“learning and unlearning” using acog’s & smfm …...fetal and neonatal morbidity in the...

“Learning and Unlearning”

Using ACOG’s & SMFM

Obstetric Care Consensus

published March 2014

as discussion model

Randall J. Morgan MD MBA

When will you adopt

new hair styles?

Which new hair styles

will you adopt & why?

Which new hair styles

will you reject & why?

Simmelweis 1841

• Found lower incidence in

puerperal fever in

women who delivered at

home vs maternity wards

• His teaching were

rejected and he

ultimately was committed

to mental asylum

Oliver Wendell Holmes

1843

• Before the Boston

Society for Medical

Improvement read the 1st

of his famous papers on

the “Contagiousness of

Puerperal Fever.

Conclusion: average of 17 years for research to reach clinical practice.

Which Guidelines will you adopt, when will you adopt them

and how will you decide ones, to adopt.

Using New Data From “The Consortium On Safe Labor” as

the focus for the conversation and new ACOG guidelines.

Conflict(s) of interest

� No financial

� However, my personal opinion is that Randall Morgan should read and understand ACOG, ASCCP, American Cancer Society, etc. guidelines within 30 days of publication

First stage of laborSafe Prevention of the Primary Cesarean

Delivery March 2014

� A prolonged latent phase (eg. greater than 20 hours in nulliparous women and greater than 14 hours in multiparous women) should not be an indication for cesarean delivery IB

� Slow but progressive labor in the first stage of labor should not be an indication for cesarean delivery IB

First stage of labor

Safe Prevention of the Primary Cesarean Delivery

March 2014

� Cervical dilation of 6 cm should be considered the

threshold for the active phase of most women in

labor. Thus, before 6 cm of dilation is achieved,

standards of active phase progress should not be

applied 1B

� Cesarean delivery for active phase arrest in the first

stage of labor should be reserved for women at or

beyond 6 cm of dilation with ruptured membranes

who fail to progress despite 4 hours of adequate

uterine activity, or at least 6 hours of oxytocin

administration with inadequate uterine activity and

no cervical change 1B

Fig. 2. Average labor curves by parity in singleton term pregnancies with spontaneous onset

of labor, vaginal delivery, and normal neonatal outcomes. P0, nulliparous women; P1, women

of parity 1; P2+, women of parity 2 or higher.Zhang. Contemporary Labor Patterns. Obstet

Gynecol 2010.

Fig. 3. The 95th percentiles of cumulative duration of labor from admission among singleton

term nulliparous women with spontaneous onset of labor, vaginal delivery, and normal

neonatal outcomes.Zhang. Contemporary Labor Patterns. Obstet Gynecol 2010.

Active-Phase Labor Arrest: Oxytocin for at least 4 hoursRouse OB GYN March 1999 p. 323-326

Nulliparous (%

vaginal

delivery) n288

Parous (%

vaginal

delivery) n254

2 hours oxytocin

augmentation

74 91

4 hours oxytocin 56 88

� Prospective trial 542

women

� Arrest diagnosed:

� > 4 cm

� < 1 cm change over

2 hours

� Treatment protocol

� c/s if no progression over

4 hours if MVU > 200

� c/s if no progression over

6 hours if MVU < 200

MVU

First stage of labor


March 2014

� Cervical dilation of 6 cm should be considered the

threshold for the active phase of most women in

labor. Thus, before 6 cm of dilation is achieved,

standards of active phase progress should not be

applied 1B

� Cesarean delivery for active phase arrest in the first

stage of labor should be reserved for women at or

beyond 6 cm of dilation with ruptured membranes

who fail to progress despite 4 hours of adequate

uterine activity, or at least 6 hours of oxytocin

administration with inadequate uterine activity and

no cervical change 1B

2nd stage of labor


March 2014

� A specific absolute maximum of time spent in the

second stage of labor beyond which all women

should undergo operative delivery has not been

identified 1B

Second stage of labor


March 2014

� Before diagnosis arrest of labor in the second

stage, if the maternal and fetal conditions permit,

allow for the following:

� At least 2 hours of pushing in multiparous women 1B

� At least 3 hours of pushing in nulliparous women 1B

� Longer durations may be appropriate on an individual bases (eg. With the use of epidural analgesia or with fetal malposition as long as progress is being documented 1B

Zhang Contemporary Labor Patterns Dec 2010 AJOBGYN



March 2014

� Before diagnosis arrest of labor in the second

stage, if the maternal and fetal conditions permit,

allow for the following:

� At least 2 hours of pushing in multiparous women 1B

� At least 3 hours of pushing in nulliparous women 1B

� Longer durations may be appropriate on an individual bases (eg. With the use of epidural analgesia or with fetal malposition as long as progress is being documented 1B



March 2014� Operative vaginal delivery in the second stage of labor by

experienced and well trained physicians should be considered

a safe, acceptable alternative to cesarean delivery. Training

in, and ongoing maintenance of, practical skills related to

operative vaginal delivery should be encouraged. 1B

� Manual rotation of the fetal occiput in the setting of fetal

malposition in the second stage of labor is a reasonable

intervention to consider before moving to operative vaginal

delivery or cesarean delivery. In order to safely prevent

cesarean deliveries in the setting of malposition, it is

important to assess the fetal position in the second stage of

labor, particularly in the setting of abnormal fetal descent. 1B

Fetal Heart Rate Monitoring


March 2014

� Amnio infusion for repetitive variable fetal heart rate decelerations may safely reduce the rate of cesarean delivery. 1B

� Scalp stimulation can be used as a means of assessing fetal acid-base status when abnormal or indeterminate (formally, nonreassuring) fetal heart patterns (eg, minimal variability) are present and is a safe alternative to cesarean delivery in the setting. 1B

Induction of labor


March 2014

�Before 41 0/7 weeks of gestation,

induction of labor generally should be

performed based on maternal and fetal

medication indications. Inductions at 41

0/7 weeks of gestation and beyond

should be performed to reduce the risk of

cesarean delivery and the risk of

perinatal morbidity and mortality. 1A

Management of Late-term and Postterm Pregnancies

August 2014

� Late-term and postterm pregnancies are associated with increased risk of perinatal morbidity and mortality A

� Induction of labor after 42 0/7 and by 42 6/7 is recommended, given evidence of increase of perinatal morbidity and mortality. A

� Induction of labor between 41 0/7 and 42 0/7 weeks of gestation can be considered. B

“Induction of Labor As Compared With Serial

Antenatal Monitoring In Post-term Pregnancy”Hannah NEJ 1992 p. 1587

� RCT, 3407 patients -studied Induction at 41

weeks vs antenatal monitoring

� Induction lower cesarean rates 24 vs 21%

� Difference in c/s rate from fetal distress (5.7

vs 8.3%)

� No difference in perinatal morbidity or

mortality

Induction of labor or serial antenatal fetal monitoring in post term pregnancy

Heimstad, OB GYN Mar 2007 p 609

� RCT 508 women to induction at 289 days or antenatal surveillance every 3rd day until spontaneous labor

� Conclusion:

� Mode of delivery no difference

� Operative vaginal delivery no difference

� 5 minute apgar –no difference

� Neonatal pH < 7-no difference

� 2nd stage shorter in induced group

Fetal and Neonatal Morbidity in the postterm

pregnancy: The impact of gestational age and fetal

growth restrictionDivonAm J OB GYN April 1998 p. 726

� Retrospective study of all deliveries occurring in Sweden between Jan 1, 1987 and Dec 1992

� Selected 1) singleton 2)reliable dates 3)gestational age > 40 weeks 4) maternal age 15-44 years

� Total 181,524 pregnancies met inclusion criteria

Fetal and Neonatal Morbidity in the postterm pregnancy:

The impact of gestational age and fetal growth restrictionDivonAm J OB GYN April 1998 p. 726

� Fetal death OR was

� 1.5 at 41 weeks

� 1.8 at 42 weeks

� 2.9 at 43 weeks

� Neonatal death rate not associated with gestational age

� Fetal growth restriction at every age was associated with mortality

� Fetal death OR 7.1 to 10

� Neonatal death 3.4 to 9.4

Prolonged Pregnancy: evaluating gestation-specific risks of fetal and infant mortality

Hilder Br J.OB GYN 1998 pp. 169-73

� Retrospective analysis of 171,527 births 1989-1991 in North East Thames Region, London

� Outcome measures –births, stillbirths, neonatal and post-neonatal deaths at each gestation after 28 completed weeks.

� Early dating scans available selectively

� Multiple pregnancies counted as 2 births



� Neonatal and post-neonatal mortality rates fell from 28-41 weeks. Nadir was 41 weeks (0.7/100 and 1.3/1000 respectively

“Induction of labour for improving birth outcomes for

women at or beyond term”Cochrane Database of Systematic Reviews 2012 Issue 6. Art. No. CD004945

� 22 RCT’s 9,383 women

� Compared expectant management with induction of labor in term and posttermpregnancies



� For term and postterm induction associated with decreased perinatal death (RR 0.31 95% CI 0.12-0.88, 17 trials of 7407 women)

� Cesarean decreased (RR 0.89 95% CI 0.81 -0.97, 21 trials of 8749 women)

� Meconium aspiration syndrome dec (RR 0.5 95% CI 0.34-0.73, 8 trials of 2371 infants)



� Number needed to treat with induction of labor to prevent one perinatal death was 410 (95% CI 322-1492)

� No differences is neonatal intensive care unit admission (RR 0.90 95% CI 0.78-1.04, 10 trials of 6,161 infants)



� Neonatal and post-neonatal mortality rates fell from 28-41 weeks. Nadir was 41 weeks (0.7/100 and 1.3/1000 respectively

Induction of labor


March 2014� Before 41 0/7 weeks of gestation, induction of labor generally

should be performed based on maternal and fetal medication

indications. Inductions at 41 0/7 weeks of gestation and

beyond should be performed to reduce the risk of cesarean

delivery and the risk of perinatal morbidity and mortality. 1A

� Late-term and postterm pregnancies are associated with

increased risk of perinatal morbidity and mortality A

� Induction of labor after 42 0/7 and by 42 6/7 is recommended,

given evidence of increase of perinatal morbidity and

mortality. A

� Induction of labor between 41 0/7 and 42 0/7 weeks of

gestation can be considered. B

Induction of labor


March 2014

� Cervical ripening methods should be used when

labor is induced in women with an unfavorable

cervix. 1B

� If the maternal and fetal status allow, cesarean

deliveries for failed induction of labor in the latent

phase can be avoided by allowing longer durations

of the latent phase (up to 24 hours or longer) and

requiring that oxytocin be administered for at least

12-18 hours after membrane rupture before deeming

the induction a failure. 1B

Rouse et al, OB GYN Feb 2011 “Failed Labor Induction”

Rouse et al, OB GYN Feb 2011 “Failed Labor Induction”

CONCLUSION: Almost 40% of the women who remained

in the latent phase after 12 hours of oxytocin and

membrane rupture were delivered vaginally. Therefore, it

is reasonable to avoid deeming labor induction a failure

in the latent phase until oxytocin has been administered

for at least 12 hours after membrane rupture.(Obstet Gynecol 2011;117:267–72)

DOI: 10.1097/AOG.0b013e318207887a

LEVEL OF EVIDENCE: III

Induction of labor


March 2014

� Cervical ripening methods should be used when

labor is induced in women with an unfavorable

cervix. 1B

� If the maternal and fetal status allow, cesarean

deliveries for failed induction of labor in the latent

phase can be avoided by allowing longer durations

of the latent phase (up to 24 hours or longer) and

requiring that oxytocin be administered for at least

12-18 hours after membrane rupture before deeming

the induction a failure. 1B

Fetal malpresentation


March 2014

� Fetal presentation should be assessed and documented beginning at 36 0/7 weeks of gestation to allow for external cephalic version to be offered. 1C

Suspected fetal macrosomia


March 2014

� Cesarean delivery to avoid potential birth trauma should be limited to estimated fetal weights of at least 5,000 g in women without diabetes and at least 4,500 g in women with diabetes. The prevalence of birth weight of 5,000 g or more is rare, and patients should be counseled that estimates of fetal weight, particularly late in gestation are imprecise. 2C

Excessive maternal weight gain


March 2014

� Women should be counseled about the IOM maternal weight guidelines in an attempt to avoid excessive weight gain. 1B

Twin gestations


March 2014

� Perinatal outcomes for twin gestations in which the first twin is in cephalic presentation are not improved by cesarean delivery. Thus, women with either cephalic/cephalic-presenting twins or cephalic/noncephalicpresenting twins should be counseled to attempt vaginal delivery. 1B

Induction of labor


March 2014

� Individuals, organizations, and governing bodies should work to ensure that research is conducted to provide a better knowledge base to guide decisions regarding cesarean delivery and to encourage policy changes that safely lower the rate of primary cesarean delivery. 1C

� When I retire, I hope when my partners or competitors look at my medical records for each patient, they can state her care and his documentation account for the guideline(s) that were published 30 days or more from her last visit.

Harper OB GYN June 2012 Normal Labor in Induction

Friedman’s CurveNullipara multipara

Prolonged latent phase >20 hours >14 hours

Average 2nd stage 50 minutes 20 minutes

Prolonged 2nd stage (with

epidural)

>2 hour (>3) > 1 hour (2 hour)

Protracted dilation (95th

percentile)

<1.2 cm/hour < 1.5 cm/hour

Protracted descent (95th

percentile)

< 1cm/hour < 2cm/hour

Arrest of dilation * > 2 hours > 2 hours

Arrest of descent* > 2 hour > 1 hour

Prolonged 3rd stage >30 minutes � 30 minute

*adequate contractions >

200Montevideo unites / 10

minutes for 2 hours

Friedman EA Dec 1955

Obstet Gynecol 6(6):567-89

“learning and unlearning” using acog’s & smfm …...fetal and neonatal morbidity in the...

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