Safety Cesarean rate
KEY POINTS
Although cesarean delivery may be an increasingly safe alternative to vaginal delivery, its
use in 1 in 3 women giving birth is likely too high.
Furthermore, the downstream impact of cesarean delivery on future pregnancies is likely
not well-considered when the first cesarean is being performed.
There are a range of practices that have become standard that should be carefully ques-
tioned and replaced by standardized, evidence-based practices to decrease the rate of
cesarean deliveries safely.
Through quality improvement efforts such as perinatal quality collaboratives, the environ-
mental changes will allow clinicians to adopt the range of practices described.
Without environmental changes, clinicians may not be able to change practice patterns
that have been encouraged by the given environments in which they practice.
INTRODUCTION
More than 100 years ago, the normal physiologic process of birth began to be moved
into hospitals. Although those initial moves were likely not specifically designed to
improve pregnancy outcomes, it has led to dramatic reductions in both the maternal
and neonatal mortality rates.1,2 It also provided the opportunity to better understand
the birth process through epidemiologic study and clinical trials that can examine
the impact of interventions. In one of the earliest cohort studies, Dr Emmanuel Fried-
man prospectively studied the labor and delivery process and reported out labor
norms.3 Unfortunately, instead of an increasing number of studies, these norms
were used to establish specific labor guidelines that have been shown to increase in-
terventions without clear evidence of benefit. One of the biggest impacts of having
birth in a hospital in combination with specific labor guidelines has been the increasing
increase in cesarean deliveries.
Department of Obstetrics and Gynecology, Oregon Health & Science University, 3181 Southwest
Sam Jackson Road, Mail Code: L-466, Portland, OR 97239, USA
E-mail address: [email protected]
— Niin. Mutta tapahtuipa pari viikkoa sitte, ettei hän enää mennyt
virkaansa eikä tullut tänne syömäänkään. Päivällisen jälkeen samana
päivänä, kun hän oli saanut kuukausipalkkansa, tuli hän luokseni,
maksoi ja sanoi minulle: "Huomenna taas en tule päivälliselle, sillä
matkustan yhdeksi päiväksi unholaan. Pitää viedä sinne tämän
kuukauden surut talteen." Ja unholaan hän kyllä matkustikin, mutta
takaisin ei hän sieltä koskaan palannut. Hän oli, näet, sen päivän
jälkeisenä päivänä humalapäissään lähtenyt ulos
ullakkohuoneestaan, kompastunut portailla ja pudonnut niin pahasti,
että parin tunnin kuluttua heitti henkensä. Sääli oli miestä, sillä
olisihan hän toki vähän paremman lopun ansainnut.
— Sääli! Sääli! — Kiitoksia kertomastanne ja suokaa anteeksi, että
vaivasin. Hyvästi! Täytyy rientää.
Kumarsin ja lähdin.
Pietarissa v. 1889.
KSENIA
*****
*****
*****
Pietarissa v. 1890.
KOTIOPETTAJATAR
Hän oli nuori ja kaunis. Ei, hän oli enemmän kuin kaunis, hän oli
oikea kaunotar. Kastanjanvärinen, aaltoileva tukka, vilkkaat, sielua
säihkyvät, mustanruskeat silmät kaarevien mustien silmäkulmien
alla, korkeataipeinen, henkevyyttä ilmaiseva nenä, tasaiset valkoiset
hampaat punertavien huulien lomassa, pieni lemmenkuoppa
vasemmassa poskessa ja solakka, täyteläinen vartalo, sanalla
sanoen, oikea etelämaan kaunotar. Ja ainoastaan yhdeksäntoista
vuoden vanha.
Silmänräpäys.
Sanomalehdet ovat viskatut pöydälle. Molemmin käsin tarttuu
patruuna neidin käsivarsiin, painaa häntä alaspäin, ettei hän voisi
nousta ylös, ja kumartuu häntä suudellakseen.
Eikä hän sitä sanonut rouvalle koskaan. Patruunan näki hän tämän
jälkeen hyvin harvoin. Kuluipa usein päiviäkin, ettei häntä nähnyt, ei
edes ruokapöydässäkään, sillä patruuna koetti aina keksiä syyn
myöhästyäkseen tahi ollakseen kokonaan poissa. Siten oli kesä
lopussa.
Vaan rouva vaati, että hän oli hevosella saatettava. Eikä mikään
auttanut, täytyi lähteä kahden kesken patruunan kanssa. Taaskin oli
koetus kestettävä.
Vieretysten he istuivat rattailla, patruuna ja hän. Siitä saakka he
eivät olleet puhuneet keskenään. Eikä nytkään patruuna tahtonut
saada sanaa suustansa. Neiti tunsi ja näki syrjäsilmällä, että tämä,
hevosta ajaessaan, melkein puolen matkaa katseli häntä, katseli ja
tahtoi sanoa jotakin, mutta odotti. Vihdoin kuuli hän sanat:
Pietarissa v. 1890.
"ELÄMÄÄNSÄ KYLLÄSTYNYT"
*****
*****
— Voi rakas Jumala! Sinäkin niin puhut! Vai mene hänen luo? Etkö
luule, että ensimäiseksi menin juuri hänen luo? Mutta hänkin
kääntää mulle selkänsä. "Olenkos minä siihen syypää?" sanoi hän.
"ja mistä sen tietää, kenenkä kanssa sinä olet ollut."
— Entäs äiti?! Kolmen viikon kuluttua palaa hän maalta. Ei, minä
en tätä kestä. Minä… hukutan itseni.
— Ole hupsuttelematta!
"Vaan ei, ei se ole niin! Minä olen hyljännyt Herran eikä Hän minua
ja siksi kohtaa minua nyt Herran rangaistus."
"Ei, ei, minä en kestä, minä en kestä tätä…! Herra Jesus Kristus
auta!" ja hän purskahtaa hurjaan itkuun ja vaipuu alas suin
vuoteellensa, yksinäisessä pienessä huoneessansa.
Ja siten makasi hän siinä koko yön, aamuun asti, väliin koettaen
rukoilla, väliin taas itkien rajusti, väliin raueten unen ja valvomisen
väliseen tilaan, jolloin aivot toivat hänen eteensä sekavia kuvia ja
hänen päähänsä johdottomia, päättömiä ajatuksia. Toisinaan hän
tiesi, että hän siinä makasi, ja tuntui aivan kuin olisi pitänyt nousta
ylös ja lähteä puotia avaamaan, mutta ettei jaksanut nousta. Eikä
vain jaksanut, mutta ei viitsinyt, ettei tahtonut, että oli samantekevä,
menikö tahi oli menemättä. Mutta sitte piti taas tehdä jotakin, piti
välttämättä nousta ylös ja tehdä jotakin. Mitä oikeastaan, se oli
epäselvä, mutta että se oli tehtävä ennen kuin äiti ehti tulla, se oli
välttämätöntä. Ja hirveästi teki mieli saada selville, mitä se oli, jota
piti tehdä, mutta se vain ei tahtonut millään muotoa selvitä. Aina sitä
oli jo vähän niinkuin jäljellä ja perille pääsemässä, mutta sitte
sekaantui taas kaikki.
Siinä hän istui jonkun aikaa ja mietti. Rantaa pitkin ajoi mies
vesitynnyriä. Ajaja puhui huutaen muutaman sanan kirvesmiesten
kanssa ja ajoi eteenpäin. Silloin nousee Elna nopeasti ylös, menee
laiturin äärimäiseen päähän, seisoo kotvan ja — hyppää veteen.
Kuuluu paukaus.
Ne olivat kirvesmiehet, jotka, tämän huomattuaan, juoksivat
sillalle ja heittivät siinä kumossa olevan veneen veteen. Toinen heistä
hyppäsi veneeseen ja veti Elnan ylös.
Ja Elna jäi eloon, mutta älkää kysykökään, kuinka hänen sitte kävi.
Siinä alkaa taas toinen tarina, ehkä surullisempi kuin tämä,
paatuneen sydämen tarina.
Pietarissa v. 1890.
MIETTISEN MUMMON ASIA
— Hyvää päivää!
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