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Management of Labor
How to cite this document:
Creedon D, Akkerman D, Atwood L, Bates L, Harper C, Levin A, McCall C, Peterson D, Rose C, Setterlund L,
Walkes B, Wingeier R. Institute for Clinical Systems Improvement. Management of Labor. Updated March 2013.
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Management of Labor
Fifth Edition
March 2013
< 37 weeks?
See Management of
Signs/Symptoms of
Preterm Labor
algorithm and
annotations
yes
no
10
Previous
uterine
incision?
yes
yes
no
Admit for
labor?
no
yes
11
Have
membranes
ruptured?
no
8
yes
12
Intrapartum care
Cervical exam
Supportive care
Adequate pain relief
Consider amniotomy unless
contraindicated
Monitoring of fetal heart rate
Nurse ausculatory monitoring
or continuous EFM-ext
Subsequent
labor?
no
9
Out of
guideline
13
Any concerns or
complications?
no
14
15
Normal vaginal
delivery
Management of third
stage of labor
yes
16
18
17
Is progression of
labor a concern?
no
yes
no
Other
Out of guideline
yes
19
20
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Copyright 2013 by Institute for Clinical Systems Improvement
Management of Labor
Fifth Edition/March 2013
21
Assessment includes:
Sterile speculum exam
- Fetal fibronectin testing
- Consider GBS, wet prep
for bacterial vaginosis
- GC, chlamydia
Digital cervical exam
Transvaginal ultrasound
for cervical length (if
available)
Ultrasound for growth,
fluid, placenta
Assess contraction patterns
Assess fetal well-being
Urinalysis and urine culture
21
23
22
Obstetric/medical
consultation as indicated;
treat per standard emergency
medical and obstetric
procedures
no
yes
24
Is there a critical
event?
24
Critical events:
Cervix 5+ cm dilated
pPROM
Vaginal bleeding
Chorioamnionitis
suspected
25
yes
no
26
Cervix > 2 cm
dilated, > 80%
effaced, contractions
4/20 or 6/60?
yes
no
27
28
Ultrasound cervical
length < 3.0 cm or fFn
positive?
no
yes
30
31
29
Cervical change?
yes
See Management of
Critical Event algorithm
no
32
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Institute for Clinical Systems Improvement
Management of Labor
Fifth Edition/March 2013
33
34
35
Cervix 5+ cm
dilated?
37
36
yes
39
Consider magnesium
sulfate for
neuroprotection
yes
Is delivery
imminent?
no
no
40
Chorioamnionitis
suspected?
41
yes
Broad spectrum
antibiotics
Plan for delivery
38
Stabilize on tocolytics
Transfer mother to
appropriate level of care
if possible
no
42
Stabilize on tocolytics
Transfer mother to
appropriate level of care
if possible
44
43
Antenatal corticosteroids
23-34 weeks
46
45
Sonogram for:
Amniotic fluid index (AFI)
Presentation/placentation
Follow-up level II as indicated
Sonogram
detects gross
anomaly?
47
Fetal anomaly
compatible with
life?
yes
no
Await spontaneous
labor
no
yes
48
50
49
yes
ROM?
Vaginal pool +
amniocentesis at 32+
weeks for fetal lung
maturity (FLM)
no
53
Deliver for:
Disseminated intravascular
coagulation (DIC)
FLM
Fetal distress
Non-reassuring FHT
Significant bleeding
51
52
Vaginal
bleeding?
no
55
Deliver for:
Fetal distress
Chorioamnionitis
Active labor
34 weeks PROM
Other obstetrical indicators
54
no
Preterm delivery
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Management of Labor
Fifth Edition/March 2013
58
58
Special considerations of
labor management
59
Vaginal birth
appropriate for
planned VBAC?
yes
60
no
no
63
Repeat Caesarean
delivery
Normal labor?
61
Complicated labor
management
yes
61
62
Vaginal birth
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Management of Labor
Fifth Edition/March 2013
64
Labor dystocia
diagnosis
73
65
72
Stage I labor
74
Stage II labor
Fetal head
descent
> 1 cm/hour?
yes
Normal vaginal
delivery
no
66
75
no
yes
67
76
Is the head
descending?
yes
no
77
68
Adequate
contractions labor
for 2 hours with
cervical change?
no
69
yes
Is cervix
completely
dilated?
yes
Assisted
vaginal delivery
indicated?
78
yes
Assisted vaginal
delivery
no
no
70
Arrest of labor
71
Caesarean delivery
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Management of Labor
Fifth Edition/March 2013
79
80
Continuous EFM-ext or
EFM-int (if needed)
81
82
FHR pattern is
predictive of normal
acid-base status?
yes
no
84
Assessment and
intrauterine resuscitation
85
83
FHR pattern
predictive of
normal acid-base
status now?
yes
no
86
87
Expedited vaginal
delivery
yes
Vaginal delivery
imminent?
no
88
Further FHR
assessment predictive
of normal acid-base
status?
yes
no
89
Emergent delivery
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Management of Labor
Fifth Edition/March 2013
Table of Contents
Work Group Leader
Douglas Creedon, MD
OB/Gyn, Mayo Clinic
HealthPartners Medical
Group and Regions
Hospital
Cherida McCall, CNM
Nurse Midwife
Mayo Clinic
Lori Bates, MD
Family Medicine
Carl Rose, MD
Maternal-Fetal Medicine
Becky Walkes, RN
Nursing
Park Nicollet Health
Services
Dale Akkerman, MD
OB/Gyn
Anna Levin, CNM
Nurse Midwife
ICSI
Cindy Harper
Systems Improvement
Coordinator
Linda Setterlund, MA,
CPHQ
Clinical Systems
Improvement Facilitator
Algorithm (Main)..................................................................................................................1
Algorithm (Management of Signs/Symptoms of Preterm Labor [PTL])..............................2
Algorithm (Management of Critical Event)..........................................................................3
Algorithm (Vaginal Birth After Caesarean [VBAC])............................................................4
Algorithm (Management of Labor Dystocia)........................................................................5
Algorithm (Intrapartum Fetal Heart Rate [FHR] Management)...........................................6
Evidence Grading.............................................................................................................. 8-9
Foreword
Scope and Target Population..........................................................................................10
Aims...............................................................................................................................10
Clinical Highlights................................................................................................... 10-11
Related ICSI Scientific Documents...............................................................................11
Definition.......................................................................................................................11
Abbreviations Used in This Guideline...........................................................................11
Annotations................................................................................................................... 12-31
Annotations (Main).................................................................................................. 12-18
Annotations (Management of Signs/Symptoms of Preterm Labor [PTL]).............. 18-19
Annotations (Management of Critical Event).......................................................... 19-23
Annotations (Vaginal Birth After Caesarean [VBAC])........................................... 23-25
Annotations (Management of Labor Dystocia)....................................................... 25-28
Annotations (Intrapartum Fetal Heart Rate [FHR] Management)........................... 28-31
References..................................................................................................................... 48-54
Appendix A ICSI Shared Decision-Making Model.....................................................55-59
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Management of Labor
Fifth Edition/March 2013
Evidence Grading
Literature Search
A consistent and defined process is used for literature search and review for the development and revision of
ICSI guidelines. The literature search was divided into two stages to identify systematic reviews, (stage I)
and randomized controlled trials, meta-analysis and other literature (stage II). Literature search terms used
for this revision include partograms, induction of labor, expectant management of labor, cervical ripening,
active management of labor and oxytocin from January 2011 through October 2012.
GRADE Methodology
Following a review of several evidence rating and recommendation writing systems, ICSI has made a decision
to transition to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.
GRADE has advantages over other systems including the current system used by ICSI. Advantages include:
explicit and comprehensive criteria for downgrading and upgrading quality of evidence ratings;
clear separation between quality of evidence and strength of recommendations that includes a
transparent process of moving from evidence evaluation to recommendations;
clear, pragmatic interpretations of strong versus weak recommendations for clinicians, patients and
policy-makers;
All existing Class A (RCTs) studies have been considered as high quality evidence unless specified
differently by a work group member.
All existing Class B, C and D studies have been considered as low quality evidence unless specified
differently by a work group member.
All existing Class M and R studies are identified by study design versus assigning a quality of
evidence. Refer to Crosswalk between ICSI Evidence Grading System and GRADE.
All new literature considered by the work group for this revision has been assessed using GRADE
methodology.
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Management of Labor
Fifth Edition/March 2013
Evidence Grading
Crosswalk between ICSI Evidence Grading System and GRADE
High, if no limitation
Low
Class B: [observational]
Cohort study
Class C: [observational]
Non-randomized trial with concurrent or
historical controls
Case-control study
Population-based descriptive study
Study of sensitivity and specificity of a
diagnostic test
Low
Low
*Low
* Following individual study review, may be elevated to Moderate or High depending upon study design
Meta-analysis
Systematic Review
Decision Analysis
Cost-Effectiveness Analysis
Class D: [observational]
Cross-sectional study
Case series
Case report
Class M: Meta-analysis
Systematic review
Decision analysis
Cost-effectiveness analysis
Low
Low
Low
Guideline
Low
Low
Evidence Definitions:
High Quality Evidence = Further research is very unlikely to change our confidence in the estimate of effect.
Moderate Quality Evidence = Further research is likely to have an important impact on our confidence in the
estimate of effect and may change the estimate.
Low Quality Evidence = Further research is very likely to have an important impact on our confidence in the
estimate of effect and is likely to change the estimate or any estimate of effect is very uncertain.
In addition to evidence that is graded and used to formulate recommendations, additional pieces of
literature will be used to inform the reader of other topics of interest. This literature is not given an
evidence grade and is instead identified as a Reference throughout the document.
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Management of Labor
Fifth Edition/March 2013
Foreword
Scope and Target Population
All women who present in labor.
Return to Table of Contents
Aims
1. Increase the percentage of patients with preterm labor of less than 34 weeks who receive antenatal
corticosteroids. (Annotations #35, 43, 48)
2. Increase the percentage of patients who have procedures done that assist in progress to vaginal birth.
(Annotations #12, 67)
3. Increase the percentage of patients who are assessed for risk status on entry to labor and delivery.
(Annotation #13)
4. Increase the percentage of patients who have intrauterine resuscitation techniques for fetal tachysystole
or Category III heart rate tracings. (Annotation #84)
Return to Table of Contents
Clinical Highlights
Rupture of membranes can be confirmed by checking for pooling andferning, a nitrazine test or
with a commercially available indicator such as AmniSure.
(Annotation #5)
Assess fetal well-being with either intermittent auscultation or continuous electronic fetal heart rate
monitoring. (Annotation #12)
Initiate treatment for preterm labor as soon as possible after the diagnosis is established. (Annotation
#21; Aim #1)
Women with preterm labor at appropriate gestational age should receive a course of antepartum steroids
to promote fetal lung maturity. (Annotations #35, 43, 48; Aim #1)
Conduct regular cervical checks (cervical checks afford best opportunity to detect labor progress and
prevent failure to progress). (Annotation #66)
Augment with oxytocin to achieve adequate labor for two to four hours for protracted Stage I labor.
(Annotation #67)
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Management of Labor
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Foreword
If patient is in Stage II labor and is not making progress, initiate management of protraction disorders
(positioning, oxytocin augmentation, OB/surgical consult). (Annotation #75; Aim #2)
When necessary, discontinue oxytocin and initiate intrauterine resuscitation such as maternal position,
cervical exam for cord prolapse, monitoring maternal blood pressure, assessment for uterine hyperstimulation and amnioinfusion. (Annotation #84; Aim #4)
Recognize and manage fetal heart rate abnormal patterns. (Annotation #82; Aim #4)
Definition
Clinician All health care professionals whose practice is based on interaction with and/or treatment of a
patient.
Return to Table of Contents
fetal fibronectin
FHR
FLM
GBS
group B streptococcus
PROM
pPROM
PTL
preterm labor
VBAC
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Management of Labor
Fifth Edition/March 2013
Algorithm Annotations
The recommendations in this guideline are supported by large controlled studies. The guideline work
group would prefer to refer to double-blind studies, but it is not feasible to blind a woman to whether she
is having labor or delivery. It is unsafe to blind care clinicians to whether a woman has had a previous
Caesarean delivery or not or previous labor and delivery complications. It is also unsafe to blind clinicians
to whether persistent non-reassuring heart rate tracings have occurred. Given these limitations, the work
group feels confident of the literature support for the recommendations within this guideline. Furthermore,
these recommendations are consistent with the latest practice patterns published by the American College
of Obstetricians and Gynecologists.
Hospital and/or clinic triage for the labor patient will include these questions. Triage staff will assess general
questions from OB experience. Some questions may require more details for assessment. Generally, the
patient is encouraged to remain home as long as possible. The caregiver will manage any/all medical
concerns according to accepted standards.
General Questions:
Was your cervix dilated at least 2-3 cm on your last office visit?
Did you have medical complications during your pregnancy? Get specifics.
Specific Questions:
Return to Algorithm
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Management of Labor
Fifth Edition/March 2013
Algorithm Annotations
Spontaneous contractions at least 2 per 15 minutes and at least two of the following:
Rupture of membranes can be confirmed by checking for pooling andferning, a nitrazine test
or with a commercially available indicator such as AmniSure.
Only patients who meet this definition of labor should be admitted for careful management of labor.
Careful assessment of presenting patients is critical.
Return to Algorithm
When a patient presents to hospital, and assessment shows the patient is NOT in labor, patient education
will include signs to look for, changes to assess, and reassurance that she can come back to the hospital
when changes occur. When the caregiver prefers to hold and observe the patient, a reassessment must be
conducted prior to release from the hospital.
In 2006, approximately one in five labors was induced in the United States. This rate has doubled since 1990
and is thought to be responsible, at least in part, for the increased Caesarean section rate, which is currently
32% in the United States (American College of Obstetrics and Gynecology, The, 2009a [Guideline]). There
are numerous circumstances that could warrant induction of labor. Broadly, such circumstances are divided
into two categories: medical and elective. These categories are discussed in turn.
Medical Inductions
Medical inductions are considered for indications in which delivery is judged to be of lesser risk to maternal
or fetal health than continuation of the pregnancy. Some of those indications include gestational hypertension, pre-eclampsia, eclampsia, placental abruption, premature rupture of membranes, post-term pregnancy,
diabetes mellitus, renal disease, antiphospholipid syndrome, chorioamnionitis, oligohydramnios and fetal
growth restriction. This list is not comprehensive and other factors, though not strictly medical, may be a
consideration, too.
Elective Inductions
Elective deliveries are deliveries initiated without a specific medical indication. These include elective inductions of labor (IOLs) and elective Caesarean deliveries (primary or repeat). Elective IOLs are frequently
performed for patient or clinician convenience, although other psychological factors may be involved. The
most common reason for an elective Caesarean delivery is a repeat Caesarean.
Induction Decision-Making
While the decision to perform an induction rests with patient and her clinician, there are important considerations and outcomes that should be included as part of this decision. For each case, the risks to the fetus
for delivery at the current gestational age (timing of induction), the condition of the cervix (cervical favorability), and the clinician's assessment of the risk to the fetus and mother in continuing the pregnancy (list
Return to Algorithm
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Management of Labor
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Algorithm Annotations
of medical indications), must be weighed in deciding on timing and mode of delivery. See Appendix A,
"ICSI Shared Decision-Making Model."
Timing of Induction
Although "term" is generally considered after 37 weeks, there is a substantial body of evidence that delivery
prior to 39 completed weeks gestation is associated with increased fetal morbidity such as low Apgars and
respiratory distress syndrome (Engle, 2008 [Low Quality Evidence]). Because of these risks, ACOG guidelines for elective IOL and elective Caesarean delivery include confirmation that the pregnancy is at least 39
weeks gestation by one of the following dating criteria:
Ultrasound measurement at less than 20 weeks of gestation supports gestational age of 39 weeks
or greater.
Fetal heart tones have been documented as present for 30 weeks by Doppler ultrasonography.
It has been 36 weeks since a positive serum or urine human chorionic gonadotropin pregnancy test
result.
One exception to the rule has been documented: fetal lung maturity if elective delivery is planned prior to
39 weeks. However, recent evidence suggests that even fetuses with documented fetal lung maturity prior
to 39 weeks gestation have greater risk of adverse outcomes (Bates, 2010 [Low Quality Evidence]). There
are also risks associated with post-dates pregnancies; the question of when to induce is still unclear (Stock,
2012 [Low Quality Evidence).
Cervical Favorability
With an elective IOL, the goal is to effect a vaginal delivery, so the likelihood of a successful vaginal delivery
becomes an important consideration. In 1968, Bishop, using a cervical scoring system that bears his name,
evaluated multiparous women induced with oxytocin and found that women with a cervical score > 8 had
a 95% chance of a vaginal delivery. Since that hallmark study, numerous studies have assessed factors that
impact IOL outcomes, and several have shown that nulliparous women with an unfavorable cervix (Bishop
score 5 or less) have double the risk of a Caesarean delivery (Jonsson, 2012 [Low Quality Evidence];
Vahratian, 2005 [Low Quality Evidence]; Vrouenraets, 2005 [Low Quality Evidence]).
Caesarean section
Return to Algorithm
34-35 weeks
36-37 weeks
37-38 weeks
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Management of Labor
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Algorithm Annotations
Fetal
Fetal growth restriction, otherwise
uncomplicated singleton
38-39 weeks
34-37 weeks
Twins, dichorionic/diamniotic
38 weeks
Twins, monochorionic/diamniotic
34-37 weeks
36-37 weeks
Maternal
Chronic hypertension, controlled on
medication
37-39 weeks
Gestational hypertension
37-38 weeks
At time of diagnosis
34-39 weeks
34-39 weeks
Obstetric
Prior stillbirth
At or after 34 weeks
Elective* 39 weeks
*While there are no documented long-term risks to the fetus associated with elective deliveries, there is clear
potential for harm and increased cost. The decision to consider an elective IOL should involve an informed
consent discussion including the risks of prolonged labor and possible Caesarean section. This should
be documented in the patient record before proceeding (Bates, 2010 [Low Quality Evidence]; American
College of Obstetricians and Gynecologists The, 2009a [Guideline]; Engle, 2008 [Low Quality Evidence];
Vrouenraets, 2005 [Low Quality Evidence]). See Appendix A, "ICSI Shared Decision-Making Model."
Return to Algorithm
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Management of Labor
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Algorithm Annotations
Cervical exam #2
Appropriate supportive care/comfort measures as per individual clinician. May include but are not
limited to PO fluids, fluid balance maintenance, position changes, back rubs, music, ambulation,
and tub bath/shower. Management of labor using patient care measures and comfort measures is
supported. Documentation of progress of labor using a graphic medium is helpful to patient and
staff (Radin, 1993 [Low Quality Evidence]; McNiven, 1992 [Low Quality Evidence]).
Adequate pain relief. This includes parenteral analgesics, e.g., fentanyl, nalbuphine hydrochloride
(such as Nubain) or hydroxyzine hydrochloride (such as Vistaril), or epidural or intrathecal opioids
for patients in active progressing labor (continued dilation of the cervix) (Rogers, 1999 [Low Quality
Evidence]; Clark, 1998 [High Quality Evidence]; Halpern, 1998 [Meta-analysis]).
Monitoring of fetal heart rate. (See Intrapartum Fetal Heart Rate [FHR] Management algorithm
and annotations).
In nulliparous patients, early amniotomy is a component in the active management of labor protocol
and has been shown to reduce the duration of labor (Smyth, 2013 [Systematic Review]; Fraser, 1993
[High Quality Evidence]).
Contraindications for amniotomy include:
Patient refuses
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Management of Labor
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Algorithm Annotations
Analysis of data from randomized trials comparing these two techniques shows:
No difference in the rate of intrapartum fetal death rate (approximately 0.5 per 1,000 births with
either approach)
Neither approach has resulted in a reduction in cerebral palsy or incidence of infant neurologic
impairment
Several advantages of EFM have been demonstrated, including a reduction in neonatal seizures (Alfirevic,
2006 [Systematic Review]) and better prediction of fetal acidemia at birth (Vintzileos, 1995 [Meta-analysis];
Vintzileos, 1993 [High Quality Evidence]). One disadvantage of EFM is that it leads to higher assisted
deliveries and Caesarean birth without an associated neonatal benefit (Alfirevic, 2006 [Systematic Review]).
Compared to intermittent auscultation, EFM is associated with a twofold increase in Caesarean delivery
rate for non-reassuring FHR patterns.
Return to Algorithm
Risk assessment should be performed on all patients in active labor and is the responsibility of all members
of the health care team. This includes but is not limited to nurses, midwives and physicians. (See Annotation #5, "Admit for Labor?" for specific definition.)
Initial assessments on entry into labor and delivery area:
Fetal heart rate assessment (Cheyne, 2003 [High Quality Evidence]; Impey, 2003 [High Quality
Evidence])
Patient assessment
Abnormal fetal heart rate (see Intrapartum Fetal Heart Rate [FHR] Monitoring algorithm and annotations)
Situations that involve arrest or protraction disorders (see Management of Labor Dystocia algorithm
and annotations)
Bleeding
Breech presentation
Dysfunctional labor
Maternal diabetes
Gestational diabetes
Maternal hypertension
Return to Algorithm
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Management of Labor
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Algorithm Annotations
Maternal lupus
Multiple gestation
Oligohydramnios
Other serious chronic and acute medical conditions of mother and/or fetus
Oxytocin use
Thick meconium
Return to Algorithm
Active management of the third stage of labor should be offered to women since it reduces the incidence
of postpartum hemorrhage due to uterine atony. Active management of the third stage of labor consists of
interventions designed to facilitate the delivery of the placenta by increasing uterine contractions and to
prevent postpartum hemorrhage by averting uterine atony. The usual components include:
(Begley, 2011 [Low Quality Evidence]; International Confederation of Midwives, 2004 [Low Quality
Evidence]; Elbourne, 2001 [Systematic Review])
Return to Algorithm
Be certain intervention is appropriate, including certainty of gestational age. A sonogram should be considered if one has not been done.
A thorough medical evaluation should include the following:
estimate dilation and effacement of the cervix and look for pooling of amniotic fluid as a sign
of ruptured membranes; and
obtain samples for fetal fibronectin testing (fFN)*, consider samples for gonorrhea, chlamydia,
(Andrews, 2000 [Low Quality Evidence]) wet prep for bacterial vaginosis**, group B streptococcus (GBS), and a sample for detecting amniotic fluid with either ferning, nitrazine paper or
Amnisure.
* Perform fetal fibronectin testing (fFN) if patient is between 24 and 33 weeks gestation and cervix
is less than 3 cm dilated. A negative fFN result was associated with a 97.4% likelihood of the
pregnancy continuing more than seven days after testing (Skoll, 2006 [Low Quality Evidence]).
Return to Algorithm
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Management of Labor
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Algorithm Annotations
Perform digital cervical exam if membranes are intact and there is no vaginal bleeding. If ruptured,
digital exams increase the risk of infection.
Obtain transvaginal sonogram (TVS) for cervical length for monitoring of patients with sign/symptoms of preterm labor and early cervical change. Cervical length of less than 3.0 cm or a rapidly
thinning cervix correlate with increased preterm birth rates (Rose, 2010 [Low Quality Evidence];
Iams, 2003 [Low Quality Evidence]; Vendittelli, 2000 [Low Quality Evidence]).
Biophysical profile
Ruptured membranes or
Intact membranes and cervical change during observation. These can be measured by changes in
dilation or effacement, or by changes in cervical length measured clinically or by ultrasound.
Return to Algorithm
A pregnant woman whose labor begins early (before 37 weeks gestation) may experience a tremendous
amount of anxiety and fear, not knowing or understanding the risks to the baby and herself. She will have
many questions and concerns. It is imperative that the clinicians caring for the mother and unborn baby
communicate with the patient and other family members often and in terms they can understand.
Please refer to Annotation #48, "Initiate Tocolytics, Antenatal Corticosteroids and Antibiotic Group B
Strepcoccus (GBS) Prophylaxis," for information on dosing of other corticosteroids.
Return to Algorithm
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Management of Labor
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Algorithm Annotations
The work group consensus is that use of magnesium sulfate for the purpose of neuroprotection may be
beneficial for gestational age 32 weeks or less.
Several randomized controlled trials (Marret, 2007 [High Quality Evidence]; Rouse, 2008 [High Quality
Evidence]) have evaluated the administration of magnesium sulfate in clinical situations when preterm
delivery is regarded as imminent. Review of these trials has suggested magnesium sulfate does not work
well as a tocolytic, but does provide a reduction in both the frequency and severity of cerebral palsy for those
infants surviving the immediate intrapartum time frame (American College of Obstetricians and Gynecologists, The, 2010a [Guideline]; Doyle, 2009 [Low Quality Evidence]). The term "neuroprotection" is used
to describe the possible indication for magnesium sulfate in these clinical situations. The following points
from these studies are important to note:
Very preterm birth (less than 34 weeks) and very low birth weight (less than 1,500 g) are principal
risk factors for cerebral palsy, making up between 17 and 32% of all cases of cerebral palsy.
Evidence from population-based registries shows the prevalence of cerebral palsy is rising in very
low birth weight infants.
Recent retrospective studies confirm that the increasing prevalence of cerebral palsy is from higher
rates in preterm, not term, infants.
The most adequately powered United States randomized controlled trial (Rouse, 2008 [High Quality
Evidence]) showed no difference in the primary composite outcome of stillbirth or infant death by one year
of age or moderate or severe cerebral palsy between the magnesium sulfate group and the placebo group
(11.3% and 11.7%, RR 0.97, 95% CI 0.77-1.23). However, a secondary analysis did show a decreased
rate of moderate or severe cerebral palsy in the magnesium sulfate group in infants < 28 weeks gestation at
randomization (1.9% vs. 3.5% placebo; RR 0.55; 95% CI 0.32-0.95).
A meta-analysis involving individual patient data from five randomized controlled trials (n=5,235 fetuses/
infants) demonstrated a reduction in cerebral palsy (RR 0.70, 95% CI 0.55-0.89) and moderate-severe cerebral palsy (RR 0.60, 95% CI 0.43-0.84), but not a reduction in the rate of death or cerebral palsy (RR 0.92,
95% CI 0.83-1.03) with in utero exposure to magnesium sulfate. There was no evident increase in the risk
of death (RR 1.01, 95% CI 0.89-1.14) (Costantine, 2009 [Meta-analysis]).
Return to Algorithm
Several medications are available for the inhibition of preterm labor (tocolysis). These drugs have different
routes of administration, dose schedules, safety profiles, contraindications, and fetal and maternal side effects
(Simhan, 2007 [Low Quality Evidence]). Although several medications can prevent delivery for 24-48 hours
(allowing time for the administration and beneficial effects of corticosteroid therapy), the longer-term efficacy
of all tocolytics is poor (Gyetvai, 1999 [Systematic Review]).
Calcium channel blockers
Nifedipine is the drug most commonly employed from this class of medications for tocolysis. No placebocontrolled trials have evaluated the drug for this indication, but comparative trials have demonstrated the
efficacy and safety of the drug (King, 2003 [Systematic Review]; Papatsonis, 1997 [High Quality Evidence]).
Beta-adrenergic-receptor agonists
Terbutaline is one of the commonly employed drugs from this class of medications for tocolysis. Available
studies show a prolongation of pregnancy similar to the results of calcium channel blockers, but no significant reduction in perinatal morbidity or mortality (Anotayanonth, 2004 [Systematic Review]). However,
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Management of Labor
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Algorithm Annotations
the U.S. Food and Drug Administration (FDA) notified health care professionals that oral and injectable
terbutaline should not be used in pregnant women for prolonged treatment (beyond 48-72 hours) of preterm
labor because of the potential for serious maternal heart problems and death: http://www.fda.gov/Safety/
MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm243843.htm.
Cyclooxygenase inhibitors
Indomethacin is the drug most commonly employed from this class of medications for tocolysis. A metaanalysis of three comparative trials with other classes of tocolytics showed a reduction of preterm births
(< 37 week) (King, 2005 [Systematic Review]). Indomethacin should be used only at less than 32 weeks
gestation and only for 48 hours maximum to allow for the administration of antenatal corticosteroids (Doyle,
2005 [Low Quality Evidence]; Loe, 2005 [Systematic Review]).
Magnesium sulfate
Review of the literature does not support the efficacy of magnesium sulfate as a tocolytic. The largest
randomized, placebo-controlled trial showed no benefit over placebo (Cox, 1990 [High Quality Evidence]).
A more recent meta-analysis of 11 studies showed no benefit regarding the risk of preterm birth (less than
37 weeks) or very preterm birth (less than 34 weeks). Moreover, in seven of the trials analyzed, the risk
of perinatal mortality was increased for infants exposed to magnesium sulfate (Grimes, 2006 [Low Quality
Evidence]; Crowther, 2002 [Systematic Review]; Mittendorf, 2002 [Low Quality Evidence]). The work
group does not recommend the use of this medication for this indication.
Maternal Transfer
Maternal transfer to prevent the need for premature neonatal transfer reduces preterm neonatal morbidity
and mortality. Very low birth weight infants (less than 1,500 grams) inborn to Level III perinatal centers
have lower mortality, reduced incidence of Grade III and Grade IV intraventricular hemorrhage, and lower
sensorineural disability rates than outborn infants (Towers, 2000 [Low Quality Evidence]; Menard, 1998
[Low Quality Evidence]; Yeast, 1998 [Low Quality Evidence]).
Return to Algorithm
Broad-spectrum antibiotic coverage appears to lengthen the latency from preterm premature rupture of
membranes (pPROM) until delivery and/or chorioamnionitis. Antibiotic therapy reduces maternal and
neonatal morbidity in women with pPROM. There is no consensus on the choice of antibiotic or dose. A
combination of ampicillin and erythromycin is considered protocol in some organizations (Bar, 2000 [Low
Quality Evidence]; Edwards, 2000 [Low Quality Evidence]; Kenyon, 2001 [Systematic Review]; Mercer,
1997 [High Quality Evidence]).
Return to Algorithm
See Annotation #38, "Stabilize on Tocolytics/Transfer Mother to Appropriate Level of Care if Possible,"
for a discussion about tocolytics.
Return to Algorithm
Please refer to Annotation #48, "Initiate Tocolytics, Antenatal Corticosteroids and Antibiotic Group B
Streptococcus (GBS) Prophylaxis," for dosing of betamethasone and other corticosteroids.
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Management of Labor
Fifth Edition/March 2013
Algorithm Annotations
Agents to be considered for tocolytic therapy include terbutaline sulfate, indomethacin and nifedipine. In
February 1997, the FDA alerted practitioners to use caution in the continuous subcutaneous administration of terbutaline sulfate. As noted in Annotation #38, review of available studies does not support using
magnesium sulfate for tocolysis, although it may be considered for neuroprophylaxis in pregnancy to 32
weeks gestation. See Annotation #36, "Consider Magnesium Sulfate for Neuroprotection."
See Annotation #38, "Stabilize on Tocolytics/Transfer Mother to Appropriate Level of Care if Possible," for
a detailed discussion of particular tocolytics.
Other considerations for initial management of preterm labor include the following:
Initiate antenatal corticosteroids if 23-34 weeks gestation. Please refer below to "Pharmacologic
Management of Preterm Labor" for more information on administration of betamethasone and other
corticosteroids.
Administer IV antibiotic effective against group B streptococcus (GBS) until GBS results are back
or if patient is known to be positive for GBS (Thorp, 2002 [Low Quality Evidence]).
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Algorithm Annotations
B. Administer antibiotics for group B streptococcus (GBS) prophylaxis until GBS results are back.
Please refer to the GBS prophylaxis guidelines at your institution (Hager, 2000 [Low Quality Evidence]).
The Agency for HealthCare Research and Quality reviewed literature on the use of antibiotics in preterm
labor (Agency for HealthCare Research and Quality, 2000 [Guideline]).
(Centers for Disease Control and Prevention, 2002 [Guideline])
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Phosphatidyl glycerol (PG) is a reliable indicator of FLM if present in vaginal pool specimens. Lecithin/
sphingomyelin ratio is unreliable if blood and/or meconium are present in the fluid. Certain assays of PG
may be influenced by the presence of heavy growth of gardnerella vaginalis. Please consult with your local
hospital clinical laboratory (Beazley, 1996 [Low Quality Evidence]).
Maternal chorioamnionitis and hospital length of stay were lessened with induction of labor in preterm
premature rupture of membranes (pPROM) with mature fetal lung maturity studies after 32 weeks, with
no difference in neonatal outcomes compared with expectant management (Mercer, 1993 [Low Quality
Evidence]).
Return to Algorithm
Complete blood counts (CBCs) with platelets, prothrombin time (PT), partial thromboplastin time
(PTT) and fibrinogen.
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A "break point" in neonatal morbidity was observed at 34 weeks gestation, which supports induction of
labor at this gestional age (Neerhof, 1999 [Low Quality Evidence].
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A well-thought-out and informed discussion between the clinician and the patient about VBAC should have
occurred prior to the pregnant woman presenting for delivery. Once labor begins, the clinicians must keep
the patient informed of the progress (or lack of it) of labor and the status of the baby. If it is likely that a
vaginal delivery will be harmful to the baby or the mother, this must be communicated and options discussed.
Availability of a team capable of performing a Caesarean delivery within a short time (American College
of Obstetricians and Gynecologists, The Practice Bulletin, 2010c [Guideline]).
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Algorithm Annotations
Review the prior operative report(s) to ensure that the uterine incision did not involve the contractile
portion of the uterus such as a classical incision. A VBAC after a Caesarean with classical incision
carries a tenfold higher risk of uterine rupture compared to a low transverse uterine incision.
Intermittent auscultation or continuous electronic fetal heart rate monitoring should be done. See Intrapartum Fetal Heart Rate (FHR) Management algorithm.
Augmentation or induction of labor with oxytocin increases the risk of uterine rupture (Blanchette, 2001
[Low Quality Evidence]) though the risk is still low (1-2.4%). Oxytocin and prostaglandin were not
individually associated with uterine rupture except when sequential prostaglandin-oxytocin was used
(Macones, 2005 [Low Quality Evidence]). A meta-analysis (Dodd, 2006 [Low Quality Evidence]) found
sufficient evidence to help in choosing planned induction in VBAC versus elective repeat Caesarean
delivery.
The ACOG Committee on Obstetric Practice recommends that misoprostol not be used for induction
of labor in women with prior Caesareans or major uterine surgery (American College of Obstetricians
and Gynecologists, The, 2010c [Guideline]).
Use of the Foley bulb catheter has a uterine rupture rate close to that of women laboring spontaneously
and has a VBAC success rate similar to that of women who have induced labor (Ravasia, 2000 [Low
Quality Evidence]). The intracervical catheter ripening method does not stimulate uterine contractions,
which is an advantage for women with previous Caesareans (Bujold, 2004 [Low Quality Evidence]).
The Society of Obstetricians and Gynecologists of Canada has endorsed the use of the Foley bulb
catheter for cervical ripening for women with a low transverse uterine scar. ACOG has no statement
either endorsing or discouraging mechanical dilators for cervical ripening in women attempting VBAC
(SOGC Clinical Practice Guidelines, 2005 [Guideline]).
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The same considerations for intervention in labor apply to VBACs as for other attempted deliveries.
Complicated labor can be manifested in several categories:
Failure to progress the same considerations for intervention including amniotomy, oxytocin,
epidural anesthesia/analgesia apply to VBACs. If indication for primary Caesarean was dystocia,
percentage successful VBACs was 77%. Women who required oxytocin for induction had 58%
successful vaginal delivery versus 88% who required oxytocin for augmentation (Sakala, 1990 [Low
Quality Evidence]; Silver, 1987 [Low Quality Evidence]; Stovall, 1987 [Low Quality Evidence]).
Fetal distress see Intrapartum Fetal Heart Rate (FHR) Management algorithm and annotations.
Maternal complications preeclampsia and exacerbation of pre-existing maternal illness are managed
similarly in complicated VBAC versus a complicated vaginal labor patient.
Uterine rupture the scarred uterus has an increased potential to rupture. Uterine rupture occurs in
between 1/100 and 1/11,000 deliveries, depending on whose data one uses and the clinical presentation. The type of scar makes a difference in frequency of rupture and severity of symptoms,
also (LST 0.2-0.8 Classical 4.3-8.8, T4.3-8.8, Low Vertical 0.5-6.5) (Pridjian, 1992 [Low Quality
Evidence]).
Rupture through a low segment transverse scar is much more likely to go undetected or produce
maternal hypovolemia or gradual fetal distress. Complete rupture with expulsion of fetus or placenta
is a true obstetric emergency and can lead to maternal or hypovolemic complication, even death,
as well as fetal hypoxia and death.
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Algorithm Annotations
Conditions that increase the risk for uterine rupture:
Uterine defects not related to trauma, e.g., congenital defect, invasive mole
Intrapartum hyperstimulation, difficult forceps, internal podalic versions, fundal pressure, etc.
Multiple previous Caesarean deliveries
Fetal distress 50-70% of detected ruptures present with abnormal FH tracings (e.g., variable
decelerations that evolve into late decelerations)
Uterine pain, especially pain over previous incision that continues between contractions
Hemorrhage intra-abdominal, vaginal or urinary
Palpation of fetal parts
Loss of contractions
Scar dehiscence Opening of previous scar, with intact overlying peritoneum (uterine serosa), no
expulsion of uterine contents
Incomplete rupture Opening of previous scar, but not overlying peritoneum, extraperitoneal extrusion of intrauterine contents
Complete rupture Opening of previous scar and overlying peritoneum with extrusion of intrauterine
contents into peritoneal cavity
(American College of Obstetricians and Gynecologists, 2006 [Guideline]; Pridjian, 1992 [Low
Quality Evidence])
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During labor dystocia the patient plays a significant role as a partner in her care. It is imperative that the
clinicians keep the mother informed about her labor and discuss what interventions/options are necessary
for a safe delivery of the baby. Explain status, using terms the patient can understand.
Labor abnormalities are classified as either protraction disorders (slower than normal progress) or arrest
disorders (complete cessation of progress). Labor dystocia can only be defined when labor is in the active
phase. Management of labor dystocia is especially important in nulliparous women to prevent unneeded
Caesarean sections (Gifford, 2000 [Low Quality Evidence]).
Friedman provided the definition for "normal labor" in the 1950s. Further observation has shown that the
definition of "normal labor" is broader than Friedman's definition. Recent evidence obtained in the context
of contemporary obstetric practice suggests that the inflection point for transition from the latent to active
phase of labor occurs at 6 cm dilation. It further suggests that progress in the active phase of labor may
occur at a faster rate in multiparas than nulliparas (Zhang, 2010 [Low Quality Evidence]). This has lead
to more flexibility in the management of abnormal labor, assuming that mother and baby are doing well.
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Management of Labor
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Algorithm Annotations
Labor progress is measured by checking for cervical change using a digital cervical exam. During the active
phase of labor, cervical exams should document at least 1 cm dilation every two hours. Regular cervical
checks during active labor afford the best opportunity to assess the progress of labor and to diagnose labor
with abnormal progress.
At least one clinical trial testing the effectiveness of active management of labor in reducing Caesarean
deliveries used hourly cervical exams; others studies have used every-two-hour exams. The "two-hour" rule
for determining dilatation has been challenged; however, there is evidence indicating that in both nulliparas
and multiparas, it may take up to two hours to demonstrate 1 cm of change in cervical dilation during the
active phase of labor (Zhang, 2010 [Low Quality Evidence]; American College of Obstetricians and Gynecologists, The Practice Bulletin, 2003 [Guideline]; Zhang, 2002 [Low Quality Evidence]; Frigoletto, 1995
[High Quality Evidence]; Lpez-Zeno, 1992 [High Quality Evidence]).
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If the patient in Stage I labor is not making progress, management of protraction disorders will include evaluating the potential causes and directing management appropriately (Sadler, 2000 [High Quality Evidence];
Frigoletto, 1995 [High Quality Evidence]; Lpez-Zeno, 1992 [High Quality Evidence]).
Power: hypocontractile uterine activity is the most common cause of first stage of labor abnormalities.
Adequate contractions are defined as a minimum of 200 Montevideo units in 10 minutes (Bakker, 2010
[High Quality Evidence]).
Possible interventions:
IV fluids (IV fluids 150 cc/hr may decrease the need for oxytocin augmentation) (Garite, 2000
[High Quality Evidence].
Artificial rupture of membranes if membranes are intact and there are no contraindications. (See
Annotation #12, "Intrapartum Care.") Although amniotomy is often performed in cases of protracted
labor as an isolated intervention, there is evidence that this does not shorten the duration of labor
nor reduce Caesarean delivery (Smyth, 2013 [Systematic Review]).
Discontinuing or reducing epidural anesthesia, as the use of epidurals, has been shown to increase the
length of labor. However, there is no increased rate of Caesarean birth for dystocia when epidural
anesthesia is in use (Rogers, 1999 [Low Quality Evidence]; King, 1997 [Low Quality Evidence]).
Oxytocin has been associated with tachysystole (> 75 contractions per 10 minutes) (American
College of Obstetricians and Gynecologists, The, 2009a [Guideline]).
The use of oxytocin augmentation has been shown to shorten labor by hours (Hinshaw, 2008 [High
Quality Evidence]).
Contraindications to oxytocin augmentation include:
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Algorithm Annotations
Return to Algorithm
When the patient has reached Stage II labor, a reassessment at least every 30 minutes for two consecutive
hours is done to assess descent of the fetus and rotation of the fetus. If the patient is making appropriate
progress, the caregiver can anticipate vaginal delivery. Fetal descent should be greater than 1 cm per hour.
If labor is not progressing, consider an internal monitor to measure strength of uterine contractions. After
two hours of internal monitoring there should be enough evidence to determine if patient is making progress
(Harbert, 1992 [Low Quality Evidence]).
Relative contraindications to direct, invasive monitoring include HIV maternal infection, certain fetal presentations and conditions that preclude vaginal examinations such as placenta previa or undiagnosed vaginal
bleeding (Association of Women's Health Obstetrics and Neonatal Nurses, 2003 [Guideline]).
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If the patient in Stage II labor is not making progress, management of protraction disorders will include
evaluating the potential causes and directing management appropriately.
Evaluate the maternal position: consider having the patient move into different positions such
as on hands and knees to change the relative size of the pelvis.
Consider OB/surgical consultation, and plan when to assemble team for Cesarean birth.
(Saunders, 1992 [Low Quality Evidence]; Minnesota Clinical Comparison and Assessment Project, 1991
[Guideline])
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Prolongation of the second stage of labor beyond an arbitrary time limit is no longer an indication for assisted
vaginal or Caesarean delivery. As long as progress is being made and fetal monitoring is Category I or II, the
patient can continue pushing (Cheng, 2004 [Low Quality Evidence]; Myles, 2003 [Low Quality Evidence]).
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Algorithm Annotations
If there is no descent for two hours despite optimizing labor, an assisted delivery or surgical consult is
suggested. Vacuum extraction or mid/low forceps delivery contraindications include:
clinician is inexperienced,
patient refusal.
Note: When using vacuum extraction or forcep application with a suspected macrosomic infant, be aware
of the risk of shoulder dystocia.
(Shields, 2007 [Low Quality Evidence]; Rouse, 2001 [Low Quality Evidence]; O'Driscoll, 1984 [Low
Quality Evidence])
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Electronic fetal monitoring (EFM) is indicated in all high-risk situations and may be considered in situations
when the auscultatory pattern is unclear. Internal EFM may allow easier patient positioning and promote
patient activity by being less confining than external EFM. Low-risk patients should be encouraged to be
as active and mobile as possible.
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All obstetrical nurses, nurse midwives and physicians must achieve competence and confidence in fetal heart
rate monitoring and FHR pattern analysis. Based on careful review of the available options, a three-tier
system for the categorization of FHR patterns is recommended. Fetal heart rate tracing patterns can provide
information on the current acid-base status of the fetus but cannot predict the development of cerebral palsy.
Categorization of the FHR tracing evaluates the fetus at that point in time; tracing patterns can and will
change (Macones, 2008 [Low Quality Evidence]).
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Management of Labor
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Algorithm Annotations
Table 1. Electronic Fetal Monitoring Definitions
Category of
FHR Pattern
Interpretation
Baseline (BL)
and Variability
Accelerations
(15 x 15)
Decelerations
Interventions
Category I:
strongly
predictive of
normal fetal acidbase status
BL 110-160
Moderate
variability
Present or
absent
No specific
interventions
required, ongoing
assessment and
evaluation.
Category II:
Indeterminate.
Not predictive of
abnormal fetal
acid-base status
BL < 110
without absent
variability
BL > 160
Marked
variability
Absent
variability
without
decelerations
Absence of
accelerations
after fetal
stimulation
Prolonged
decelerations
(> 2 minutes but
< 10 minutes)
Recurrent late
decels with
moderate
variability
Recurrent variable
decels with
minimal or
moderate
variability
Requires evaluation
and continued
surveillance. Review
and take into account
associated clinical
circumstances.
Category III:
Predictive of
abnormal fetal
acid-base status at
the time of
observation
Absent
variability and
any of the
following:
Recurrent late
decels
Recurrent
variable decels
BL < 110
Sinusoidal
pattern
Prompt evaluation
and management
indicated. May
include:
Maternal position
change
Maternal oxygen
Discontinuation of
labor stimulus
Treatment of
possible underlying
condition
Expedited delivery
Early decelerations
Onset, nadir and recovery mirror the beginning, peak and ending of the contraction.
Variable decelerations
Abrupt decrease in the FHR with onset to nadir of deceleration reached in less than 30 seconds,
decrease in FHR is 15 seconds or greater and less than two minutes in duration.
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Algorithm Annotations
Variability
Fluctuations in the FHR baseline over a 10-minute window, accelerations and decelerations are not
included in the range.
Minimal - amplitude range is between 2 beats per minutes (bpm) and 5 bpm.
Recurrent
Decelerations that occur with 50% or greater of uterine contractions in any 20-minute window.
Sinusoidal pattern
Cyclic, smooth, sine wavelike undulating pattern in the FHR baseline frequency cycle of 3-5 per
minute that persists for 20 minutes or longer.
(American College of Obstetricians and Gynecologists, The, 2010 [Guideline]; American College of Obstetricians and Gynecologists, The, 2009a [Guideline]; Macones, 2008 [Low Quality Evidence])
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A persistent Category II or Category III FHR tracing requires evaluation of the possible causes. Initial
evaluation and treatment may include:
cervical examination to assess for umbilical cord prolapse or rapid cervical dilation or descent of
the fetal head
changing maternal position to the left or right lateral recumbent position, reducing compression of
the vena cava and improving uteroplacental blood flow
monitoring maternal blood pressure level for evidence of hypotension, especially in those with
regional anesthesia (if present, treatment with ephedrine or phenylephrine may be warranted)
assessment of patient for uterine tachysystole that affects fetal heart rate tracing by evaluating uterine
contraction frequency and duration
amnioinfusion indications for therapeutic amnioinfusion include repetitive severe variable decelerations and prolonged decelerations (Fraser, 2005 [High Quality Evidence]; Rinehart, 2000 [High
Quality Evidence]; Miyazaki, 1985 [High Quality Evidence]). Amnioinfusion for thick meconium
is no longer recommended
(American College of Obstetricians and Gynecologists, The, 2010 [Guideline]; American College of Obstetricians and Gynecologists, The Practice Bulletin, 2009b [Guideline])
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Management of Labor
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Algorithm Annotations
Scalp stimulation or vibroacoustic testing may be used for further fetal assessment. A 15-beat-per-minute
rise in FHR lasting 15 seconds from the beginning to the end of the acceleration in response to scalp stimulation or to vibration or sound is predictive of normal fetal acid-base status. If the scalp stimulation test or
vibroacoustic test response is abnormal, immediate delivery is indicated.
Other tests to assess fetal acid-base status may be helpful if available. This includes fetal scalp sampling
for pH. A scalp pH greater than 7.19 is a positive result (Skupski, 2002 [Meta-analysis]; Smith, 1986 [Low
Quality Evidence]).
However, proper FHR pattern interpretation and the response to scalp stimulation or vibroacoustic stimulation can allow the clinician to detect tracings predictive of abnormal feta acid-base status.
Knowledge of the fetal oxygen saturation is not associated with a reduction in the rate of Caesarean delivery
or with improvement in the condition of the newborn (Bloom, 2006 [High Quality Evidence]).
Return to Algorithm
Tracings predictive of abnormal fetal acid-base status (Category III) indicate the need for emergent delivery.
Delivery should be affected by appropriate means, depending on the clinical situation. This may include
vacuum extraction, forceps or Caesarean delivery, depending upon fetal presentation and the expertise of
the attending physician(s).
Caesarean delivery should be performed if vacuum extraction or forceps are inappropriate for use.
If a Caesarean delivery is performed, the suitability of a VBAC in a subsequent pregnancy should be
discussed with the patient.
The following are indications for Caesarean birth based on abnormal FHR monitoring, according to the
Minnesota Clinical Comparison and Assessment Project:
Late decelerations that comprise the majority of contractions over a minimum 20-minute period in
the absence of adequate beat-to-beat variability and that do not respond to remedial techniques.
Severe variable decelerations that comprise the majority of contractions over 20-60 minutes and
that do not respond to remedial techniques.
Scalp pH less than 7.2 or negative FHR acceleration test (confirmation in 15-20 minutes recommended).
There may be other combinations or non-remediable patterns that may not meet severity criteria listed
above that may be indications for preparation for Caesarean birth. A scalp pH or FHR acceleration
test (scalp or acoustic) may help clarify the issue. Consultation or second opinion is suggested.
In the second stage of labor, depending on the judgment and skill of the physician, operative vaginal
delivery may be the least hazardous for the mother and child.
If one-minute Apgar is less than three, or five-minute Apgar is less than six, cord pH or gases are recommended. Cord pH is a better indicator than Apgar for fetal compromise. A segment of umbilical cord is
isolated with clamps and may be stored up to 60 minutes after delivery with reliable umbilical artery pH
determination. The segment does not need to be heparinized or placed on ice (Johnson, 1993 [Low Quality
Evidence]; Duerbeck, 1992 [Low Quality Evidence]).
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Management of Labor
The Aims and Measures section is intended to provide protocol users with a menu
of measures for multiple purposes that may include the following:
population health improvement measures,
quality improvement measures for delivery systems,
measures from regulatory organizations such as Joint Commission,
measures that are currently required for public reporting,
measures that are part of Center for Medicare Services Physician Quality
Reporting initiative, and
other measures from local and national organizations aimed at measuring
population health and improvement of care delivery.
This section provides resources, strategies and measurement for use in closing
the gap between current clinical practice and the recommendations set forth in the
guideline.
The subdivisions of this section are:
Aims and Measures
Implementation Recommendations
Implementation Tools and Resources
Implementation Tools and Resources Table
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Management of Labor
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Measurement Specifications
Measurement #1a
Percentage of patients with preterm labor who received antenatal corticosteroids prior to delivery.
Population Definition
Data of Interest
# of patients less than 34 weeks gestation who received antenatal corticosteroids prior to delivery
# patients in preterm labor
Numerator/Denominator Definitions
Numerator:
Number of patients in preterm labor who received antenatal corticosteroids prior to delivery.
Denominator:
Review electronic medical records for information on patients who delivered preterm. Determine the number
of patients who delivered preterm who received antenatal corticosteroids prior to delivery.
Notes
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Management of Labor
Fifth Edition/March 2013
Measurement #2a
Population Definition
having contractions,
singleton fetus,
cephalic presentation,
Data of Interest
Numerator/Denominator Definitions
Numerator:
Denominator:
Review electronic medical records to determine the number of patients as described in population definition who were in protracted labor. Then determine the number of those patients who were given oxytocin.
Notes
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Management of Labor
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Measurement #3a
Percentage of patients who are assessed for risk status on entry to labor and delivery.
Population Definition
Data of Interest
# of patients who are assessed for risk status on entry to labor and delivery
# of patients who present in labor
Numerator/Denominator Definitions
Numerator:
Number of patients with evidence of assessment for risk status on entry to labor and
delivery to include:
Denominator:
patient assessment,
Review electronic medical records to determine the number of patients who were in labor. Then determine
the number of patients who had assessment for risk status on entry to labor and delivery which could include
the following:
patient assessment,
Notes
Risk assessment should be performed on all patients in active labor and is the responsibility of all members
of the health care team. That includes but is not limited to nurses, midwives and physicians.
This is a process measure, and improvement is noted as an increase in the rate.
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Management of Labor
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Measurement #4a
Population Definition
Data of Interest
Numerator/Denominator Definitions
Numerator:
Denominator:
Review electronic medical records to determine the number of women who were in labor. Then determine
the number of women who had oxytocin discontinued.
Notes
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Management of Labor
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Measurement #4b
Population Definition
Data of Interest
Numerator/Denominator Definitions
Numerator:
Denominator:
Review electronic medical records to determine the number of patients who were in labor. Then determine
the number of patients who had IV fluid bolus administered.
Notes
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Management of Labor
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Measurement #4c
Percentage of patients whose position is changed to the left or right side to decrease compression of vena cava.
Population Definition
Data of Interest
# of patients whose position is changed to the left or right side to decrease compression of vena cava
# of patients who present in labor
Numerator/Denominator Definitions
Numerator:
Number of patients whose position is changed to the left or right side to decrease compression
of vena cava.
Denominator:
Review electronic medical records to determine the number of patients who were in labor. Then determine the
number of patients whose position is changed to the left or right side to decrease compression of vena cava.
Notes
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Management of Labor
Fifth Edition/March 2013
The author, source and revision dates for the content are included where possible.
The content is clear about potential biases and when appropriate conflicts of interests and/or
disclaimers are noted where appropriate.
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Management of Labor
Fifth Edition/March 2013
Title/Description
Audience
American College of
Nurse Midwives
Public
http://www.midwife.org
American College of
Obstetricians &
Gynecologists (ACOG)
Public
OB/GYN topics
Professionals
http://www.sales.acog.org
1-800-762-2264
AP087
http://www.acog.org
Public
Public
http://www.sales.acog.org
1-800-762-2264
#AP070
Public &
Professionals
http://www.marchofdimes.com
March of Dimes
Public
March of Dimes
Public
1-800-367-6630
#37-2447-09
Mayo Clinic
Public
American College of
Obstetricians &
Gynecologists (ACOG)
American College of
Obstetricians &
Gynecologists (ACOG)
American College of
Obstetricians &
Gynecologists (ACOG)
March of Dimes
http://www.sales.acog.org
1-800-762-2264 x830;
#18015
1-800-367-6630
English #09-1099-98; 37-2379-08
Spanish #09-1100-98 37-2045-06
http://www.mayoclinic.com
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Legend
ICSI order sets utilize two types of boxes for orders. One is the open box that clinicians will need to check
for the order to be carried out. The second box is a pre-checked box and are those orders that have strong
evidence and/or are standard of care and require documentation if the clinician decides to "uncheck" the order.
There is increasing evidence that pre-checked boxes are more effective in the delivery of care than physician
reminders, even within the computerized medical record environment. Organizations are recognizing the
benefit of using pre-checked boxes for other orders to promote efficiency. Organizations are encouraged,
through a consensus process, to identify those orders to utilize pre-checked boxes to increase efficiency,
reduce calls to clinicians, and to reduce barriers for nursing and other professionals to provide care that is
within their scope.
Annotations Numbers
Throughout the order set you will note annotation numbers. These annotation numbers correspond with the
guideline itself and provide associated discussion and evidence when available.
Medication
It is assumed that clinicians will supplement this information from standard pharmaceutical sources to
inform their decisions for individual patients.
42
Management of Labor
Fifth Edition/March 2013
Order Set
This order set pertains to those orders for routine
obstetrical labor admission and does not include
preoperative and screening orders from the
physicians office.
Legend:
Open boxes are orders that a clinician will need to
order by checking the box.
Pre-checked boxes are those orders with strong
supporting evidence and/or regulatory requirements
that require documentation if not done.
Diagnosis
Admitting Dx:
Active labor
Contractions
Other
Secondary Dx:
E.D.D.
Wk. Gest.
Gravida
Para
Condition
Stable
Other
Vitals
Routine (as defined by institution)
every
Notify physician/CNM if temperature exceeds
Patient weight:
Patient height:
hour
Co (
F o)
kg
cm
Activity
Activity (encourage movement, shower, rocker, birth ball) as tolerated
Bathroom privileges with assist as needed
Strict bed rest, encourage lying on side
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Management of Labor
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Order Set
Type of reaction:
Type of reaction:
Type of reaction:
Diet
as tolerated
nothing by mouth
diabetic
clear liquids
IVs
Establish IV saline lock with flush
IV D5LR at _____ mL/hour
IV lactated ringers at _____ mL/hour (for diabetic patients)
Other:
at
mL/hour
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Order Set
Management of Labor
Fifth Edition/March 2013
IV
Other Medications
Antacid (institutional preference) 30 ml by mouth for GI discomfort. May repeat one dose.
Acetaminophen 325 mg (1-3 tabs) by mouth every 6 hours as needed for headache
Diphenhydramine 25 mg by mouth every 4 hours as needed for sleep/pruritus
Hydroxyzine hydrochloride (Vistaril)
mg every
hours by
mouth
IM
Sodium phosphate enema as needed for constipation
Antibiotics (If Group B Strep positive or unknown)
No allergies
Penicillin G 5 million units with 10 mg Lidocaine per 100 mL piggyback IV load in labor, then 2.5 million
units with 10 mg Lidocaine per 100 mL piggyback IV, every 4 hours until delivery (if no Lidocaine allergy)
Penicillin allergy no anaphylaxis
Cefazolin 2 g IV then 1g every 8 hours until delivery
Penicillin allergy with anaphylaxis (if organism sensitive to penicillin and cefazolin)
Clindamycin 900 mg IV every 8 hours until delivery
If resistant to clindamycin and erythromycin or sensitivities unknown
Vancomycin 1 gm every 12 hours until delivery
Other _____________________________
mg every
hours until delivery
Lab/Diagnostic Tests
Hemoglobin
Type and Screen
Drug Screen (obtain consent if necessary)
If not available from prenatal records:
ABO Rh
Rubella Antibody, IgG
Hepatitis B Surface Antigen
Rapid Plasma Reagin (VDRL)
Group B Strep test
HIV (obtain consent to test)
Other tests: ________________________
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Management of Labor
Fifth Edition/March 2013
Order Set
Other
Consults
Obstetrical
Surgical
Endocrinology
Neonatology
Pediatrics
Other orders
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Supporting Evidence:
Labor Management
47
Management of Labor
Fifth Edition/March 2013
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References
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Doyle NM, Gardner MO, Wells L, et al. Outcome of very low birth weight infants exposed to antenatal
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Duerbeck NB, Chaffin DG, Seeds JW. A practical approach to umbilical artery pH and blood gas
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References
Management of Labor
Fifth Edition/March 2013
Edwards RK, Locksmith GJ, Duff P. Expanded-spectrum antibiotics with preterm premature rupture of
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Elbourne DR, Prendiville WJ, Carroli G, et al. Prophylactic use of oxytocin in the third stage of labour.
Cochrane Database Syst Rev 2001;(4):CD001808. (Systematic Review)
Engle WA, Kominiarek MA. Late preterm infants, early term infants, and timing of elective deliveries.
Clin Perinatol 2008;35:325-41. (Low Quality Evidence)
Fraser WD, Hofmeyr J, Lode R, et al. Amnioinfusion for the prevention of the meconium aspiration
syndrome. N Engl J Med 2005;353:909-17. (High Quality Evidence)
Fraser WD, Marcoux S, Moutquin JM, et al. Effect of early amniotomy on the risk of dystocia in nulliparous women. N Engl J Med 1993;328:1145-49. (High Quality Evidence)
Freeman RK. Problems with intrapartum fetal heart rate monitoring interpretation and patient management. Obstet Gynecol 2002;100:813-26. (Low Quality Evidence)
Frigoletto FD Jr, Lieberman E, Lang JM, et al. A clinical trial of active management of labor. N Engl J
Med 1995;333:745-50. (High Quality Evidence)
Garite TJ, Kurtzman J, Maurel K, Clark R. Impact of a 'rescue course' of antenatal corticosteroids:
a multicenter randomized placebo-controlled trial. Am J Obstet Gynecol 2009;200:248.e1-e9. (High
Quality Evidence)
Garite TJ, Weeks J, Peters-Phair K, et al. A randomized controlled trial of the effect of increased intravenous hydration on the course of labor in nulliparous women. Am J Obstet Gynecol 2000;183:154448. (High Quality Evidence)
Gifford DS, Morton SC, Fiske M, et al. Lack of progress in labor as a reason for Cesarean. Obstet
Gynecol 2000;95:589-95. (Low Quality Evidence)
Grimes DA, Nanda K. Magnesium sulfate tocolysis: time to quit. Obstet Gynecol 2006;108:986-89.
(Low Quality Evidence)
Guinn DA, Atkinson MW, Sullivan L, et al. Single vs weekly courses of antenatal corticosteroids for
women at risk of preterm delivery: a randomized controlled trial. JAMA 2001;286:1581-87. (High
Quality Evidence)
Gyetvai K, Hannah ME, Hodnett ED, Ohlsson A. Tocolytics for preterm labor: a systematic review.
Obstet Gynecol 1999;94:869-77. (Systematic Review)
Hager WD, Schuchat A, Gibbs R, et al. Prevention of perinatal group B streptococcal infection: current
controversies. Obstet Gynecol 2000;96:141-45. (Low Quality Evidence)
Halpern SH, Leighton BL, Ohlsson A, et al. Effect of epidural vs parenteral opioid analgesia on the
progress of labor. JAMA 1998;280:2105-10. (Meta-analysis)
Harbert GM Jr. Assessment of uterine contractility and activity. Clin Obstet Gynecol 1992;35:546-58.
(Low Quality Evidence)
Hauth JC. Spontaneous preterm labor and premature rupture of membranes at late preterm gestations:
to deliver or not to deliver. Semin Perinatol 2006;30:98-102. (Low Quality Evidence)
Hinshaw K, Simpson S, Cummings S, et al. A randomised controlled trial of early versus delayed oxytocin
augmentation to treat primary dysfunctional labour in nulliparous women. BJOG 2008;115:1289-96.
(High Quality Evidence)
Iams JD. Prediction and early detection of preterm labor. Obstet Gynecol 2003;101:402-12. (Low
Quality Evidence)
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References
Management of Labor
Fifth Edition/March 2013
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References
Management of Labor
Fifth Edition/March 2013
Mittendorf R, Dambrosia J, Pryde PG, et al. Association between the use of antenatal magnesium
sulfate in preterm labor and adverse health outcomes in infants. Am J Obstet Gynecol 2002;186:111118. (Low Quality Evidence)
Miyazaki FS, Nevarez F. Saline amnioinfusion for relief of repetitive variable decelerations: a prospective randomized study. Am J Obstet Gynecol 1985;153:301-06. (High Quality Evidence)
Myles TD, Santolaya J. Maternal and neonatal outcomes in patients with a prolonged second stage of
labor. Obstet Gynecol 2003;102:52-58. (Low Quality Evidence)
Neerhof MG, Cravello C, Haney EI, Silver RK. Timing of labor induction after premature rupture of
membranes between 32 and 36 weeks' gestation. Am J Obstet Gynecol 1999;180:349-52. (Low
Quality Evidence)
O'Driscoll K, Foley M, MacDonald D. Active management of labor as an alternative to Cesarean section
for dystocia. Obstet Gynecol 1984;63:485-90. (Low Quality Evidence)
Papatsonis DNM, Van Geijn HP, Ader HJ, et al. Nifedipine and ritodrine in the management of preterm
labor: a randomized multicenter trial. Obstet Gynecol 1997;90:230-34. (High Quality Evidence)
Pridjian G. Labor after prior Caesarean section. Clin Obstet Gynecol 1992;35:445-56. (Low Quality
Evidence)
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of healthy, nulliparous women. Birth 1993;20:14-21. (Low Quality Evidence)
Ravasia DJ, Wood SL, Pollard JK. Uterine rupture induced trial of labor among women with previous
Caesarean delivery. Am J Obstet Gynaecol 2000;183:1176-79. (Low Quality Evidence)
Rinehart BK, Terrone DA, Barrow H, et al. Randomized trial of intermittent or continuous amnioinfusion
for variable decelerations. Obstet Gynecol 2000;96:571-74. (High Quality Evidence)
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on length of labor and mode of delivery. Obstet Gynecol 1999;93:995-98. (Low Quality Evidence)
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Am J Obstet Gynecol 2010;203:250.e1-5. (Low Quality Evidence)
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management of labour. Br J Obstet Gynaecol 2000;107:909-15. (High Quality Evidence)
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References
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Fifth Edition/March 2013
Silver RK, Gibbs RS. Predictors of vaginal delivery in patients with a previous Caesarean section, who
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Evidence)
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(Low Quality Evidence)
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Vendittelli F, Volumenie J. Transvaginal ultrasonography examination of the uterine cervix in hospitalised
women undergoing preterm labour. Eur J Obstet Gynecol Reprod Biol 2000;90:3-11. (Low Quality
Evidence)
Vintzileos AM, Antsaklis A, Varvarigos I, et al. A randomized trial of intrapartum electronic fetal heart rate
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Vintzileos AM, Nochimson DJ, Guzman ER, et al. Intrapartum electronic fetal heart rate monitoring
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Vrouenraets FP, Roumen FJ, Dehing CJ, et al. Bishop score and risk of Cesarean delivery after induction of labor in nulliparous women. Obstet Gynecol 2005;105:690-97. (Low Quality Evidence)
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Fifth Edition/March 2013
Yeast JD, Poskin M, Stockbauer JW, Shaffer S. Changing patterns in regionalization of perinatal care
and the impact on neonatal mortality. Am J Obstet Gynecol 1998;178:131-35. (Low Quality Evidence)
Zhang J, Landy HJ, Branch W, et al. Contemporary patterns of spontaneous labor with normal neonatal
outcomes. Obstet Gynecol 2010;116:1281-87. (Low Quality Evidence)
Zhang J, Troendle JF, Yancey MK. Transactions of the twenty-second annual meeting of the society
for maternal-fetal medicine: reassessing the labor curve in nulliparous women. Am J Obstet Gynecol
2002;187:824-28. (Low Quality Evidence)
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The technical aspects of Shared Decision-Making are widely discussed and understood.
Decisional conflict occurs when a patient is presented with options where no single option satisfies all the patients objectives, where there is an inherent difficulty in making a decision, or where
external influencers act to make the choice more difficult.
Decision support clarifies the decision that needs to be made, clarifies the patients values and
preferences, provides facts and probabilities, guides the deliberation and communication and monitors the progress.
Decision aids are evidence-based tools that outline the benefits, harms, probabilities and scientific
uncertainties of specific health care options available to the patient.
However, before decision support and decision aids can be most advantageously utilized, a Collaborative
ConversationTM should be undertaken between the clinician and the patient to provide a supportive framework for Shared Decision-Making.
Collaborative ConversationTM
A collaborative approach toward decision-making is a fundamental tenet of Shared Decision-Making
(SDM). The Collaborative ConversationTM is an inter-professional approach that nurtures relationships,
enhances patients knowledge, skills and confidence as vital participants in their health, and encourages
them to manage their health care.
Within a Collaborative Conversation, the perspective is that both the patient and the clinician play key
roles in the decision-making process. The patient knows which course of action is most consistent with his/
her values and preferences, and the clinician contributes knowledge of medical evidence and best practices.
Use of Collaborative ConversationTM elements and tools is even more necessary to support patient, care
clinician and team relationships when patients and families are dealing with high stakes or highly charged
issues, such as diagnosis of a life-limiting illness.
The overall framework for the Collaborative ConversationTM approach is to create an environment in which
the patient, family and care team work collaboratively to reach and carry out a decision that is consistent with
the patients values and preferences. A rote script or a completed form or checklist does not constitute this
approach. Rather it is a set of skills employed appropriately for the specific situation. These skills need to be
used artfully to address all aspects involved in making a decision: cognitive, affective, social and spiritual.
Key communication skills help build the Collaborative ConversationTM approach. These skills include
many elements, but in this appendix only the questioning skills will be described. (For complete instruction,
see OConnor, Jacobsen Decisional Conflict: Supporting People Experiencing Uncertainty about Options
Affecting Their Health [2007], and Bunn H, OConnor AM, Jacobsen MJ Analyzing decision support
and related communication [1998, 2003].)
1. Listening skills:
Encourage patient to talk by providing prompts to continue such as go on, and then?, uh huh, or by
repeating the last thing a person said, Its confusing.
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Management of Labor
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Paraphrase content of messages shared by patient to promote exploration, clarify content and to
communicate that the persons unique perspective has been heard. The clinician should use his/her own
words rather than just parroting what he/she heard.
Reflection of feelings usually can be done effectively once trust has been established. Until the clinician feels that trust has been established, short reflections at the same level of intensity expressed by
the patient without omitting any of the messages meaning are appropriate. Reflection in this manner
communicates that the clinician understands the patients feelings and may work as a catalyst for further
problem solving. For example, the clinician identifies what the person is feeling and responds back in
his/her own words like this: So, youre unsure which choice is the best for you.
Summarize the persons key comments and reflect them back to the patient. The clinician should
condense several key comments made by the patient and provide a summary of the situation. This assists
the patient in gaining a broader understanding of the situations rather than getting mired down in the
details. The most effective times to do this are midway through and at the end of the conversation. An
example of this is, You and your family have read the information together, discussed the pros and
cons, but are having a hard time making a decision because of the risks.
Perception checks ensure that the clinician accurately understands a patient or family member, and
may be used as a summary or reflection. They are used to verify that the clinician is interpreting the
message correctly. The clinician can say So you are saying that youre not ready to make a decision
at this time. Am I understanding you correctly?
2. Questioning Skills
Open and closed questions are both used, with the emphasis on open questions. Open questions ask
for clarification or elaboration and cannot have a yes or no answer. An example would be What else
would influence you to choose this? Closed questions are appropriate if specific information is required
such as Does your daughter support your decision?
Other skills such as summarizing, paraphrasing and reflection of feeling can be used in the questioning
process so that the patient doesnt feel pressured by questions.
Verbal tracking, referring back to a topic the patient mentioned earlier, is an important foundational
skill (Ivey & Bradford-Ivey). An example of this is the clinician saying, You mentioned earlier
3. Information-Giving Skills
Providing information and providing feedback are two methods of information giving. The distinction
between providing information and giving advice is important. Information giving allows a clinician to
supplement the patients knowledge and helps to keep the conversation patient centered. Giving advice,
on the other hand, takes the attention away from the patients unique goals and values, and places it on
those of the clinician.
Providing information can be sharing facts or responding to questions. An example is If we look at the
evidence, the risk is Providing feedback gives the patient the clinicians view of the patients reaction.
For instance, the clinician can say, You seem to understand the facts and value your daughters advice.
Eye contact
Respect
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Empathy
Partnerships
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Self-examination by the clinician involved in the Collaborative ConversationTM can be instructive. Some
questions to ask oneself include:
Have I helped the decision-makers recognize that preferences may change over time?
Am I willing and able to assist the patient in reaching a decision based on his/her values, even when
his/her values and ultimate decision may differ from my values and decisions in similar circumstances?
Regardless of the decision complexity there are cues applicable to all situations that indicate an opportune
time for a Collaborative ConversationTM. These cues can occur singularly or in conjunction with other cues.
Life goal changes: Patients priorities change related to things the patient values such as activities,
relationships, possessions, goals and hopes, or things that contribute to the patients emotional and
spiritual well-being.
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Change in medical evidence or interpretation of medical evidence: Clinicians can clarify the
change and help the patient understand its impact.
Clinician/caregiver contact: Each contact between the clinician/caregiver and the patient presents
an opportunity to reaffirm with the patient that his/her care plan and the care the patient is receiving
are consistent with his/her values.
Patients and families have a role to play as decision-making partners, as well. The needs and influencers
brought to the process by patients and families impact the decision-making process. These are described
below.
Request for support and information: Decisional conflict is indicated by, among other things,
the patient verbalizing uncertainty or concern about undesired outcomes, expressing concern about
choice consistency with personal values and/or exhibiting behavior such as wavering, delay, preoccupation, distress or tension. Generational and cultural influencers may act to inhibit the patient from
actively participating in care discussions, often patients need to be given permission to participate
as partners in making decisions about his/her care.
Support resources may include health care professionals, family, friends, support groups, clergy and
social workers. When the patient expresses a need for information regarding options and his/her
potential outcomes, the patient should understand the key facts about options, risks and benefits,
and have realistic expectations. The method and pace with which this information is provided to
the patient should be appropriate for the patients capacity at that moment.
Advance Care Planning: With the diagnosis of a life-limiting illness, conversations around advance
care planning open up. This is an opportune time to expand the scope of the conversation to other
types of decisions that will need to be made as a consequence of the diagnosis.
Consideration of Values: The personal importance a patient assigns potential outcomes must
be respected. If the patient is unclear how to prioritize the preferences, value clarification can be
achieved through a Collaborative ConversationTM and by the use of decision aids that detail the
benefits and harms of potential outcomes in terms the patient can understand.
Trust: The patient must feel confident that his/her preferences will be communicated and respected
by all caregivers.
Care Coordination: Should the patient require care coordination, this is an opportune time to
discuss the other types of care-related decisions that need to be made. These decisions will most
likely need to be revisited often. Furthermore, the care delivery system must be able to provide
coordinated care throughout the continuum of care.
Responsive Care System: The care system needs to support the components of patient- and familycentered care so the patients values and preferences are incorporated into the care he/she receives
throughout the care continuum.
The Collaborative ConversationTM Map is the heart of this process. The Collaborative ConversationTM Map
can be used as a stand-alone tool that is equally applicable to clinicians and patients as shown in
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Table 2. Clinicians use the map as a clinical workflow. It helps get the Shared Decision-Making process
initiated and provides navigation for the process. Care teams can used the Collaborative ConversationTM
to document team best practices and to formalize a common lexicon. Organizations can build fields from
the Collaborative ConversationTM Map in electronic medical records to encourage process normalization.
Patients use the map to prepare for decision-making, to help guide them through the process and to share
critical information with their loved ones.
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ICSI has long had a policy of transparency in declaring potential conflicting and
competing interests of all individuals who participate in the development, revision
and approval of ICSI guidelines and protocols.
In 2010, the ICSI Conflict of Interest Review Committee was established by the
Board of Directors to review all disclosures and make recommendations to the board
when steps should be taken to mitigate potential conflicts of interest, including
recommendations regarding removal of work group members. This committee
has adopted the Institute of Medicine Conflict of Interest standards as outlined in
the report, Clinical Practice Guidelines We Can Trust (2011).
Where there are work group members with identified potential conflicts, these are
disclosed and discussed at the initial work group meeting. These members are
expected to recuse themselves from related discussions or authorship of related
recommendations, as directed by the Conflict of Interest committee or requested
by the work group.
The complete ICSI policy regarding Conflicts of Interest is available at
http://bit.ly/ICSICOI.
Funding Source
The Institute for Clinical Systems Improvement provided the funding for this
guideline revision. ICSI is a not-for-profit, quality improvement organization
based in Bloomington, Minnesota. ICSI's work is funded by the annual dues of
the member medical groups and five sponsoring health plans in Minnesota and
Wisconsin. Individuals on the work group are not paid by ICSI but are supported
by their medical group for this work.
ICSI facilitates and coordinates the guideline development and revision process.
ICSI, member medical groups and sponsoring health plans review and provide
feedback but do not have editorial control over the work group. All recommendations are based on the work group's independent evaluation of the evidence.
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Acknowledgements:
Management of Labor
All ICSI documents are available for review during the revision process by
member medical groups and sponsors. In addition, all members commit to
reviewing specific documents each year. This comprehensive review provides
information to the work group for such issues as content update, improving
clarity of recommendations, implementation suggestions and more. The
specific reviewer comments and the work group responses are available to
ICSI members at http://bit.ly.Labors.
The ICSI Patient Advisory Council meets regularly to respond to any
scientific document review requests put forth by ICSI facilitators and work
groups. Patient advisors who serve on the council consistently share their
experiences and perspectives in either a comprehensive or partial review of a
document, and engaging in discussion and answering questions. In alignment
with the Institute of Medicine's triple aims, ICSI and its member groups are
committed to improving the patient experience when developing health care
recommendations.
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Acknowledgements
Invited Reviewers
During this revision, the following groups reviewed this document. The work group would like to thank
them for their comments and feedback.
Hennepin County Medical Center, Minneapolis, MN
Mayo Clinic, Rochester, MN
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Document History
In July of 2005, this guideline was created as a result of merging the following
ICSI guidelines:
Document Drafted
Jul Sep 2005
First Edition
Nov 2005
Second Edition
Apr 2007
In May of 2011, the order set for Management of Labor was incorporated into
the body of the guideline.
Third Edition
Jun 2009
Fourth Edition
Jun 2011
Fifth Edition
Begins Apr 2013
The Management of Labor guideline is the result of merging the Preterm Birth Prevention
(Preterm), Intrapartum Fetal Heart Rate Monitoring (IFHRM), The Prevention, Diagnosis and Treatment of
Failure to Progress in Obstetrical Labor (FTP), and Vaginal Birth after Caesarean (VBAC) guidelines.
Work Group Leaders
Health Education
Family Practice
Nurse Midwife
OB/GYN
Measurement Advisor
Facilitators
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Since 1993, the Institute for Clinical Systems Improvement (ICSI) has developed more than 60 evidence-based
health care documents that support best practices for the prevention, diagnosis, treatment or management of a
given symptom, disease or condition for patients.
The information contained in this ICSI Health Care Guideline is intended primarily for health professionals and
other expert audiences.
This ICSI Health Care Guideline should not be construed as medical advice or medical opinion related to any
specific facts or circumstances. Patients and families are urged to consult a health care professional regarding their
own situation and any specific medical questions they may have. In addition, they should seek assistance from a
health care professional in interpreting this ICSI Health Care Guideline and applying it in their individual case.
This ICSI Health Care Guideline is designed to assist clinicians by providing an analytical framework for the
evaluation and treatment of patients, and is not intended either to replace a clinician's judgment or to establish a
protocol for all patients with a particular condition.
ICSI's medical group members and sponsors review each guideline as part of the revision process. They provide
comment on the scientific content, recommendations, implementation strategies and barriers to implementation.
This feedback is used by and responded to by the work group as part of their revision work. Final review and
approval of the guideline is done by ICSI's Committee on Evidence-Based Practice. This committee is made up
of practicing clinicians and nurses, drawn from ICSI member medical groups.
These are provided to assist medical groups and others to implement the recommendations in the guidelines.
Where possible, implementation strategies are included that have been formally evaluated and tested. Measures
are included that may be used for quality improvement as well as for outcome reporting. When available, regulatory or publicly reported measures are included.
Scientific documents are revised every 12-24 months as indicated by changes in clinical practice and literature.
ICSI staff monitors major peer-reviewed journals every month for the guidelines for which they are responsible.
Work group members are also asked to provide any pertinent literature through check-ins with the work group
midcycle and annually to determine if there have been changes in the evidence significant enough to warrant
document revision earlier than scheduled. This process complements the exhaustive literature search that is done
on the subject prior to development of the first version of a guideline.
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