FIRST STAGE OF LABOR UCSF AIM conference for the invitation to - PowerPoint PPT Presentation

6/14/2019 Acknowledgements FIRST STAGE OF LABOR • UCSF AIM conference for the invitation to present • Oregon Health & Science University mentors, collaborators, patients, students, and community HOW DO WE MANAGE IN 2019? • Special thanks to the OHSU CNM patients whose data contributed to our latent labor analyses and to the OHSU CNMs who entered this data in addition to completing EMR! Ellen Tilden, CNM, PhD, FACNM Oregon Health and Science University • No financial disclosures School of Nursing, Midwifery Department School of Medicine, Department of Obstetrics & Gynecology #2- A healthy woman G1P0 has been at 7 cms for 2 #1- regarding cervical dilation associated hours. FHT are category 1 and there are no other with active phase onset, 6 is the… concerns about her well-being or fetal well-being. You should: 96% A. New 2 67% A. Start oxytocin B. New 4 B. Cesarean C. New 8 33% C. Not intervene D. 2-4-6-8, who do we appreciate? 3% 1% 0% 1% 2 4 8 ? w w w e t e e e a N N N c i e r p p a e w o n n e d i a n c e e o o r h t a v y s r w x e e o t , C n 8 t i - r 6 a o t - t 4 S N 2 - 1

6/14/2019 Since we already know 2019 management… 1. HOW DO WE KNOW ABOUT FIRST STAGE LABOR PROGRESS? 2. WHAT ABOUT LATENT LABOR? THE SUN SHOULD NOT RISE OR 3. HOW ARE WE CURRENTLY USING THIS SET TWICE ON A WOMAN IN INFORMATION? LABOR -African proverb 4. WHAT MIGHT BE NEXT? Labor that is too long can hurt women + newborns THE SUN SHOULD NOT RISE OR SET TWICE ON A WOMAN IN LABOR -African proverb 1821 2

6/14/2019 RESEARCH CLINICAL 68% most labors 1930 CALKINS (US), FREY (Germany), GEISENDORF (France) No clinical implementation recommended < 5% >95% 1940 WOLF (Germany), ZIMMER (Germany), KOLLER No clinical implementation quick labors tedious labors (Switzerland) recommended 1950 FRIEDMAN 1960 FRIEDMAN Duration of time in the first stage of labor 1970 FRIEDMAN 1980 1990 2000 68% 68% most labors most labors < 5% >95% < 5% >95% quick labors tedious labors quick labors tedious labors = risk Duration of time in the first stage of labor Duration of time in the first stage of labor 3

6/14/2019 RESEARCH CLINICAL 68% YES Maternal: most labors 1930 CALKINS (US), FREY (Germany), GEISENDORF (France) No clinical implementation 1) Urinary retention recommended < 5% >95% 2) Postpartum hemorrhage 3) Chorioamnionitis 1940 WOLF (Germany), ZIMMER (Germany), KOLLER No clinical implementation quick labors tedious labors = risk (Switzerland) recommended Fetal/neonatal/infant: 1950 FRIEDMAN 1) Apgar < 7 at 5 m 2) NICU admit 1960 FRIEDMAN NO or not yet established Duration of time in the first stage of labor No long-term infant/child morbidity 1970 FRIEDMAN PHILPOTT & CASTLE No maternal or child mortality CERVICOGRAPH 1980 1990 2000 68% RESEARCH CLINICAL most labors 1930 CALKINS (US), FREY (Germany), GEISENDORF (France) No clinical implementation recommended < 5% >95% 1940 WOLF (Germany), ZIMMER (Germany), KOLLER No clinical implementation quick labors tedious labors (Switzerland) recommended 1950 FRIEDMAN 1960 FRIEDMAN Duration of time in the first stage of labor 1970 FRIEDMAN PHILPOTT & CASTLE CERVICOGRAPH 1980 ALBERS DUBLIN TRIAL / O’DRISCOLL FRIEDMAN- 1950s: ‘ABERRATIONS’ ‘PROLONGATION’ ACTIVE MANAGEMENT 1990 ALBERS DUBLIN TRIAL / O’DRISCOLL PHILPOTT- 1970s: ‘ALERT LINE’ ‘ACTION LINE’ ACTIVE MANAGEMENT 2000 ZHANG 6 IS THE NEW 4 4

6/14/2019 TEAM ZHANG TEAM FRIEDMAN TEAM ZHANG TEAM FRIEDMAN You used the wrong statistical approach You are a bunch of statistics-obsessed eggheads You also used the wrong sample Your results are different because birthing women now are older and heavier And, BTW, your work has led to You are so inexperienced with the unnecessary intervention during many markers of normal labor normal labors all over the world progress that you can’t understand the ‘dynamic beauty and logic’ of birth ‘ Outcome[s] vary from one woman to another. Our findings question the rigid limits currently applied in clinical practice’ Abalos 2018 ‘Our findings call into question the universal application of clinical standards that are conceptually based on linear labour progression in all women’ –Oladapo 2018 5

6/14/2019 HUMBLE and CURIOUS 6

6/14/2019 When does latent labor start ? Since we already know 2019 management… 4 latent labor studies in the US… Of these 1) Friedman EA. 1955 1. HOW DO WE KNOW ABOUT FIRST STAGE LABOR Don’t clearly define latent onset PROGRESS? 2) Friedman EA . 1956 2. WHAT ABOUT LATENT LABOR? 3) Chelmow D, et al 1993 3. HOW ARE WE CURRENTLY USING THIS INFORMATION? 4) Peisner DB, et al 1985 4. WHAT MIGHT BE NEXT? When does latent labor start ? When does latent labor start ? 4 latent labor studies in the US… Of these 4 latent labor studies in the US… Of these 1) Friedman EA. 1955 1) Friedman EA. 1955 Don’t clearly define latent onset Don’t clearly define latent onset 2) Friedman EA . 1956 2) Friedman EA . 1956 Defines latent onset as time of Defines latent onset as time of 3) Chelmow D, et al 1993 3) Chelmow D, et al 1993 hospital admission hospital admission 4) Peisner DB, et al 1985 4) Peisner DB, et al 1985 Defines latent onset by start of symptoms 7

6/14/2019 665 nulliparous and 616 multiparous >21 years, term singleton vertex The objectives of this study were to: 1) characterize latent phase duration among low-risk U.S. women in spontaneous labor using the women’s self-identified onset; and 2) quantify associations between demographic and maternal/newborn health characteristics and the latent phase duration. FRIEDMAN 1950s – 1970s Study Nulliparous Multiparous mean median mean median Peisner 1985 7.5 hours * 5.2 hours * Friedman 1955-56 8.6 hours 7.5 hours 5.3 hours 4.5 hours Tilden 2019 11.8 hours 9.0 hours 9.3 hours 6.8 hours * = not reported 8

6/14/2019 TILDEN ZHANG ZHANG LATENT ACTIVE LATENT ACTIVE LABOR DYSTOCIA IN ACTIVE OR 2 nd STAGE Tilden , Phillippi, Carlson, Dissanayake, Lee, Caughey , Snowden, under review at AJOG AUGMENTATION, EPIDURAL Longer Latent Same sample Labor LONGER ACTIVE AND 2 nd STAGE The objective of this study was to evaluate the association between the duration of the latent phase at five points of distribution (mean, median, 80 th , 90 th , and 95 th percentiles) and perinatal processes and outcomes that occurred during active labor, MULTIPS >80% = NICU * but 2/3 for observation second stage, birth, and the immediate postpartum. 9

6/14/2019 QUALITY IMPROVEMENT Since we already know 2019 management… 2018 6351 nullips France CD decreased from 9.4% to 6.6% No increase adverse outcomes 1. HOW DO WE KNOW ABOUT FIRST STAGE LABOR PROGRESS? 2. WHAT ABOUT LATENT LABOR? 3. HOW ARE WE CURRENTLY USING THIS INFORMATION? 4. WHAT MIGHT BE NEXT? QUALITY IMPROVEMENT QUALITY IMPROVEMENT 2018 2018 6351 nullips 6351 nullips France France CD decreased from 9.4% to 6.6% CD decreased from 9.4% to 6.6% No increase adverse outcomes No increase adverse outcomes 2018 2018 Maternal care consensus bundles Maternal care consensus bundles ACOG, ACNM, AWHONN ACOG, ACNM, AWHONN 2019 119,000 nullips CA CD decreased from 29.3% to 25% Decreased adverse outcomes 10

6/14/2019 Dublin Trial / O’Driscoll Active Management of Labor Dublin Trial / O’Driscoll Active Management of Labor 1. Amniotomy within one hour of dx active labor 1. Amniotomy within one hour of dx active labor 2. CVX exams Q2 hours 2. CVX exams Q2 hours 3. Insufficient progress = oxytocin started at 4 mu and increased by 4 Q 15 3. Insufficient progress = oxytocin started at 4 mu and increased by 4 Q 15 4. Midwife in charge diagnoses active labor 4. Midwife in charge diagnoses active labor 5. Continuous nursing care and support 5. Continuous nursing care and support O’Driscoll et al 1969 ‘Prevention of Prolonged Labour’ British Medical Journal, 2 O’Driscoll et al 1969 ‘Prevention of Prolonged Labour’ British Medical Journal, 2 PARTOGRAMS 2018 27,077 nullips Dublin Trial / O’Driscoll Active Management of Labor US Latent admit: CD = 18.0% Active admit: CD = 7.2% 1. Amniotomy within one hour of dx active labor Adverse outcomes more common 2. CVX exams Q2 hours if admitted in latent 3. Insufficient progress = oxytocin started at 4 mu and increased by 4 Q 15 4. Midwife in charge diagnoses active labor 5. Continuous nursing care and support O’Driscoll et al 1969 ‘Prevention of Prolonged Labour’ British Medical Journal, 2 11

6/14/2019 PARTOGRAMS PARTOGRAMS 2018 2018 27,077 nullips 27,077 nullips US US Latent admit: CD = 18.0% Latent admit: CD = 18.0% Active admit: CD = 7.2% Active admit: CD = 7.2% Adverse outcomes more common Adverse outcomes more common if admitted in latent if admitted in latent 2019 2019 7,277 nullips 7,277 nullips Norway Norway Friedman/WHO partogram = Friedman/WHO partogram = 9.5% CD → 5.9% CD 9.5% CD → 5.9% CD Zhang partogram = Zhang partogram = 9.3% CD → 6.8% CD 9.3% CD → 6.8% CD 2018 9,475 11 studies included Effects of routine partogram use unclear Since we already know 2019 management… 1. HOW DO WE KNOW ABOUT FIRST STAGE LABOR PROGRESS? + 2. WHAT ABOUT LATENT LABOR? 3. HOW ARE WE CURRENTLY USING THIS INFORMATION? 4. WHAT MIGHT BE NEXT? HIGH TOUCH and HIGH TECH? 12