Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes

University of Utah, Salt Lake City, Utah, United States
Obstetrics and Gynecology (Impact Factor: 5.18). 12/2010; 116(6):1281-7. DOI: 10.1097/AOG.0b013e3181fdef6e
Source: PubMed


To use contemporary labor data to examine the labor patterns in a large, modern obstetric population in the United States.
Data were from the Consortium on Safe Labor, a multicenter retrospective study that abstracted detailed labor and delivery information from electronic medical records in 19 hospitals across the United States. A total of 62,415 parturients were selected who had a singleton term gestation, spontaneous onset of labor, vertex presentation, vaginal delivery, and a normal perinatal outcome. A repeated-measures analysis was used to construct average labor curves by parity. An interval-censored regression was used to estimate duration of labor, stratified by cervical dilation at admission and centimeter by centimeter.
Labor may take more than 6 hours to progress from 4 to 5 cm and more than 3 hours to progress from 5 to 6 cm of dilation. Nulliparous and multiparous women appeared to progress at a similar pace before 6 cm. However, after 6 cm, labor accelerated much faster in multiparous than in nulliparous women. The 95 percentiles of the second stage of labor in nulliparous women with and without epidural analgesia were 3.6 and 2.8 hours, respectively. A partogram for nulliparous women is proposed.
In a large, contemporary population, the rate of cervical dilation accelerated after 6 cm, and progress from 4 cm to 6 cm was far slower than previously described. Allowing labor to continue for a longer period before 6 cm of cervical dilation may reduce the rate of intrapartum and subsequent repeat cesarean deliveries in the United States.

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Available from: Helain J Landy, Mar 16, 2015
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    • "These include the provision of continuous support in labour, labouring in a midwifery unit, encouraging mobility and posture change and having access to water immersion. Further research is needed to establish more robust criteria for diagnosing dystocia and should include a trial of Zhang's alternative partogram [12] premised on step-like cervical dilatation and an active phase commencing at 6 cm. Research is also needed to explore the aetiology of irregular and inefficient contractions in the active phase of the first stage of labour and possible interventions to address this, including the effectiveness of oxytocin infusion. "
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    ABSTRACT: The objective of the review is to critically review the diagnosis and management of dystocia in the first stage of labour. We conducted a narrative review of research since 1998. Eight studies were identified, four about the onset and duration of active phase of the first stage of labour, one on the diagnosis of dystocia, and three focused on the treatment of dystocia. The review demonstrates that current understandings of dystocia rest on outdated definitions of active first stage of labour, its progress and on treatments with an equivocal evidence base. These include the cervical dilatation threshold for active first stage, uncertainty over whether a reduced rate of dilatation and reduced strength of uterine contractions always represent pathology and the effectiveness of amniotomy/oxytocin for treating dystocia. Prospective studies should evaluate the impact of defining the active phase of the first stage of labour as commencing at 6cm dilated and should test this definition in combination with Zhang's revised partogram.
    European Journal of Obstetrics & Gynecology and Reproductive Biology 09/2014; 182C:123-127. DOI:10.1016/j.ejogrb.2014.09.011 · 1.70 Impact Factor
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    • "The methodological development was motivated by the consortium on safe labor (CSL) study. The CSL study is a multi-center retrospective observational study conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), and explained elsewhere in detail (Zhang et al., 2010). In brief, the study was conducted from 2002 to 2008 with the main objective to describe contemporary labor patterns and establish time to Cesarean delivery in women with labor protraction and arrest. "
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    ABSTRACT: In some longitudinal studies the initiation time of the process is not clearly defined, yet it is important to make inference or do predictions about the longitudinal process. The application of interest in this article is to provide a framework for modeling individualized labor curves (longitudinal cervical dilation measurements) where the start of labor is not clearly defined. This is a well-known problem in obstetrics where the benchmark reference time is often chosen as the end of the process (individuals are fully dilated at 10 cm) and time is run backwards. This approach results in valid and efficient inference unless subjects are censored before the end of the process, or if we are focused on prediction. Providing dynamic individualized predictions of the longitudinal labor curve prospectively (where backwards time is unknown) is of interest to aid obstetricians to determine if a labor is on a suitable trajectory. We propose a model for longitudinal labor dilation that uses a random-effects model with unknown time-zero and a random change point. We present a maximum likelihood approach for parameter estimation that uses adaptive Gaussian quadrature for the numerical integration. Further, we propose a Monte Carlo approach for dynamic prediction of the future longitudinal dilation trajectory from past dilation measurements. The methodology is illustrated with longitudinal cervical dilation data from the Consortium of Safe Labor Study.
    Biometrics 08/2014; 70(4). DOI:10.1111/biom.12218 · 1.57 Impact Factor
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    • "The use of partogram or ICD-code is fraught with difficulties in accurate assessment with a true prolonged labour because they are based on the Friedman standards. The consortium of safe labour data [41] are now accepted and has been highlighted by the American college of obstetricians and gynecologist to revise definitions of normal labour progress and to introduce new guidelines for evidence based labour care. "
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    ABSTRACT: Background: Prolonged labour very often causes suffering from difficulties that may have lifelong implications. This study aimed to explore the prevalence and treatment of prolonged labour and to compare birth outcome and women's experiences of prolonged and normal labour. Method: Women with spontaneous onset of labour, living in a Swedish county, were recruited two months after birth, to a cross-sectional study. Women (n = 829) completed a questionnaire that investigated socio-demographic and obstetric background, birth outcome and women's feelings and experiences of birth. The prevalence of prolonged labour, as defined by a documented ICD-code and inspection of partogram was calculated. Four groups were identified; women with prolonged labour as identified by documented ICD-codes or by partogram inspection but no ICD-code; women with normal labour augmented with oxytocin or not. Results: Every fifth woman experienced a prolonged labour. The prevalence with the documented ICD-code was (13%) and without ICD-code but positive partogram was (8%). Seven percent of women with prolonged labour were not treated with oxytocin. Approximately one in three women (28%) received oxytocin augmentation despite having no evidence of prolonged labour. The length of labour differed between the four groups of women, from 7 to 23 hours.Women with a prolonged labour had a negative birth experience more often (13%) than did women who had a normal labour (3%) (P <0.00). The factors that contributed most strongly to a negative birth experience in women with prolonged labour were emergency Caesarean section (OR 9.0, 95% CI 1.2-3.0) and to strongly agree with the following statement 'My birth experience made me decide not to have any more children' (OR 41.3, 95% CI 4.9-349.6). The factors that contributed most strongly to a negative birth experience in women with normal labour were less agreement with the statement 'It was exiting to give birth' (OR 0.13, 95% CI 0.34-0.5). Conclusions: There is need for increased clinical skill in identification and classification of prolonged labour, in order to improve care for all women and their experiences of birthing processes regardless whether they experience a prolonged labour or not.
    BMC Pregnancy and Childbirth 07/2014; 14(1):233. DOI:10.1186/1471-2393-14-233 · 2.19 Impact Factor
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