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Although labor management strategies predicated on the recent Consortium on Safe Labor information have not been assessed yet, some insight into how management of abnormal first-stage labor might be optimized can be deduced from prior studies.
A study of more than 500 women found that extending the minimum period of oxytocin augmentation for active phase arrest from 2 hours to at least 4 hours allowed the majority of women who had not progressed at the 2-hour mark to give birth vaginally without adversely affecting neonatal outcome 22. The researchers defined active phase labor arrest as 1 cm or less of labor progress over 2 hours in women who entered labor spontaneously and were at least 4 cm dilated at the time arrest was diagnosed. The vaginal delivery rate for women who had not progressed despite 2 hours of oxytocin augmentation was 91% for multiparous women and 74% for nulliparous women. For women who had not progressed despite 4 hours of oxytocin (and in whom oxytocin was continued at the judgment of the health care provider), the vaginal delivery rates were 88% in multiparous women and 56% in nulliparous women. Subsequently, the researchers validated these results in a different cohort of 501 prospectively managed women 23. An additional study of 1,014 women conducted by different authors demonstrated that using the same criteria in women with spontaneous labor or induced labor would lead to a significantly higher proportion of women achieving vaginal delivery with no increase in neonatal complications 24. Of note, prolonged first stage of labor has been associated with an increased risk of chorioamnionitis in the studies listed, but whether this relationship is causal is unclear (ie, evolving chorioamnionitis may predispose to longer labors). Thus, although this relationship needs further elucidation, neither chorioamnionitis nor its duration should be an indication for cesarean delivery 25.
Given these data, as long as fetal and maternal status are reassuring, cervical dilation of 6 cm should be considered the threshold for the active phase of most women in labor Box 1. Thus, before 6 cm of dilation is achieved, standards of active phase progress should not be applied Table 3. Further, cesarean delivery for active phase arrest in the first stage of labor should be reserved for women at or beyond 6 cm of dilation with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity, or at least 6 hours of oxytocin administration with inadequate uterine activity and no cervical change Table 3 22.
Scalp stimulation to elicit a fetal heart rate acceleration is an easily employed tool when the cervix is dilated and can offer clinician reassurance that the fetus is not acidotic. Spontaneous or elicited heart rate accelerations are associated with a normal umbilical cord arterial pH (7.20 or greater) 54 56. Recurrent variable decelerations, thought to be a physiologic response to repetitive compression of the umbilical cord, are not themselves pathologic. However, if frequent and persistent, they can lead to fetal acidemia over time. Conservative measures, such as position change, may improve this pattern. Amnioinfusion with normal saline also has been demonstrated to resolve variable fetal heart rate decelerations 57 58 59 and reduce the incidence of cesarean delivery for a nonreassuring fetal heart rate pattern 59 60 61. Similarly, other elements of Category II fetal heart rate tracings that may indicate fetal acidemia, such as minimal variability or recurrent late decelerations, should be approached with in utero resuscitation 48.
Available randomized trial data comparing induction of labor versus expectant management reinforce the more recent observational data. For example, a meta-analysis of prospective randomized controlled trials conducted at less than 42 0/7 weeks of gestation, found that women who underwent induction of labor had a lower rate of cesarean delivery compared with those who received expectant management 84. In addition, a meta-analysis of three older, small studies of induction of labor before 41 0/7 weeks of gestation also demonstrated a statistically significant reduction in the rate of cesarean delivery 85. Additionally, increases in stillbirth, neonatal, and infant death have been associated with gestations at 41 0/7 weeks and beyond 86 87. In a 2012 Cochrane meta-analysis, induction of labor at 41 0/7 weeks of gestation and beyond was associated with a reduction in perinatal mortality when compared with expectant management 85. Therefore, before 41 0/7 weeks of gestation, induction of labor generally should be performed based on maternal and fetal medical 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 Table 3.
Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula. A Cochrane meta-analysis of 12 trials and more than 15,000 women demonstrated that the presence of continuous one-on-one support during labor and delivery was associated with improved patient satisfaction and a statistically significant reduction in the rate of cesarean delivery 111. Given that there are no associated measurable harms, this resource is probably underutilized.
Changing the local culture and attitudes of obstetric care providers regarding the issues involved in cesarean delivery reduction also will be challenging. Several studies have demonstrated the feasibility of using systemic interventions to reduce the rate of cesarean delivery across indications and across community and academic settings. A 2007 review found that the cesarean delivery rate was reduced by 13% when audit and feedback were used exclusively but decreased by 27% when audit and feedback were used as part of a multifaceted intervention, which involved second opinions and culture change 112. Systemic interventions, therefore, provide an important strategic opportunity for reducing cesarean delivery rates. However, the specific interventional approaches have not been studied in large, prospective trials, thus specific recommendations cannot be made.
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