Cervical dilatation patterns of 'low-risk' women with spontaneous labour and normal perinatal outcomes: a systematic review

An exploratory review on the empirical evaluation of the quality of reporting and analyzing labor duration

INTRODUCTION

This exploratory review aimed to provide empirical evidence on the definitions of labor, the statistical approaches and measures reported in randomized controlled trials (RCTs) and observational studies measuring the duration of labor.

METHODS

A systematic electronic literature search was conducted using different databases. An extraction form was designed and used to extract relevant data. English, French, and German studies published between 1999 and 2019 have been included. Only RCTs and observational studies analyzing labor duration (or a phase of labor duration) as a primary outcome have been included.

RESULTS

Ninety-two RCTs and 126 observational studies were eligible. No definition of the onset of labor was provided in 21.7% (n = 20) of the RCTs and 23.8% (n = 30) of the observational studies. Mean was the most frequently applied measure of labor duration in the RCTs (89.1%, n = 82), and median in the observational studies (54.8%, n = 69). Most RCTs (83%, n = 76) and observational studies (70.6%, n = 89) analyzed labor duration using a bivariate method, with the t-test being the most frequently applied (45.7% and 27%, respectively). Only 10.8% (n = 10) of the RCTs and 52.4% (n = 66) of the observational studies conducted a multivariable regression: 3 (30%; out of 10) RCTs and 37 (56%; out of 66) observational studies used a time-to-event adapted model.

CONCLUSION

This survey reports a lack of agreement with respect to how the onset of labor and phases of labor duration are presented. Concerning the statistical approaches, few studies used survival analysis, which is the appropriate statistical framework to analyze time-to-event data.

Physiological plateaus during normal labor and birth: A novel definition

BACKGROUND

Diagnoses of labor dystocia, and subsequent labor augmentation, make one of the biggest contributions to childbirth medicalization, which remains a key challenge in contemporary maternity care. However, labor dystocia is poorly defined, and the antithetical concept of physiological plateaus remains insufficiently explored.

AIM

To generate a definition of physiological plateaus as a basis for further research.

METHODS

This qualitative study applied grounded theory methods and comprised interviews with 20 midwives across Australia, conducted between September 2020 and February 2022. Data were coded in a three-phase approach, starting with inductive line-by-line coding, which generated themes and subthemes, and finally, through axial coding.

RESULTS

Physiological plateaus represent a temporary slowing of one or multiple labor processes and appear to be common during childbirth. They are reported throughout the entire continuum of labor, typically lasting between a few minutes to several hours. Their etiology/function appears to be a self-regulatory mechanism of the mother-infant dyad. Physiological plateaus typically self-resolve and are followed by a self-resumption of labor. Women with physiological plateaus during labor appear to experience positive birth outcomes.

DISCUSSION

Despite appearing to be common, physiological plateaus are insufficiently recognized in contemporary childbirth discourse. Consequently, there seems to be a significant risk of misinterpretation of physiological plateaus as labor dystocia. While findings are limited by the qualitative design and require validation through further quantitative research, the proposed novel definition provides an important starting point for further investigation.

CONCLUSION

A better understanding of physiological plateaus holds the potential for a de-medicalization of childbirth through preventing unjustified labor augmentation.

Customization and acceptability of the WHO labor care guide to improve labor monitoring among health workers in Uganda. An iterative development, mixed method study

Cognisant of persistently high maternal and perinatal mortality rates, WHO called for adoption and evaluation of new adaptable and context-specific solutions to improve labor monitoring and health outcomes. We aimed at customizing/refining the new WHO labour care guide (LCG) to suite health care provider needs (HCP) in monitoring labour in Uganda. We used mixed methods to customize/refine and pilot test the new WHO LCG using stakeholder perspectives. Between 1st July 2023 and 30th December 2023, we conducted; 1)30 stakeholder interviews to identify user needs/challenges that informed initial modifications of the WHO LCG; 2)15 HCP in-depth interviews to identify any further needs to modify the LCG; 3) Two focus group discussions and 4) Two exit expert panels to identify any further user needs to further refine proposed modifications into the final prototype. Questionnaires were administered to assess acceptability. We interviewed 125 stakeholders with median age of 36 years (IQR;26-48) exposed to the LCG for at least 12 months with 11.8(SD = 4.6) years of clinical practice. Simple useful modifications/customizations based on format, HCP's perceived function and role in improving decision making during monitoring labour included; 1) Customizing LCG by adding key socio-demographic data; 2) Adjusting observation ordering; 3) Modification of medication dosages and 4) Provision for recording key clinical notes/labour outcome data on reverse side of the same A4 paper. All HCPs found the modified WHO LCG useful, easy to use, appropriate, comprehensive, appealing and would recommend it to others for labour monitoring. It was implementable and majority took less than 2 minutes to completely record/fill observations on the LCG after each labour assessment. Active involvement of end-users improved inclusiveness, ownership, acceptability and uptake. The modified LCG prototype was found to be simple, appropriate and easy-to-use. Further research to evaluate large-scale use, feasibility and effectiveness is warranted.

Effect of implementation of the WHO intrapartum care model on maternal and neonatal outcomes: a randomized control trial

BACKGROUND

In 2018, the World Health Organization published a set of recommendations for further emphasis on the quality of intrapartum care to improve the childbirth experience. This study aimed to determine the effects of the WHO intrapartum care model on the childbirth experience, fear of childbirth, the quality of intrapartum care (primary outcomes), as well as post-traumatic stress disorder symptoms, postpartum depression, the duration of childbirth stages, the frequency of vaginal childbirth, Apgar score less than 7, desire for subsequent childbearing, and exclusive breastfeeding in the 4 to 6 weeks postpartum period (secondary outcomes).

METHODS

This study was a randomized controlled trial involving 108 pregnant women admitted to the maternity units of Al-Zahra and Taleghani hospitals in Tabriz-Iran. Participants were allocated to either the intervention group, which received care according to the ' 'intrapartum care model, or the control group, which received the' 'hospital's routine care, using the blocked randomization method. A Partograph chart was drawn for each participant during pregnancy. A delivery fear scale was completed by all participants both before the beginning of the active phase (pre-intervention) and during 7 to 8 cm dilation (post-intervention). Participants in both groups were followed up for 4 to 6 weeks after childbirth and were asked to complete questionnaires on childbirth experience, postpartum depression, and post-traumatic stress disorder symptoms, as well as the pregnancy and childbirth questionnaire and checklists on the desire to have children again and exclusive breastfeeding. The data were analyzed using independent T and Mann-Whitney U tests and analysis of covariance ANCOVA with adjustments for the parity variable and the baseline scores or childbirth fear.

RESULTS

The average score for the childbirth experience total was notably higher in the intervention group (Adjusted Mean Difference (AMD) (95% Confidence Interval (CI)): 7.0 (0.6 to 0.8), p < 0.001). Similarly, the intrapartum care quality score exhibited a significant increase in the intervention group (AMD (95% CI): 7.0 (4.0 to 10), p < 0.001). Furthermore, the post-intervention fear of childbirth score demonstrated a substantial decrease in the intervention group (AMD (95% CI): -16.0 (-22.0 to -10.0), p < 0.001). No statistically significant differences were observed between the two groups in terms of mean scores for depression, PTSD symptoms, duration of childbirth stages, frequency of vaginal childbirth, Apgar score less than 7, and exclusive breastfeeding in the 4 to 6 weeks postpartum (p > 0.05).

CONCLUSION

The intrapartum care model endorsed by the World Health Organization (WHO) has demonstrated effectiveness in enhancing childbirth experiences and increasing maternal satisfaction with the quality of obstetric care. Additionally, it contributes to the reduction of fear associated with labor and childbirth. Future research endeavors should explore strategies to prioritize and integrate respectful, high-quality care during labor and childbirth alongside clinical measures.

Labor curves based on cervical dilatation over time and their accuracy and effectiveness: A systematic scoping review

OBJECTIVES

This systematic scoping review was conducted to 1) identify and describe labor curves that illustrate cervical dilatation over time; 2) map any evidence for, as well as outcomes used to evaluate the accuracy and effectiveness of the curves; and 3) identify areas in research that require further investigation.

METHODS

A three-step systematic literature search was conducted for publications up to May 2023. We searched the Medline, Maternity & Infant Care, Embase, Cochrane Library, Epistemonikos, CINAHL, Scopus, and African Index Medicus databases for studies describing labor curves, assessing their effectiveness in improving birth outcomes, or assessing their accuracy as screening or diagnostic tools. Original research articles and systematic reviews were included. We excluded studies investigating adverse birth outcomes retrospectively, and those investigating the effect of analgesia-related interventions on labor progression. Study eligibility was assessed, and data were extracted from included studies using a piloted charting form. The findings are presented according to descriptive summaries created for the included studies.

RESULTS AND IMPLICATIONS FOR RESEARCH

Of 26,073 potentially eligible studies, 108 studies were included. Seventy-three studies described labor curves, of which ten of the thirteen largest were based mainly on the United States Consortium on Safe Labor cohort. Labor curve endpoints were 10 cm cervical dilatation in 69 studies and vaginal birth in 4 studies. Labor curve accuracy was assessed in 26 studies, of which all 15 published after 1986 were from low- and middle-income countries. Recent studies of labor curve accuracy in high-income countries are lacking. The effectiveness of labor curves was assessed in 13 studies, which failed to prove the superiority of any curve. Patient-reported health and well-being is an underrepresented outcome in evaluations of labor curves. The usefulness of labor curves is still a matter of debate, as studies have failed to prove their accuracy or effectiveness.

Cesarean section rate: navigating the gap between WHO recommended range and current obstetrical challenges

The cesarean section (CS) rate is very heterogeneous all over the world, reflecting the differences in the access to healthcare services. In higher-income countries, changes observed in the obstetrical population brought to an increased rate of cesarean section for maternal request. Besides, clinicians are facing an increasing number of induction of labor, with the consequent risk of CS if the management is inappropriate. Analyzing the rate of primary CS, the interpretation of intrapartum CTG and a tailored management of labor are also red flags that must be considered. In this optic, the implementation of obstetrics training and simulation programs and the improvement of clinical protocols with the latest evidence can lead to the reduction of unnecessary CS.

Exploring women's experiences, views and understanding of vaginal examinations during intrapartum care: A meta-ethnographic synthesis

OBJECTIVE

To conduct a systematic review exploring women's experiences, views and understanding of any vaginal examinations during intrapartum care, in any care setting and by any healthcare professional. Intrapartum vaginal examination is deemed both an essential assessment tool and routine intervention during labour. It is an intervention that can cause significant distress, embarrassment, and pain for women, as well as reinforce outdated gender roles. In view of its widespread and frequently reported excessive use, it is important to understand women's views on vaginal examination to inform further research and current practice.

DESIGN

A systematic search and meta-ethnography synthesis informed by Noblit and Hare (1988) and the eMERGe guidance (France et al. 2019) was undertaken. Nine electronic databases were searched systematically using predefined search terms in August 2021, and again in March 2023. Studies meeting the following criteria: English language, qualitative and mixed-method studies, published from 2000 onwards, and relevant to the topic, were eligible for quality appraisal and inclusion.

FINDINGS

Six studies met the inclusion criteria. Three from Turkey, one from Palestine, one from Hong Kong and one from New Zealand. One disconfirming study was identified. Following both a reciprocal and refutational synthesis, four 3rd order constructs were formed, titled: Suffering the examination, Challenging the power dynamic, Cervical-centric labour culture embedded in societal expectations, and Context of care. Finally, a line of argument was arrived at, which brought together and summarised the 3rd order constructs.

KEY CONCLUSIONS AND IMPLICATIONS OF PRACTICE

The dominant biomedical discourse of vaginal examination and cervical dilatation as central to the birthing process does not align with midwifery philosophy or women's embodied experience. Women experience examinations as painful and distressing but tolerate them as they view them as necessary and unavoidable. Factors such as context of care setting, environment, privacy, midwifery care, particularly in a continuity of carer model, have considerable positive affect on women's experience of examinations. Further research into women's experiences of vaginal examination in different care models as well as research into less invasive intrapartum assessment tools that promote physiological processes is urgently required.

First stage of labour duration and associated risk of adverse neonatal outcomes

Prior evidence evaluating the benefits and harms of expectant labour duration during active first stage is inconclusive regarding potential consequences for the neonate. Population-based cohort study in Stockholm-Gotland region, Sweden, including 46,040 women (Robson 1), between October 1st, 2008 and June 15th, 2020. Modified Poisson regression was used for the association between active first stage of labour duration and adverse neonatal outcomes. 94.2% experienced a delivery with normal neonatal outcomes. Absolute risk for severe outcomes increased from 1.9 to 3.0%, moderate outcomes increased from 2.8 to 6.2% (> 10.1 h). Compared to the reference, (< 5.1 h; median), the adjusted relative risk (aRR) of severe neonatal outcome significantly increased beyond 10.1 h (> 90th percentile) (aRR 1.53, 95% CI 1.26, 1.87), for moderate neonatal outcome the aRR began to slowly increase beyond 5.1 h (≥ 50 percentile; aRR 1.40, 95% CI 1.24, 1.58). Mediation analysis indicate that most of the association was due to a longer active first stage of labour, 13% (severe neonatal outcomes) and 20% (moderate neonatal outcomes) of the risk was mediated (indirect effect) by longer second stage of labour duration. We report an association between increasing active first stage duration and increased risk of adverse neonatal outcomes. We did not observe a clear labour duration risk threshold.

Early versus late amniotomy during induction of labor using oxytocin: A randomized controlled trial

OBJECTIVE

To assess the effect of early amniotomy on labor duration, maternal and neonatal outcomes during induction of labor (IOL).

METHODS

This was a randomized controlled trial, conducted over a period of eight months at a monocentric site. Singleton pregnancies in nulliparous and parous patients with cephalic presentation and Bishop score ≥ 6 were enrolled in the study. One hundred participants were randomized into two groups: early amniotomy (initiating IOL with amniotomy followed by oxytocin) versus late amniotomy (initiating IOL with oxytocin followed by amniotomy 4 hours later). The primary endpoint was the time to active phase (cervical dilation ≥ 5 cm) during IOL. Secondary outcomes were time to vaginal delivery, mode of delivery, and maternal and fetal outcomes.

RESULTS

Early amniotomy reduced time to active phase by 2 hours and 46 minutes compared to the late amniotomy group (3 h 42 min vs. 6 h 28 min; p<0.0001). It also reduced time to vaginal delivery by 2 hours and 52 minutes (5 h 17 min vs. 8 h 9 min; p = 0.0003). The rate of cesarean section (CS) for failed IOL was significantly lower in the early amniotomy group (31.2% vs. 70.0%; p = 0.02), without any significant difference in the overall rate of cesarean section between the two groups (32.0% vs. 40.8%; p = 0.36). There was no significant difference in maternal or fetal outcomes.

CONCLUSIONS

Early amniotomy in IOL significantly shortens the time to active phase as well as the overall duration of labor without compromising maternal and neonatal safety.

A wider agreement is needed on basic intrapartum concepts

Healthcare professionals working in labor wards worldwide regularly deal with the pressure of managing an emotionally charged and life-changing period for women, their families, and their friends. Furthermore, they frequently deal with long working hours, sleep deprivation, occasional scrutiny from the press, and legal dispute. The existing disagreements among leading scientific institutions on basic concepts of intrapartum care hinder the creation of a collective mental model in the labor ward, an aspect that is required for consistency in patient counseling and effective teamwork. Some of these disagreements are as follows: 1. When should laboring women be admitted to the hospital? 2. How long is the absence of labor progress acceptable before an intervention is proposed? 3. How long should women be allowed to push during the second stage of labor before an intervention is proposed? The international scientific community owes it to the vast number of healthcare professionals working in labor wards worldwide to agree on and provide clear definitions of these basic intrapartum concepts, thus making their work a little easier. International institutions, such as the International Federation of Gynecology and Obstetrics and the World Health Organization, have the highest authority to produce guidelines for the whole world, but the participation of leading national organizations, whose influence reaches well beyond the borders of their countries, is important for the wide dissemination of concepts.

The active phase of labor

The active phase of labor begins at various degrees of dilatation when the rate of dilatation transitions from the relatively flat slope of the latent phase to a more rapid slope. No diagnostic manifestations demarcate its onset, other than accelerating dilatation. It ends with apparent slowing of dilatation, a deceleration phase, which is usually short in duration and frequently undetected. Several aberrant labor patterns can be detected during the active phase, including protracted dilatation, arrest of dilatation, prolonged deceleration phase and failure of descent. Underlying factors may include cephalopelvic disproportion, excessive neuraxial block, poor uterine contractility, fetal malpositions, malpresentations, uterine infection, maternal obesity, advanced maternal age and previous cesarean delivery. When an active-phase disorder is identified, cesarean delivery is justifiable if there is compelling clinical evidence of disproportion. A prolonged deceleration disorder is strongly associated with disproportion and second stage abnormalities. Shoulder dystocia may occur if vaginal delivery eventuates. This review discusses several issues raised by the introduction of new clinical practice guidelines for labor management.

The sonopartogram

The assessment of labor progress from digital vaginal examination has remained largely unchanged for at least a century, despite the current major advances in maternal and perinatal care. Although inconsistently reproducible, the findings from digital vaginal examination are customarily plotted manually on a partogram, which is composed of a graphical representation of labor, together with maternal and fetal observations. The partogram has been developed to aid recognition of failure to labor progress and guide management-specific obstetrical intervention. In the last decade, the use of ultrasound in the delivery room has increased with the advent of more powerful, portable ultrasound machines that have become more readily available for use. Although ultrasound in intrapartum practice is predominantly used for acute management, an ultrasound-based partogram, a sonopartogram, might represent an objective tool for the graphical representation of labor. Demonstrating greater accuracy for fetal head position and more objectivity in the assessment of fetal head station, it could be considered complementary to traditional clinical assessment. The development of the sonopartogram concept would require further undertaking of serial measurements. Advocates of ultrasound will concede that its use has yet to demonstrate a difference in obstetrical and neonatal morbidity in the context of the management of labor and delivery. Taking a step beyond the descriptive graphical representation of labor progress is the question of whether a specific combination of clinical and demographic parameters might be used to inform knowledge of labor outcomes. Intrapartum cesarean deliveries and deliveries assisted by forceps and vacuum are all associated with a heightened risk of maternal and perinatal adverse outcomes. Although these outcomes cannot be precisely predicted, many known risk factors exist. Malposition and high station of the fetal head, short maternal stature, and other factors, such as caput succedaneum, are all implicated in operative delivery; however, the contribution of individual parameters based on clinical and ultrasound assessments has not been quantified. Individualized risk prediction models, including maternal characteristics and ultrasound findings, are increasingly used in women's health-for example, in preeclampsia or trisomy screening. Similarly, intrapartum cesarean delivery models have been developed with good prognostic ability in specifically selected populations. For intrapartum ultrasound to be of prognostic value, robust, externally validated prediction models for labor outcome would inform delivery management and allow shared decision-making with parents.

Implementing the WHO Labour Care Guide to reduce the use of Caesarean section in four hospitals in India: protocol and statistical analysis plan for a pragmatic, stepped-wedge, cluster-randomized pilot trial

BACKGROUND

The World Health Organization (WHO) Labour Care Guide (LCG) is a paper-based labour monitoring tool designed to facilitate the implementation of WHO's latest guidelines for effective, respectful care during labour and childbirth. Implementing the LCG into routine intrapartum care requires a strategy that improves healthcare provider practices during labour and childbirth. Such a strategy might optimize the use of Caesarean section (CS), along with potential benefits on the use of other obstetric interventions, maternal and perinatal health outcomes, and women's experience of care. However, the effects of a strategy to implement the LCG have not been evaluated in a randomised trial. This study aims to: (1) develop and optimise a strategy for implementing the LCG (formative phase); and (2) To evaluate the implementation of the LCG strategy compared with usual care (trial phase).

METHODS

In the formative phase, we will co-design the LCG strategy with key stakeholders informed by facility assessments and provider surveys, which will be field tested in one hospital. The LCG strategy includes a LCG training program, ongoing supportive supervision from senior clinical staff, and audit and feedback using the Robson Classification. We will then conduct a stepped-wedge, cluster-randomized pilot trial in four public hospitals in India, to evaluate the effect of the LCG strategy intervention compared to usual care (simplified WHO partograph). The primary outcome is the CS rate in nulliparous women with singleton, term, cephalic pregnancies in spontaneous labour (Robson Group 1). Secondary outcomes include clinical and process of care outcomes, as well as women's experience of care outcomes. We will also conduct a process evaluation during the trial, using standardized facility assessments, in-depth interviews and surveys with providers, audits of completed LCGs, labour ward observations and document reviews. An economic evaluation will consider implementation costs and cost-effectiveness.

DISCUSSION

Findings of this trial will guide clinicians, administrators and policymakers on how to effectively implement the LCG, and what (if any) effects the LCG strategy has on process of care, health and experience outcomes. The trial findings will inform the rollout of LCG internationally.

TRIAL REGISTRATION

CTRI/2021/01/030695 (Protocol version 1.4, 25 April 2022).

Women's views and experiences of augmentation of labour with synthetic oxytocin infusion: A qualitative evidence synthesis

OBJECTIVE

To explore and synthesise women's views and experiences of augmentation of labour with synthetic oxytocin infusion.

DESIGN

A qualitative evidence synthesis was conducted. The SPIDER acronym was used to develop the search terms and determine the inclusion criteria. Six bibliographic databases: MEDLINE, CINAHL, EMBASE, PsycINFO, Maternity and Infant Care and Web of Science Core Collection were searched in October 2021. Grey literature sources, EThOS, DART-Europe, and the World Health Organization's Clinical Trials Registry were searched, and reference lists of included studies were reviewed. Methodological quality of included studies was assessed using the Evidence for Policy and Practice Information and Co-ordinating (EPPI) Centre assessment tool. Data were synthesised thematically. The confidence of each review finding was assessed using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual). Research ethical approval was not required.

SETTING AND PARTICIPANTS

Women of any age, parity, and cultural background who underwent augmentation of labour with synthetic oxytocin infusion were included.

FINDINGS

A total of 9306 citations were retrieved. Twenty-five studies conducted across 14 countries met the inclusion criteria and contributed data. Three principal analytical themes emerged: feeling stuck; past and present shaping the future; and cause and effect of augmentation of labour. The decision to augment women's labour was often performed without their informed consent. Women's views and experiences of augmentation of labour were shaped according to their knowledge, beliefs and support received during labour. Irrespective of the context, women consistently associated augmentation of labour with pain.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Clinical guidelines on augmentation of labour need to be informed by research that includes women's views and experiences as a main outcome. Future research exploring the experience of augmentation of labour rather than the experience of labour dystocia would be beneficial. Increasing women's awareness and knowledge of augmentation of labour may help to ensure that their informed consent is obtained. Healthcare providers should discuss the effects, side effects and implications of augmentation of labour with women, ideally before labour.

Advancement in Partograph: WHO's Labor Care Guide

Worldwide, the partograph, also known as a partogram, is used as a labor monitoring tool to detect difficulties early, allowing for referral, intervention, or closer observations to follow. Despite widespread support from health experts, there are worries that the partograph has not yet fully realized its potential for enhancing therapeutic results. As a result, the instrument has undergone several changes, and numerous studies have been conducted to examine the obstacles and enablers to its use. Nevertheless, the partograph was widely embraced and has been a component of evaluating labor progress. Earlier it was also used as a standard method for monitoring labor progress. Even though it is widely used, there have been reports of usage and accurate execution rates. The WHO Labor Care Guide (LCG) was created so that medical professionals could keep an eye on the health of pregnant women and their unborn children during labor by conducting routine evaluations to spot any abnormalities. The tool intends to enhance women-centered care and encourage collaborative decision-making between women and healthcare professionals. The LCG is designed to be a tool for ensuring high-quality research centered on health, reducing pointless measures, and offering comfort measures.

Impact of WHO Labor Care Guide on reducing cesarean sections at a tertiary center: an open-label randomized controlled trial

BACKGROUND

The World Health Organization Labor Care Guide was introduced in December 2020 to implement World Health Organization (WHO) guidelines on intrapartum care for a positive childbirth experience.

OBJECTIVE

This study aimed to determine the effect of the WHO Labor Care Guide on labor outcomes, especially in reducing primary cesarean deliveries, and its acceptability by healthcare providers.

STUDY DESIGN

This open-label randomized control trial was conducted from September 2021 to December 2021 on 280 low-risk antenatal women admitted for delivery at a busy tertiary care institute in North India. After informed consent, women were allocated into the study and control groups. Labor monitoring was performed using the WHO Labor Care Guide in the study group and the World Health Organization–modified partograph in the control group. Women who had a cesarean delivery in the latent phase of labor were excluded from the study. The primary outcome was mode of delivery, whereas the secondary outcomes were duration of active labor, maternal complications (postpartum hemorrhage and puerperal sepsis), duration of hospital stay, Apgar score at 5 minutes, and neonatal intensive care unit admission. The labor outcomes in both groups were compared. In the study group, the acceptability, difficulty, and satisfaction levels of the users were assessed using a 5-point Likert scale. The “learning curve” for the use of the Labor Care Guide (LCG) was determined. SPSS software (version 21.0; IBM Corporation, Chicago, IL) was used for statistical analysis.

RESULTS

After excluding women who underwent cesarean delivery in the latent phase, 136 women in the study group and 135 women in the control group were observed for labor outcomes. The cesarean delivery rate was 1.5% in the study group vs 17.8% in the control group (P=.0001). The duration of the active phase of labor was significantly shorter in the study group than in the control group (P<.001). The 2 groups were similar in terms of maternal complications, duration of hospital stay, and Apgar score. The learning curve took average levels of 6.50 and 2.25 Labor Care Guide plots to shift from “very difficult” to “neutral” and “neutral” to “easy,” respectively. After an initial learning curve, acceptability and satisfaction levels were found to be high in the WHO Labor Care Guide users.

CONCLUSION

The WHO Labor Care Guide is a simple labor monitoring tool for the reducing primary cesarean delivery rate without increasing the duration of hospital stay and fetomaternal complications.

Physiological plateaus during normal labor and birth: A scoping review of contemporary concepts and definitions

BACKGROUND

Physiological plateaus (slowing, stalling, pausing) during normal labor and birth have been reported for decades, but have received limited attention in research and clinical practice. To date, heterogeneous conceptualizations and terminology have impeded effective communication and research in this area, raising concern as to whether some physiological plateaus might be misinterpreted as dystocia. To address this issue, we provide a point of orientation, mapping contemporary concepts, and terminologies of physiological plateaus during normal labor and birth.

METHODS

We conducted a scoping review, considering published and unpublished reports of physiological plateaus, reported in any language, between 1990 and 2021. Database searches of CINAHL, EMBASE, Emcare, MIDIRS, MEDLINE, Scopus, and Open Grey yielded 1,953 records, with an additional 35 reports identified by hand searching. In total, 43 reports from eleven countries were included in this scoping review.

RESULTS

Conceptualizations of physiological plateaus are heterogeneous and can be allocated to six conceptual groups: cervical reversal or recoil, plateaus, lulls during transition, "rest and be thankful" stage, deceleration phase, and latent phases. Across included material, we identified over 60 different terms referring to physiological plateaus. Overall, physiological plateaus are reported across the entire continuum of normal labor and birth.

CONCLUSIONS

Physiological plateaus may be an essential mechanism of self-regulation of the mother-infant dyad, facilitating feto-maternal adaptation and preventing maternal and fetal distress during labor and birth.

Association between first and second stage of labour duration and mode of delivery: A population-based cohort study

BACKGROUND

Active first stage of labour duration can widely vary between women. However, the nature of the relationship between the active first stage and second stage of labour duration is sparsely studied.

OBJECTIVES

To determine whether active first stage of labour duration (i) influences second stage of labour duration; and (ii) is associated with mode of delivery.

METHODS

A population-based cohort study of 13,379 women primiparous women, with spontaneous start in Stockholm-Gotland Region, Sweden, between 2008 and 2014. Duration of the active first stage of labour was examined in relation to second-stage duration using univariate and multivariable quantile regressions, with the first quartile (first stage duration) as the reference. Nonlinearity of associations was tested by restricted cubic splines. Association between active first-stage duration with mode of delivery was estimated using a multinomial logistic regression based on adjusted odds ratios.

RESULTS

Longer active first stage of labour duration was linearly associated with longer second stage of labour duration until approximately 12 h of active first stage of labour duration. After 12 h, a non-linear trend is seen, demonstrated by a plateau in the second-stage duration. In addition, longer active first stage of labour duration was associated with increased occurrence of operative vaginal delivery (adjusted odds ratio 3.36, 95% confidence interval [CI] 2.89, 3.89) and caesarean delivery (adjusted odds ratio 4.75, 95% CI 3.85, 5.80).

CONCLUSIONS

Among primiparous women with spontaneous onset of labour, longer active first stage of labour duration was associated with both longer second stage of labour duration and higher odds of operative delivery. This study contributes with findings, which may inform future discussions regarding how to properly account for second-stage duration, with applications in obstetric and perinatal epidemiology.

Women’s views and experiences of augmentation of labour with synthetic oxytocin infusion. A protocol for a qualitative evidence synthesis

Background: Augmentation of labour (AOL) is the most common intervention to treat labour dystocia. Previous research reported extensive disparities in AOL rates across countries and institutions.  Despite its widespread use, women’s views on and experiences of intrapartum augmentation with infused synthetic oxytocin are limited.

Methods: A qualitative evidence synthesis on women’s views and experiences of AOL with synthetic oxytocin after spontaneous onset of labour will be conducted. Qualitative studies and studies employing a mixed methods design, where qualitative data can be extracted separately, will be included, as will surveys with open-ended questions that provide qualitative data. A systematic search will be performed of the databases: MEDLINE, CINAHL, EMBASE, PsycINFO, Maternity and Infant Care and Web of Science Core Collection from the date of inception. The methodological quality of included studies will be assessed using the Evidence for Policy and Practice Information and Co-ordinating Centre’s appraisal tool. A three-stage approach, coding of data from primary studies, development of descriptive themes and generation of analytical themes, will be used to synthesise findings. Confidence in findings will be established by the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research.

Discussion: This qualitative evidence synthesis may provide valuable information on women’s experiences of AOL and contribute to a review of clinical practice guidelines for maternity care providers.

PROSPERO registration: CRD42021285252 (14/11/2021)

Analysis of spontaneous labor progression of breech presentation at term

Background

Cervical dilatation curves are widely used to describe normal and abnormal labor progression for cephalic presentation. Labor curves for breech presentations have never been described.

Objectives

The aims of this study were to examine the pattern of labor progression in women with a breech presentation and to determine whether the type of breech or parity can influence the speed of cervical dilatation.

Study design

We analyzed the labor data from 349 women with a term, singleton, and breech fetus after spontaneous onset of labor in 2010–2018. Cesarean deliveries were excluded. The patterns of labor progression were described by examining the relationship between the elapsed times from the full dilatation and cervical dilatation stages. Average labor curves were developed using repeated-measures analysis with 3^rd degree polynomial modeling. The results were interpreted according to parity and the type of breech.

Results

The first stage of labor progression was divided into a latency phase from 0 to 5 cm of dilatation and an active phase from 5 to 10 cm. In the active phase, the median speed of cervical dilatation was 1.67 cm/h [1.25, 2.61] (2 cm/h for multipara and 1.54 cm/h for nullipara). The difference by parity was significant in the active phase (p< 0.05). The cervical dilatation rate from 3 cm to 10 cm did not significantly differ between the complete and frank breeches (1.56 cm/h vs 1.75 cm/h, p = 0.48). However, the median cervical dilatation rate from 8 cm to complete dilatation was faster for complete breeches (1.92 cm/h versus 1.33 cm/h, p = 0.045).

Conclusion

As with cephalic presentation, the first stage of labor progression for breech presentation can be divided into a latent and active phase. Labor progression should be interpreted with respect to parity, and women should be informed that the type of breech does not seem to influence the cervical dilatation rate when there is adequate management.

Women’s views and experiences of augmentation of labour with synthetic oxytocin infusion: a protocol for a qualitative evidence synthesis

Background: Augmentation of labour (AOL) is the most common intervention to treat labour dystocia. Previous research reported extensive disparities in AOL rates across countries and institutions.  Despite its widespread use, women’s views on and experiences of intrapartum augmentation with infused synthetic oxytocin are limited. Methods: A qualitative evidence synthesis on women’s views and experiences of AOL with synthetic oxytocin after spontaneous onset of labour will be conducted. Qualitative studies and studies employing a mixed methods design, where qualitative data can be extracted separately, will be included, as will surveys with open-ended questions that provide qualitative data. A systematic search will be performed of the databases: MEDLINE, CINAHL, EMBASE, PsycINFO, Maternity and Infant Care and Web of Science Core Collection from the date of inception. The methodological quality of included studies will be assessed using the Evidence for Policy and Practice Information and Co-ordinating Centre’s appraisal tool. A three-stage approach, coding of data from primary studies, development of descriptive themes and generation of analytical themes, will be used to synthesise findings. Confidence in findings will be established by the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research. Discussion: This qualitative evidence synthesis may provide valuable information on women’s experiences of AOL and contribute to a review of clinical practice guidelines for maternity care providers. PROSPERO registration: CRD42021285252 (14/11/2021)

Spontaneous labor curve based on a retrospective multi-center study in Japan

Aim

In Japan, the criteria of the latent and active phases of the first stage of labor have not been decided. The Japan Society of Obstetrics and Gynecology (JSOG) Perinatal Committee conducted a study to construct a spontaneous labor curve in order to determine the point of onset of the active phase.

Methods

The participants were women who had spontaneous deliveries at four health facilities in Japan between September 1, 2011, and September 31, 2019. Spontaneous delivery was defined as the spontaneous onset of labor at term (37 weeks, 0 days to 41 weeks, 6 days) with vaginal delivery of a mature fetus in a cephalic position without uterotonic agents or epidural analgesia. The time points for each “cm” of dilation were collected starting from the time of full dilation retrogradely. The relationship between time since labor onset and cervical dilation was expressed as a curve using a smoothing B‐spline.

Results

A total of 4215 primiparous and 5266 multiparous women were included in this study. The spontaneous labor curve showed that in both primiparous and multiparous women, labor progress was slow until 5 cm cervical dilation, accelerating between 5 and 6 cm dilation, and steadily progressed after 6 cm dilation.

Conclusion

We propose that the active phase of the first stage of labor be defined as starting at 5 cm dilation of the cervix, and that it be divided into an acceleration phase (5–6 cm dilation) and a maximal phase (>6 cm dilation).

Middle-East OBGYN graduate education (MOGGE) foundation practice guidelines: use of labor charts in management of labor. Practice guideline no. 04-O-21

Since the 50 s of the last century, labor charts have been proposed and appraised as a tool to diagnose labor abnormalities and guide decision-making. The partogram, the most widely adopted form of labor charts, has been endorsed by the world health organization (WHO) since 1994. Nevertheless, recent studies and systematic reviews did not support clinical significance of application of the WHO partogram. These results have led to further studies that investigate modifications to the structure of the partogram, or more recently, to reconstruct new labor charts to improve their clinical efficacy. This guideline appraises current evidence on use of labor charts in management of labor specially in low-resource settings.

Exploring concepts and definitions of plateaus during normal labor and birth: a scoping review protocol

OBJECTIVE

In this scoping review, contemporary concepts and definitions of phenomena during normal labor and birth, wherein the process appears to plateau (slow, stall, or pause) but remains within physiological limits, will be mapped.

INTRODUCTION

During labor and birth, it is frequently perceived as pathological if contractions, cervical dilation, or fetal descent plateau. However, there is evidence to suggest that some plateaus during labor may be physiological, and a variety of concepts and terms refer to this phenomenon. Where a physiological plateau is perceived as pathological arrest, this may contribute to undue interventions, such as augmentation of labor. Therefore, it is important to advance understanding of physiological labor patterns, including potentially physiological labor plateaus.

INCLUSION CRITERIA

Publications mentioning any plateaus of the processes of normal human labor and birth will be considered. This may also include phenomena where labor is perceived to "reverse," for example, a closing cervix or a rise of the presenting fetal part. Publications where plateaus are defined as pathological will be excluded.

METHODS

All types of evidence, published and unpublished, will be considered. The search strategy will be applied to the databases MEDLINE, Embase, MIDIRS, Emcare, CINAHL, and Scopus, and will be limited to the past 30 years. Gray literature will be searched via Open Grey, reference list screening, and contacting authors. Data extraction will comprise information on concept boundaries, terminology, precedents, consequences, concept origin, and types of evidence that report this phenomenon. Results will be presented in tabular, diagrammatical, and narrative manner.

Caesarean section rates: applying the modified ten-group Robson classification in an Australian tertiary hospital

The aim of this study was to determine the main contributors to caesarean section (CS) rates at an Australian tertiary hospital. We conducted a retrospective review of women who delivered in an Australian tertiary hospital between 2014 and 2017. Women were allocated according to a modified Robson Ten-Group Classification System and CS indications were collected in nulliparous women and women with previous CS. The largest contributor to the 35.7% overall CS rate was women with a term cephalic infant and a previous CS (31.5% relative CS rate) and the most common indication was repeat CS. The group CS rate in nulliparous women with a cephalic term infant was higher when labour was induced compared to occurring spontaneously (36.6% and 18.1% respectively). The primary CS indication for these women was labour dystocia and maternal request was the most common CS indication for nulliparous women with a pre-labour CS.IMPACT STATEMENTWhat is already known on this subject? Significantly increasing caesarean section (CS) rates continue to prompt concern due to the associated neonatal and maternal risks. The World Health Organisation have endorsed the Robson Ten-Group Classification System to identify and analyse CS rate contributors.What do the results of this study add? We have used the modified Robson Ten-Group Classification System to identify that women with cephalic term infants who are nulliparous or who have had a previous CS are the largest contributors to overall CS rates. CS rates were higher in these nulliparous women if labour was induced compared to occurring spontaneously and the primary CS indication was labour dystocia. In nulliparous women with a CS prior to labour the most common CS indication was maternal request. Majority of women with a previous CS elected for a repeat CS.What are the implications of these findings for clinical practice? Future efforts should focus on minimising repeat CS in multiparous women and primary CS in nulliparous women. This may be achieved by redefining the definition of labour dystocia, exploring maternal request CS reasoning and critically evaluating induction timing and indication. Appropriately promoting a trial of labour in women with a previous CS in suitable candidates may reduce repeat CS incidence.

The development of the WHO Labour Care Guide: an international survey of maternity care providers

Background

The partograph is the most commonly used labour monitoring tool in the world. However, it has been used incorrectly or inconsistently in many settings. In 2018, a WHO expert group reviewed and revised the design of the partograph in light of emerging evidence, and they developed the first version of the Labour Care Guide (LCG). The objective of this study was to explore opinions of skilled health personnel on the first version of the WHO Labour Care Guide.

Methods

Skilled health personnel (including obstetricians, midwives and general practitioners) of any gender from Africa, Asia, Europe and Latin America were identified through a large global research network. Country coordinators from the network invited 5 to 10 mid-level and senior skilled health personnel who had worked in labour wards anytime in the last 5 years. A self-administered, anonymous, structured, online questionnaire including closed and open-ended questions was designed to assess the clarity, relevance, appropriateness of the frequency of recording, and the completeness of the sections and variables on the LCG.

Results

A total of 110 participants from 23 countries completed the survey between December 2018 and January 2019. Variables included in the LCG were generally considered clear, relevant and to have been recorded at the appropriate frequency. Most sections of the LCG were considered complete. Participants agreed or strongly agreed with the overall design, structure of the LCG, and the usefulness of reference thresholds to trigger further assessment and actions. They also agreed that LCG could potentially have a positive impact on clinical decision-making and respectful maternity care. Participants disagreed with the value of some variables, including coping, urine, and neonatal status.

Conclusions

Future end-users of WHO Labour Care Guide considered the variables to be clear, relevant and appropriate, and, with minor improvements, to have the potential to positively impact clinical decision-making and respectful maternity care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01074-2.

Usability, acceptability, and feasibility of the World Health Organization Labour Care Guide: A mixed-methods, multicountry evaluation

INTRODUCTION

The World Health Organization's (WHO) Labour Care Guide (LCG) is a "next-generation" partograph based on WHO's latest intrapartum care recommendations. It aims to optimize clinical care provided to women and their experience of care. We evaluated the LCG's usability, feasibility, and acceptability among maternity care practitioners in clinical settings.

METHODS

Mixed-methods evaluation with doctors, midwives, and nurses in 12 health facilities across Argentina, India, Kenya, Malawi, Nigeria, and Tanzania. Purposively sampled and trained practitioners applied the LCG in low-risk women during labor and rated experiences, satisfaction, and usability. Practitioners were invited to focus group discussions (FGDs) to share experiences and perceptions of the LCG, which were subjected to framework analysis.

RESULTS

One hundred and thirty-six practitioners applied the LCG in managing labor and birth of 1,226 low-risk women. The majority of women had a spontaneous vaginal birth (91.6%); two cases of intrapartum stillbirths (1.63 per 1000 births) occurred. Practitioner satisfaction with the LCG was high, and median usability score was 67.5%. Practitioners described the LCG as supporting precise and meticulous monitoring during labor, encouraging critical thinking in labor management, and improving the provision of woman-centered care.

CONCLUSIONS

The LCG is feasible and acceptable to use across different clinical settings and can promote woman-centered care, though some design improvements would benefit usability. Implementing the LCG needs to be accompanied by training and supportive supervision, and strategies to promote an enabling environment (including updated policies on supportive care interventions, and ensuring essential equipment is available).

Cervical Ripening and Labor Induction and Augmentation, 5th Edition

Cervical ripening and induction and augmentation of labor are common procedures in labor and birth units. The potential risks and benefits for the procedure should be explained to women so that they can make informed decisions. Clinicians should be knowledgeable about the methods and medications used and be skilled in maternal-fetal assessment. Adequate nurse staffing is required to monitor the mother and fetus to promote the best possible outcomes. This practice monograph includes information on mechanical and pharmacologic methods for cervical ripening; labor induction and augmentation with oxytocin, a high alert drug; and nurse staffing levels and skills needed to provide safe and effective care during cervical ripening and labor induction and augmentation.

Defining arrest in the first and second stages of labor

Normal labor is identified as regular uterine contractions in addition to dilation and effacement of the cervix. It is necessary to define normal labor in order to delineate when a woman's labor pattern diverges from that observed in most women. Labor irregularities are subdivided into protraction disorders and arrest disorders. Identifying abnormal labor patterns and initiating appropriate interventions is essential because prolonged labor is associated with an increase in perinatal morbidity. The aim of this review was to delineate both normal labor progress and also discuss the current evidence-based diagnosis and treatment of protraction and arrest disorders. Many subtleties go into defining the boundaries of the first and second stages of labor. Historically, the Friedman curve established normal limits; but currently Zhang has advanced these definitions by accounting for current demographical characteristics and practice environments. The most significant variables for defining normal progress of labor are parity and regional anesthesia status. The most common causes of labor abnormalities are uterine inactivity, obesity, cephalopelvic disproportion and fetal malposition. Risks of extending the first and/or second stage of labor include postpartum hemorrhage, intraamniotic infection and potentially an increase in neonatal adverse outcomes. The management of labor disorders consists of oxytocin administration, amniotomy, intrauterine pressure catheter use and shared decision-making regarding proceeding with expectant management, operative vaginal delivery or cesarean delivery after weighing the risks and benefits of each option. The decision to extend the duration of labor is personalized for each mother-baby dyad and should be agreed upon depending on individual maternal and fetal circumstances.

First stage progression in women with spontaneous onset of labor: A large population-based cohort study

Objective

To describe the duration, progression and patterns of first stage of labor among Swedish women.

Design

Population-based cohort study.

Population

Data from Stockholm-Gotland Obstetric Cohort 2008–2014 including ¼ of all births in Sweden, the final sample involved a total of 85,408 women with term, singleton, vertex, live fetuses experiencing spontaneous labor onset and vaginal delivery with normal neonatal outcomes.

Main outcome measures

Time to progress during first stage of labor using three approaches: 1) Traverse time in hours to progress centimeter to centimeter, 5^th, 50^th (and 95^th percentile); 2) Dilation curves for different percentiles, and; 3) Cumulative duration for the 95^th percentile by parity and dilation at admission.

Results

Variation in both the total duration and the trajectory of cervical change over time is large. Similar to the general held view, the rate of cervical dilation accelerates at 5–6 centimeters. Among nulliparous women, the median time found in our population was faster than their counterparts in studies conducted on American and African cohorts. Among nulliparous and multiparous women our data suggest that the median cervical change over time is faster than 1 cm per hour during the first stage of labor. However, traverse time of cervical change at and beyond the 95^th percentile is longer than 1 cm per hour.

Conclusions

Labor progression varies widely and labors experiencing a prolonged first stage can still result in normal outcomes. The assumption of 1 cm per hour cervical dilation rate for the first stage of labor may not be universally meaningful. There are differences in progression for women during first stage of labor in different populations. For prolonged labor progression to be more clinically meaningful, the association with adverse birth outcomes needs to be further investigated in specific populations.

Cervical Ripening and Labor Induction and Augmentation, 5th Edition

Cervical ripening and induction and augmentation of labor are common procedures in labor and birth units. The potential risks and benefits for the procedure should be explained to women so that they can make informed decisions. Clinicians should be knowledgeable about the methods and medications used and be skilled in maternal-fetal assessment. Adequate nurse staffing is required to monitor the mother and fetus to promote the best possible outcomes. This practice monograph includes information on mechanical and pharmacologic methods for cervical ripening; labor induction and augmentation with oxytocin, a high alert drug; and nurse staffing levels and skills needed to provide safe and effective care during cervical ripening and labor induction and augmentation.

General methods for measuring and comparing medical interventions in childbirth: a framework

Background

The continue increase of interventions during labour in low risk population is a controversial issue of the current obstetric literature, given the lack of evidence demonstrating the benefits of unnecessary interventions for women or infants’ health. This makes it important to have approaches to assess the burden of all medical interventions performed.

Methods

Exploiting the nature of childbirth intervention as a staged process, we proposed graphic representations allowing to generate alternative formulas for the simplest measures of the intervention intensity namely, the overall and type-specific treatment ratios. We applied the approach to quantify the change in interventions following a protocol termed Comprehensive Management (CM), using data from Robson classification, collected in a prospective longitudinal cohort study carried out at the Obstetric Unit of the Cà Granda Niguarda Hospital in Milan, Italy.

Results

Following CM a substantial reduction was observed in the Overall Treatment Ratio, as well as in the ratios for augmentation (amniotomy and synthetic oxytocin use) and for caesarean section ratio, without any increase in neonatal and maternal adverse outcomes. The key component of this reduction was the dramatic decline in the proportion of women progressing to augmentation, which resulted not only the most practiced intervention, but also the main door towards further treatments.

Conclusions

The proposed framework, once combined with Robson Classification, provides useful tools to make medical interventions performed during childbirth quantitatively measurable and comparable. The framework allowed to identifying the key components of interventions reduction following CM. In its turn, CM proved useful to reduce the number of medical interventions carried out during childbirth, without worsening neonatal and maternal outcomes.

First assessed cervical dilatation: is it associated with oxytocin augmentation during labour? A retrospective cohort study in a university hospital in Switzerland

OBJECTIVES

The primary objective of this study was to examine the association between the first assessed cervical dilatation in a labourward and the use of oxytocin augmentation during labour. Further analysis was performed by examining the actual stage of labour at the point oxytocin was first administered to those women.

DESIGN

Retrospective cohort study with the data collected from the medical records of the hospital.

SETTING

University Hospital Bern, Switzerland PARTICIPANTS: 1933 term nulliparous and multiparous women with a singleton pregnancy giving birth during the period June 2013 and May 2017, representing Robson groups 1 and 3.

MEASUREMENTS AND FINDINGS

Descriptive statistics and multivariable logistic regression models were performed. It was found that for the entire process of labour, nulliparous and multiparous women (n = 1933) with a first cervical dilatation of 5 or more cm were less likely to be augmented with oxytocin (OR 0.64, 95% CI 0.46; 0.88 and OR 0.56, 95% CI 0.38; 0.82, respectively) compared to women with a first cervical dilatation of less than 5 cm. Out of these augmented women (n = 746) having a first cervical dilatation of 5 or more cm, they had a lower likelihood of being augmented during the first stage of labour compared to women with a first cervical dilatation of less than 5 cm (OR 0.45, 95% CI 0.29; 0.7 for nulliparae and OR 0.32, 95% CI 0.16; 0.6 for multiparae). Additionally, it was observed that other factors contributed to the application of oxytocin. One such example was that epidural analgesia was associated with a high risk of oxytocin augmentation in nulliparae (OR 13.88, 95% CI 9.29; 20.74) and multiparae (OR 15.52, 95% CI 9.94; 24.22). The application of oxytocin was also found to affect the caesarean section rate in nulliparous and multiparous women as it was 20% and 13% respectively for those with oxytocin versus 13% and 4% respectively for those without oxytocin.

KEY CONCLUSIONS

Early admission to the labourward is associated with an increased use of oxytocin to augment labour, particularly, during the first stage of labour. Epidural analgesia is a main predictor for oxytocin augmentation in nulliparous and multiparous women.

IMPLICATIONS FOR PRACTICE

Pregnant women warrant more appropriate support during early labour, avoiding early maternal exhaustion and excessive obstetrical interventions.

Contemporary patterns of labor in nulliparous and multiparous women

BACKGROUND

Controversy surrounds the definition of "normal" and "abnormal" labor.

OBJECTIVE

In this study, we used contemporary labor charts to explore labor patterns in large obstetric population (2011-2016).

STUDY DESIGN

Detailed information from electronic medical records of live singleton deliveries at term (≥37 weeks of gestation) was extracted. Cases of elective cesarean deliveries, nonvertex presentation, and cesarean deliveries during the first stage of labor were excluded.

RESULTS

Overall, 35,146 deliveries were included, of whom 15,948 deliveries (45.3%) were of nulliparous women. Median cervical dilation at admission was not significantly different between nulliparous (median, 4 cm; interquartile range, 3-5 cm) and multiparous women (median, 4 cm; interquartile range, 3-6 cm). In all, 99.3% of the women delivered vaginally. For nulliparous women, the median duration of the first stage of labor was 274 minutes (interquartile range, 145-441 minutes; 95th percentile, 747.5 minutes). Likewise, for multiparous women, the corresponding duration was 133 minutes (interquartile range, 56-244 minutes; 95th percentile, 494 minutes). During the latent phase (cervical dilation at admission, ≤4 cm), the time elapsed to the second stage of labor was 120-140 minutes longer in nulliparous women, whereas the gap between the groups decreased dramatically with advanced cervical dilation on admission. Nulliparous and multiparous women appeared to progress at a similar pace during the latent phase; however, after 5 cm, labor accelerated faster in multiparous women. Epidural anesthesia lengthens duration first and second stages of labor in all parities. Partograms according to cervical dilation at presentation are proposed.

CONCLUSION

Cervical dilation rate is relatively constant between nulliparous and multiparous pregnant women during the latent phase. Time interval of the first stage was far slower than previously described, which allowed labor to continue for a longer period during this stage. These findings may reduce the rate of intrapartum iatrogenic interventions.

Changes in labor outcomes after implementing structured use of oxytocin augmentation with a 4-hour action line

Introduction: Oxytocin augmentation is essential in labor management, but how to optimize its use is still debated. Joint international guidelines regarding prolonged labor and the use of oxytocin augmentation are still not available. Due to its potential harmful side effects, a decreased use of oxytocin is encouraged. We aimed to implement a structured protocol on the use of oxytocin augmentation and to observe changes in labor outcomes.Materials and methods: The protocol was implemented at the Obstetric Department of Sørlandet Hospital, Kristiansand, Norway on 1 January 2012; therefore, data from the hospital were collected prospectively and compared for two time-period cohorts: the historic control cohort (2009-2010) and the study period cohort (2012-2013). The structured protocol instructs, and restricts, the birth attendants to diagnose prolonged labor, by protocol definition only, before commencing oxytocin infusion for augmentation. Nulliparous women with singleton, term deliveries (≥37 weeks), cephalic presentation, and spontaneous onset of labor (Ten-Group Classification System (TGCS) group 1) were included in the analysis. The main outcome was use of oxytocin augmentation.Results: The study cohort and control cohort comprised 1103 (26.2%) and 1399 (33.1%) of all laboring women, respectively (p < .01). The protocol was followed satisfactorily in 78% of the study cohort. The use of oxytocin augmentation was reduced in the study cohort versus the control cohort; 41.3 versus 48.9% (p < .01); mean oxytocin infusion duration was shorter (100 versus 123 min; p < .01); and mean total oxytocin dose decreased (1009 versus 1293 mU; p < .01). The cesarean section rate was 5.9% in the study cohort versus 8.0% in the control cohort (p = .04). The estimated mean duration of the active phase of labor increased by 47 min (p < .01) after the implementation. The frequency of estimated postpartum hemorrhage >1000 ml was higher, 4.9 versus 2.0% (p < .01), but the use of blood transfusions remained stable, 2.5 versus 2.7% (p = .78), the study cohort versus control cohort, respectively.Conclusions: Implementation of a protocol of structured use of oxytocin augmentation reduced the frequency, dosage, and duration of oxytocin without increasing the cesarean section rate in TGCS group 1.

Labor patterns in Asian American women with vaginal birth and normal perinatal outcomes

BACKGROUND

The pattern of normal labor progression can help to define prolonged labor and dystocia. Several studies had tried to establish the process of normal labor in different races. Previous findings in Asian women were limited and often incomparable. Our aim was to examine labor patterns in Asian American women.

STUDY DESIGN

A total of 3079 women with singleton term gestation, vertex presentation, vaginal delivery, and a normal perinatal outcome were extracted from the Consortium on Safe Labor study. A repeated measure analysis and an interval-censored regression were applied to depict the average labor curves and estimate the time interval of cervical dilation by 1 cm, respectively. A sensitivity analysis was conducted to assess the impact of oxytocin augmentation. The cumulative duration of the 1st stage of labor was calculated to draw a partograph.

RESULTS

It took an average of 5.2 hours for nulliparous Asian women with spontaneous labor onset to complete the 1st stage of labor, and the 95th centile was 14.4 hours. Labor progressed at a similar rate between nulliparous and multiparous women before 6 cm. Afterward, multiparous women progressed noticeably faster than nulliparous women. The differences in labor duration between women with and without oxytocin augmentation were <0.5 hour for both nulliparous and multiparous women.

CONCLUSIONS

A new partograph that restricted the diagnosis of dystocia to the slowest 5% of nulliparous women with normal perinatal outcomes was proposed. The labor pattern in Asian American women was similar to that of the overall United States population.

The Labour Progression Study (LaPS): Duration of labour following Zhang's guideline and the WHO partograph - A cluster randomised trial

OBJECTIVE

To investigate labour duration in different phases of labour when adhering to Zhang's guideline for labour progression compared with the WHO partograph.

DESIGN

A secondary analysis of a cluster randomised controlled trial.

SETTING

Fourteen Norwegian birth care units, each with more than 500 deliveries per year constituted the clusters.

PARTICIPANTS

A total of 7277 nulliparous women with singleton foetus in a cephalic presentation and spontaneous onset of labour at term were included.

INTERVENTION

Seven clusters were randomised to the intervention group that adhered to Zhang's guideline (n = 3972) and seven to the control group that adhered to the WHO partograph (n = 3305) for labour progression.

MEASUREMENTS

The duration of labour from the first registration of cervical dilatation (≥ 4 cm) to the delivery of the baby and the duration of the first and second stages of labour; the time-to-event analysis was used to compare the duration of labour between the two groups after adjusting for baseline covariates.

FINDINGS

The adjusted median duration of labour was 7.0 h in the Zhang group, compared with 6.2 h in the WHO group; the median difference was 0.84 h with 95% confidence interval [CI] (0.2-1.5). The adjusted median duration of the first stage was 5.6 h in the Zhang group compared with 4.9 h in the WHO group; the median difference was 0.66 h with 95% CI (0.1-1.2). The corresponding adjusted median duration of the second stage was 88 and 77 min; the median difference was 0.18 h with 95% CI (0.1-0.3).

KEY CONCLUSIONS

The women who adhered to Zhang's guideline had longer overall duration and duration of the first and second stages of labour than women who adhered to the WHO partograph.

IMPLICATIONS FOR PRACTICE

Understanding the variations in the duration of labour is of great importance, and the results offer useful insights into the different labour progression guidelines, which can inform clinical practice.

Mode of delivery among nulliparous women with single, cephalic, term pregnancies: The WHO global survey on maternal and perinatal health, 2004-2008

OBJECTIVE

To determine risk factors associated with cesarean delivery among nulliparous women in spontaneous labor with a single, cephalic, term pregnancy (Robson group 1).

METHODS

Data were assessed from the WHO Global Survey of Maternal and Perinatal Health conducted in 2004-2008.

RESULTS

Among 82 280 women in Robson group 1, 67 698 (82.3%) had vaginal and 14 578 (17.7%) had cesarean delivery. In adjusted analyses, maternal factors associated with cesarean included age older than 18 years, being overweight or obese, being married or cohabitating, attending four prenatal visits or more, and being medically high risk (P<0.001). Women who were obstetrically high risk, referred during labor, or at 39 gestational weeks or more were also more likely to undergo cesarean (all P<0.001). Facility-level factors associated with cesarean were availability of an anesthesia service 24/7, being a teaching facility, requirement of fees for cesarean, availability of electronic fetal monitoring, and having providers skilled in operative vaginal delivery (all P<0.01).

CONCLUSION

The analysis highlights the importance of maintaining a healthy pre-pregnancy and pregnancy weight, optimizing management of women with medical problems, and ensuring clear referral mechanisms for women with intrapartum complications. The association between fees and cesarean delivery warrants further exploration.

Diagnostic accuracy of the partograph alert and action lines to predict adverse birth outcomes: a systematic review

BACKGROUND

There are questions about the use of the 'one-centimetre per hour rule' as a valid benchmark for assessing the adequacy of labour progress.

OBJECTIVES

To determine the accuracy of the alert (1-cm/hour) and action lines of the cervicograph in the partograph to predict adverse birth outcomes among women in first stage of labour.

SEARCH STRATEGY

PubMed, EMBASE, CINAHL, POPLINE, Global Health Library, and reference lists of eligible studies.

SELECTION CRITERIA

Observational studies and other study designs reporting data on the correlation between the alert line status of women in labour and the occurrence of adverse birth outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers at a time independently identified eligible studies and independently abstracted data including population characteristics and maternal and perinatal outcomes.

MAIN RESULTS

Thirteen studies in which 20 471 women participated were included in the review. The percentage of women crossing the alert line varied from 8 to 76% for all maternal or perinatal outcomes. No study showed a robust diagnostic test accuracy profile for any of the selected outcomes.

CONCLUSIONS

This systematic review does not support the use of the cervical dilatation over time (at a threshold of 1 cm/h during active first stage) to identify women at risk of adverse birth outcomes.

TWEETABLE ABSTRACT

Alert line of partograph does not identify women at risk of adverse birth outcomes.

Factors associated with intrapartum cesarean section in women aged 40 years or older: a single-center experience in Japan

Objective: To elucidate the efficacy and safety of attempting a vaginal birth and to understand the factors that contribute to the increased risk of operative delivery in women aged 40 years or older.Methods: A database of the Japanese Red Cross Nagoya Daiichi Hospital was reviewed to identify women aged 40 years or older with singleton, vertex, and vital pregnancies who attempted vaginal delivery at and after 37 + 0 gestational weeks between January 2011 and December 2016.Results: A total of 415 women met the criteria for inclusion in this study, including 372 and 43 women who gave birth by vaginal delivery and by intrapartum cesarean section (CS), respectively. Vaginal delivery was observed in 84.1% (201/239) and 97.2% (171/176) of nulliparous and multiparous women, respectively. In a logistic regression model, nulliparity [odds ratio (OR), 5.18; 95% confidence interval (CI), 1.91-14.00], assisted reproductive technology (OR, 2.83; 95% CI, 1.42-5.62), and admission for induction of childbirth (OR, 2.68; 95% CI, 1.08-6.67) were associated with a higher likelihood of intrapartum CS. Of 372 women who delivered vaginally, 62 women needed operative delivery. Operative delivery was necessary for 25.4% (51/201) and 6.4% (11/171) of nulliparous and multiparous women, respectively. A logistic regression model identified nulliparity (OR, 3.91; 95% CI, 1.89-8.08) and administration of ecbolic (OR, 2.49; 95% CI, 1.21-5.10) as being independent factors associated with vacuum extraction.Conclusions: Maternal age 40 years or older should not be a barrier for attempting a vaginal delivery, and those women should be encouraged to attempt a vaginal delivery.

The frequency of intrapartum caesarean section use with the WHO partograph versus Zhang's guideline in the Labour Progression Study (LaPS): a multicentre, cluster-randomised controlled trial

BACKGROUND

There is an ongoing debate concerning which guidelines and monitoring tools are most beneficial for assessing labour progression, to help prevent use of intrapartum caesarean section (ICS). The WHO partograph has been used for decades with the assumption of a linear labour progression; however, in 2010, Zhang introduced a new guideline suggesting a more dynamic labour progression. We aimed to investigate whether the frequency of ICS use differed when adhering to the WHO partograph versus Zhang's guideline for labour progression.

METHODS

We did a multicentre, cluster-randomised controlled trial at obstetric units in Norway, and each site was required to deliver more than 500 fetuses per year to be eligible for inclusion. The participants were nulliparous women who had a singleton, full-term fetus with cephalic presentation, and who entered spontaneous active labour. The obstetric units were treated as clusters, and women treated within these clusters were all given the same treatment. We stratified these clusters by size and number of previous caesarean sections. The clusters containing the obstetric units were then randomly assigned (1:1) to the control group, which adhered to the WHO partograph, or to the intervention group, which adhered to Zhang's guideline. The randomisation was computer-generated and was done in the Unit of Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway, and investigators in this unit had no further involvement in the trial. Our study design did not enable masking of participants or health-care providers, but the investigators who were analysing the data were masked to group allocation. The primary outcome was use of ICS during active labour (cervical dilatation of 4-10 cm) in all participating women. The Labour Progression Study (LaPS) is registered with ClinicalTrials.gov, number NCT02221427.

FINDINGS

Between Aug 1, 2014, and Sept 1, 2014, 14 clusters were enrolled in the LaPS trial, and on Sept 11, 2014, seven obstetric units were randomly assigned to the control group (adhering to the WHO partograph) and seven obstetric units were randomly assigned to the intervention group (adhering to Zhang's guideline). Between Dec 1, 2014, and Jan 31, 2017, 11 615 women were judged to be eligible for recruitment in the trial, which comprised 5421 (46·7%) women in the control group units and 6194 (53·3%) women in the intervention group units. In the control group, 2100 (38·7%) of 5421 women did not give signed consent to participate and 16 (0·3%) women abstained from participation. In the intervention group, 2181 (35·2%) of 6194 women did not give signed consent to participate and 41 (0·7%) women abstained from participation. 7277 (62·7%) of 11 615 eligible women were therefore included in the analysis of the primary endpoint. Of these women, 3305 (45·4%) participants were in an obstetric unit that was randomly assigned to the control group (adhering to the WHO partograph) and 3972 (54·6%) participants were in an obstetric unit that was randomly assigned to the intervention group (adhering to Zhang's guideline). No women dropped out during the trial. Before the start of the trial, ICS was used in 9·5% of deliveries in the control group obstetric units and in 9·3% of intervention group obstetric units. During our trial, there were 196 (5·9%) ICS deliveries in women in the control group (WHO partograph) and 271 (6·8%) ICS deliveries in women in the intervention group (Zhang's guideline), and the frequency of ICS use did not differ between the groups (adjusted relative risk 1·17, 95% CI 0·98-1·40; p=0·08; adjusted risk difference 1·00%, 95% CI -0·1 to 2·1). We identified no maternal or neonatal deaths during our study.

INTERPRETATION

We did not find any significant difference in the frequency of ICS use between the obstetric units assigned to adhere to the WHO partograph and those assigned to adhere to Zhang's guideline. The overall decrease in ICS use that we observed relative to the previous frequency of ICS use noted in these obstetric units might be explained by the close focus on assessing labour progression more than use of the guidelines. Our results represent an important contribution to the discussion on implementation of the new guideline.

FUNDING

Østfold Hospital Trust.