Prediction model for labour dystocia occurring in the active phase.

To establish and verify a model for labour dystocia occurring in the active phase, this study retrospectively analysed the clinical data of primiparas with singleton cephalic full-term foetuses, who had delivered after a trial of labour. The Chi-square test, t-test, Mann-Whitney U test and multivariate logistic regression analysis were used for statistical analysis. Based on the model a nomogram was established using the R programming language. Multivariate logistic regression analysis showed that the foetal abdominal circumference, premature rupture of membranes (PROM), prolonged latent phase, foetal station and foetal position at the early stage of the active phase were independent factors influencing labour dystocia occurring in the active phase. The established model could effectively and accurately support clinicians in the early identification of labour dystocia to improve maternal and infant outcomes.Impact statementWhat is already known on this subject? Labour dystocia occurring during the active phase of the first stage, is the most commonly diagnosed as labour aberration. Previous studies have suggested that maternal age, body mass index, macrosomia and abnormal foetal position are the independent risk factors for labour dystocia. However, only the risk factors were reported, and few prediction models were established.What do the results of this study add? This study uses data in the real world to establish a prediction model of full-term singleton primipara with labour dystocia occurring in the active phase by logistic regression analysis. Foetal abdomen circumference, PROM, prolonged latent phase, the foetal station and foetal position at the early stage of the active phase are independent factors influencing labour dystocia that occurs in the active phase. In addition, a nomogram is established as a visual graph to predict the probability of it.What are the implications of these findings for clinical practice and/or further research? The nomogram based on the predictive model discarded complicated calculations and presented an easy visual graph-based method to predict the probability of labour dystocia occurring in the active phase. It helps to introduce interventions that could reduce the CS rate and occurrence of adverse maternal and foetal outcomes to ensure the safety of mothers and infants.

Pre- and during- labour predictors of dystocia in active phase of labour: a case-control study.

BACKGROUND: Labour dystocia (LD) is associated with maternal and foeto-neonatal complications and increased rate of caesarean section. There are scant studies on predictive factors of labour dystocia in Iran, as well as in other countries. Therefore, this study aimed to identify the predictive factors of LD using an integrated and collaborative pre- and during- labour factors to help formulate more effective intervention strategies for prevention and management of LD. METHODS: In this case-control study, 350 women with and 350 women without LD, matched individually in terms of parity and hospital, were compared. The participants were in active labor, had singleton pregnancy, live foetus with a cephalic presentation, gestational age of 37+ 0-41+ 6 weeks, and were hospitalized for vaginal birth in two teaching hospitals in Tabriz, Iran. Data related to the socio-demographic characteristics, anxiety status (using the Spielberger State Anxiety Inventory), and woman dehydration were collected at cervical dilatation between 4 and 6 cm (before dystocia detection) and the other data at different phases of labour, and after birth (before discharge). The multivariate logistic regression was used to determine the predictors. RESULTS: The predictors of LD were severe [OR 58.0 (95% CI 26.9 to 125.1)] and moderate [8.6 (4.2 to 17.4)] anxiety, woman dehydration > 3 h [18.67 (4.0 to 87.3)] and ≤ 3 h [2.8 (1.7 to 4.8], insufficient support by the medical staff in the delivery room [5.8 (1.9 to 17.9)], remifentanil administration [3.1 (1.5 to 6.2)], labour induction [4.2 (2.5 to 7.2], low income [2.0 (1.2 to 3.3)], woman's height < 160 cm [2.0 (1.1 to 3.3)], and woman age of 16-20 y [0.3 (0.2 to 0.6)]. The proportion of the variance explained by all these factors was 74%. CONCLUSION: The controllable predictors, such as woman anxiety and dehydration, and insufficient support from medical staff during labour were strongly associated with the risk of LD. Therefore, it seems that responding to woman physical, psychological, and supportive needs during labour can play a significant role in LD prevention and control. ETHICAL CODE: IR.TBZMED.REC.1397.624.

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

BACKGROUND: The call for women-centred approaches to reduce labour interventions, particularly primary caesarean section, has renewed an interest in gaining a better understanding of natural labour progression. OBJECTIVE: To synthesise available data on the cervical dilatation patterns during spontaneous labour of 'low-risk' women with normal perinatal outcomes. SEARCH STRATEGY: PubMed, EMBASE, CINAHL, POPLINE, Global Health Library, and reference lists of eligible studies. SELECTION CRITERIA: Observational studies and other study designs. DATA COLLECTION AND ANALYSIS: Two authors extracted data on: maternal characteristics; labour interventions; the duration of labour centimetre by centimetre; and the duration of labour from dilatation at admission through to 10 cm. We pooled data across studies using weighted medians and employed the Bootstrap-t method to generate the corresponding confidence bounds. MAIN RESULTS: Seven observational studies describing labour patterns for 99 971 women met our inclusion criteria. The median time to advance by 1 cm in nulliparous women was longer than 1 hour until a dilatation of 5 cm was reached, with markedly rapid progress after 6 cm. Similar labour progression patterns were observed in parous women. The 95th percentiles for both parity groups suggest that it was not uncommon for some women to reach 10 cm, despite dilatation rates that were much slower than the 1-cm/hour threshold for most part of their first stage of labours. CONCLUSION: An expectation of a minimum cervical dilatation threshold of 1 cm/hour throughout the first stage of labour is unrealistic for most healthy nulliparous and parous women. Our findings call into question the universal application of clinical standards that are conceptually based on an expectation of linear labour progress in all women. FUNDING: UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, and the United States Agency for International Development (USAID). TWEETABLE ABSTRACT: Cervical dilatation threshold of 1 cm/hour throughout labour is unrealistic for most women, regardless of parity.

Accelerated Titration of Oxytocin in Nulliparous Women with Labour Dystocia: Results of the ACTION Pilot Randomized Controlled Trial.

OBJECTIVE: The primary objective was to determine the feasibility of a large RCT assessing the effectiveness of an accelerated oxytocin titration (AOT) protocol compared with a standard gradual oxytocin titration (GOT) in reducing the risk of CS in nulliparous women diagnosed with dystocia in the first stage of labour. The secondary objective was to obtain preliminary data on the safety and efficacy of the foregoing AOT protocol. METHODS: This was a multicentre, double-masked, parallel-group pilot RCT. This study was conducted in three Canadian birthing centres. A total of 79 term nulliparous women carrying a singleton pregnancy in spontaneous labour, with a diagnosis of labour dystocia, were randomized to receive either GOT (initial dose 2 mU/min with increments of 2 mU/min) or AOT (initial dose 4 mU/min with increments of 4 mU/min), in a 1:1 ratio. An intention-to-treat analysis was applied. RESULTS: A total of 252 women were screened and approached, 137 (54.4%) consented, and 79 (31.3%) were randomized. Overall protocol adherence was 76 of 79 (96.2%). Of the women randomized, 10 (25.6%) allocated to GOT had a CS compared with six (15.0%) allocated to AOT (Fisher exact test P = 0.27). CONCLUSION: This pilot study demonstrated that a large, multicentre RCT is not only feasible, but also necessary to assess the effectiveness and safety of an AOT protocol for labour augmentation with regard to CS rate and indicators of maternal and perinatal morbidities.

Cervical dilation at time of caesarean delivery in nulliparous women: a population-based cohort study.

OBJECTIVES: Our objective was to describe contemporary practice patterns in the timing of caesarean delivery in relation to cervical dilation, overall and by indication for caesarean. Our secondary objective was to examine how commonly caesarean delivery was performed for labour dystocia at dilations below 4 cm or without the use of oxytocin, overall and between hospitals. DESIGN: Retrospective, population-based cohort study. SETTING: Ontario, Alberta, and British Columbia, Canada, 2008-2012. POPULATION: Nulliparous women in labour who delivered term singletons in cephalic position. METHODS: Histograms were used to examine the distribution of cervical dilation at time of caesarean delivery, overall and by indication for caesarean. Funnel plots were used to illustrate variation in hospital-level rates of caesarean deliveries for labour dystocia that were performed early (<4 cm dilation) or without the use of oxytocin. MAIN OUTCOME MEASURES: Cervical dilation (in centimetres) at time of caesarean delivery. RESULTS: The population-based cohort comprised 392 025 women, of whom 18.8% had a caesarean delivery. Of first-stage caesareans for labour dystocia in women who entered labour spontaneously, 13.6% (95% CI 12.9, 14.2) had dilations <4 cm [hospital-level inter-quartile range (IQR): 6.2% to 20.0%] and 29.5% (95% CI 28.6, 30.4) did not receive oxytocin to treat their dystocia (hospital-level IQR: 22.1-54.6%). CONCLUSIONS: The proportion of caesareans done before 4 cm dilation or without oxytocin varies substantially across hospitals and suggests the need for institutions to review their practices and ensure that management of labour practice guidelines are followed. TWEETABLE ABSTRACT: Many caesareans for labour dystocia are performed early during labour (<4 cm dilation) or without oxytocin.

Inter-institutional Variation in Use of Caesarean Delivery for Labour Dystocia.

OBJECTIVE: To establish the degree of variation across hospitals in the use of Caesarean delivery for the indication of labour dystocia before and after accounting for maternal, fetal, and hospital characteristics. METHODS: This study was a retrospective, population-based cohort study of nulliparous women delivering term singletons in cephalic position following labour. Delivery visits were extracted from three provincial perinatal registries in the Canadian provinces of Ontario, Alberta, and British Columbia, from 2008-2012. Crude hospital-specific rates of Caesarean delivery for labour dystocia were reported, and these rates were then stabilized to account for hospitals with low delivery volumes. Rates were then adjusted for maternal, fetal, and hospital characteristics using hierarchical logistic regression. RESULTS: Among 403 205 women delivering at 170 hospitals, the overall Caesarean delivery rate was 21.0%, and the rate of Caesarean delivery for labour dystocia was 12.7%, indicating that 60% of all Caesarean deliveries were performed in part for this indication. The middle 95% of hospitals had Caesarean delivery rates for labour dystocia ranging from 4.5% to 24.7%. Differences in maternal case mix and hospital characteristics explained only a small proportion of this variation (95% central range 6.3%-21.7%). CONCLUSION: Considerable inter-hospital variation in rates of Caesarean delivery for labour dystocia remained after accounting for differences in maternal and hospital factors. Reporting systems that monitor variation in inter-institutional rates should incorporate stabilization and adjustment for case-mix differences and consider indication-specific rates of Caesarean delivery to more fairly compare hospital performance and better target interventions to reduce Caesarean delivery for specific indications.

Management of Spontaneous Labour at Term in Healthy Women.

OBJECTIVE: The purpose of this guideline is to provide guidance for the intrapartum management of spontaneous labour, whether normal or abnormal, in term, healthy women, and to provide guidance in the management of first and second stage dystocia to increase the likelihood of a vaginal birth and optimize birth outcomes. EVIDENCE: Published literature was retrieved through searches of PubMed and the Cochrane Library in October 2011 using appropriate, controlled vocabulary (e.g., labour pain; labour, obstetric; dystocia) and key words (e.g., obstetric labor, perineal care, dysfunctional labor). When appropriate, results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Results were limited to the last 10 years. Searches were updated on a regular basis and incorporated in the guideline up to June 15, 2015. VALUES: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). SUMMARY STATEMENTS: RECOMMENDATIONS.

Prise en charge du travail spontané chez les femmes en santé, à terme.

OBJECTIF: La présente directive vise à fournir des conseils concernant la prise en charge du travail spontané intrapartum, normal ou anormal, à terme, chez les femmes en santé, ainsi que des conseils relatifs à la prise en charge de la dystocie lors du premier et du deuxième stade du travail, pour favoriser l'accouchement vaginal et optimiser les issues de la grossesse. DONNéES PROBANTES: Des documents publiés ont été récupérés au moyen de recherches effectuées dans PubMed et la Cochrane Library, en octobre 2011, à partir d'une terminologie appropriée et contrôlée (p. ex., labour pain; labour, obstetric; dystocia) et de mots-clés (p. ex., obstetric labor, perineal care, dysfunctional labor). Lorsque cela convenait, on n'a tenu compte que des résultats qui proviennent de revues systématiques, d'essais contrôlés aléatoires ou d'essais cliniques contrôlés et d'études d'observation. Seuls les résultats des 10 dernières années ont été pris en considération; les recherches ont été régulièrement mises à jour jusqu'au 15 juin 2015 et intégrées à la directive. VALEURS: La qualité des données probantes a été évaluée en fonction des critères décrits dans le Rapport du Groupe d'étude canadien sur les soins de santé préventifs (tableau 1). DéCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Failure to progress or just normal? A constructivist grounded theory of physiological plateaus during childbirth.

BACKGROUND AND PROBLEM: During childbirth, one of the most common diagnoses of pathology is 'failure to progress', frequently resulting in labour augmentation and intervention cascades. However, failure to progress is poorly defined and evidence suggests that some instances of slowing, stalling and pausing labour patterns may represent physiological plateaus. AIM: To explore how midwives conceptualise physiological plateaus and the significance such plateaus may have for women's labour trajectory and birth outcome. METHODS: Twenty midwives across Australia participated in semi-structured interviews between September 2020 and February 2022. Constructivist grounded theory methodology was applied to analyse data, including multi-phasic coding and application of constant comparative methods, resulting in a novel theory of physiological plateaus that is firmly supported by participant data. FINDINGS: This study found that the conceptualisation of plateauing labour depends largely on health professionals' philosophical assumptions around childbirth. While the Medical Dominant Paradigm frames plateaus as invariably pathological, the Holistic Midwifery Paradigm acknowledges plateaus as a common and valuable element of labour that serves a self-regulatory purpose and results in good birth outcomes for mother and baby. DISCUSSION: Contemporary medicalised approaches in maternity care, which are based on an expectation of continuous labour progress, appear to carry a risk for a misinterpretation of physiological plateaus as pathological. CONCLUSION: This study challenges the widespread bio-medical conceptualisation of plateauing labour as failure to progress, encourages a renegotiation of what can be considered healthy and normal during childbirth, and provides a stimulus to acknowledge the significance of childbirth philosophy for maternity care practice.

Comparing compliance with commencement and use of two partograph designs for women in active labour: A randomised controlled trial.

BACKGROUND: Documentation and assessment of progress in labour using a partograph is recommended by the World Health Organisation to assist in the timely recognition of labour dystocia. Recent studies have tested new designs of partographs that aim to account for more variable rates of labour progress. However, other studies have suggested that poor compliance in the completion of partographs affects utility. The objective of this study was to compare two types of partographs for compliance in documentation and use for managing labour. METHODS: Low-risk nulliparous women in spontaneous labour (n = 228) were randomised to either an Action Line (control) (n = 114) or Dystocia Line partograph (intervention) (n = 114). Primary outcome was compliance with instructions for commencement of the partograph following a multifaceted training strategy. Secondary outcomes included compliance with the accompanying clinical management protocol for each partograph; and labour and birth outcomes. RESULTS: The compliance rate for commencing the Action line partograph was 43.2% compared to 67.0% (p = 0.02) for the Dystocia line partograph. Other than a reduction in artificial rupture of membranes in the Dystocia Line group there were no other differences in labour management or birth outcomes. The use of centralised electronic display of labour progress may be a contributing factor. CONCLUSIONS: Compliance with the commencement and use of either partograph was low. There was little indication that the partograph was being utilized in the assessment and management of prolonged labour. Further studies are needed to explore the current utility of partographs in labour management and the effect of centralised monitoring of progress in high resource settings.

The duration of spontaneous active and pushing phases of labour among 75,243 US women when intervention is minimal: A prospective, observational cohort study.

Background: Friedman's curve, despite acknowledged limitations, has greatly influenced labour management. Interventions to hasten birth are now ubiquitous, challenging the contemporary study of normal labour. Our primary purpose was to characterise normal active labour and pushing durations in a large, contemporary sample experiencing minimal intervention, stratified by parity, age, and body mass index (BMI). Methods: This is a secondary analysis of the national, validated Midwives Alliance of North America 4·0 (MANA Stats) data registry (n = 75,243), prospectively collected between Jan 1, 2012 and Dec 31, 2018 to describe labour and birth in home and birth center settings where common obstetric interventions [i.e., oxytocin, planned cesarean] are not available. The MANA Stats cohort includes pregnant people who intended birth in these settings and prospectively collects labour and birth processes and outcomes regardless of where birth or postpartum care ultimately occurs. Survival curves were calculated to estimate labour duration percentiles (e.g. 10th, 50th, 90th, and others of interest), by parity and sub-stratified by age and BMI. Findings: Compared to multiparous women (n = 32,882), nulliparous women (n = 15,331) had significantly longer active labour [e.g., median 7.5 vs. 3.3 h; 95th percentile 34.8 vs. 12.0 h] and significantly longer pushing phase [e.g., median 1.1 vs. 0.2 h; 95th percentile 5.5 vs. 1.1 h]. Among nulliparous women, maternal age >35 was associated with longer active first stage of labour and longer pushing phase, and BMI >30 kg/m² was associated with a longer active first stage of labour but a shorter pushing phase. Patterns among multiparous women were different, with those >35 years of age experiencing a slightly more rapid active labour and no difference in pushing duration, and those with BMI >30 kg/m² experiencing a slightly longer active labour but, similarly, no difference in pushing duration. Interpretation: Nulliparous women had significantly longer active first stage and pushing phase durations than multiparous women, with further variation noted by age and by BMI. Contemporary US women with low-risk pregnancies who intended birth in settings absent common obstetric interventions and in spontaneous labour with a live, vertex, term, singleton, non-anomalous fetus experienced labour durations that were often longer than prior characterizations, particularly among nulliparous women. Results overcome prior and current sampling limitations to refine understanding of normal labour durations and time thresholds signaling 'labour dystocia'. Funding: OHSU Nursing Innovation and OHSU University Shared Resources.

Management of oxytocin for labour augmentation in relation to mode of birth in Robson group 1.

OBJECTIVE: To compare mode of birth in Robson group 1 according to administration of oxytocin for labour augmentation. DESIGN AND PARTICIPANTS: A retrospective review of 724 medical records from women in Robson group 1 was performed. The outcome measurements were: mode of birth in relation to presence of labour dystocia when initiating augmentation with oxytocin, duration of augmentation with oxytocin, increase of the oxytocin infusion according to recommendations and cervical dilation when initiating augmentation with oxytocin. SETTING: The review was based on medical records from a medium-sized tertiary level obstetric unit in southern Sweden, with approximately 3700 births per year. Data was collected between January 2017 and October 2017. MEASUREMENTS AND FINDINGS: Oxytocin for labour augmentation was used in 64.1% of the births. Oxytocin administered according to the national recommendations was related to a greater likelihood of vaginal birth than when these recommendations were not followed. Only 47.8% of the women who underwent a caesarean section was treated according to recommendations. Receiving augmentation with oxytocin at a later stage of labour was related to a greater likelihood of a vaginal birth. The total time treated with oxytocin was significantly longer in women who had an assisted vaginal birth or a caesarean section than those who had a vaginal birth with augmentation. KEY CONCLUSIONS: Oxytocin for labour augmentation was over-used in Robson group 1. Oxytocin early in labour, a long duration of stimulation with oxytocin and a slower increase of the infusion than recommended had a relationship with caesarean section. IMPLICATION FOR PRACTICE: Due to risks for adverse maternal and neonatal outcomes when using oxytocin for labour augmentation, caregivers should implement strict protocols for its use. According to a high use of oxytocin there is a need to describe women's experiences of labour augmentation in labour dystocia but also when received despite normal labour progress.

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.