Management of Labor and Delivery, An Issue of Obstetrics and Gynecology Clinics

145 Pages·2017·4.85 MB·English

by  Aaron B. Caughey

Management of Labor
and Delivery
Editor
AARON B. CAUGHEY
OBSTETRICS AND
GYNECOLOGY
CLINICS OF NORTH AMERICA
www.obgyn.theclinics.com
Consulting Editor
WILLIAM F. RAYBURN
December 2017 • Volume 44 • Number 4
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ManagementofLaborandDelivery
Contributors
CONSULTING EDITOR
WILLIAMF.RAYBURN,MD,MBA
AssociateDean,ContinuingMedicalEducationandProfessionalDevelopment,
DistinguishedProfessorandEmeritusChair,ObstetricsandGynecology,Universityof
NewMexicoSchoolofMedicine,Albuquerque,NewMexico
EDITOR
AARONB.CAUGHEY,MD,PhD
ProfessorandChair,DepartmentofObstetricsandGynecology,OregonHealth&Science
University,Portland,Oregon
AUTHORS
ALLISONJ.ALLEN,MD
Maternal-FetalMedicineFellow,DepartmentofObstetricsandGynecology,Oregon
Health&ScienceUniversity,Portland,Oregon
ALISONG.CAHILL,MD,MSCI
AssociateProfessor,DepartmentofObstetricsandGynecology,Chief,Divisionof
Maternal-FetalMedicine,WashingtonUniversitySchoolofMedicineinSt.Louis,StLouis,
Missouri
AARONB.CAUGHEY,MD,PhD
ProfessorandChair,DepartmentofObstetricsandGynecology,OregonHealth&Science
University,Portland,Oregon
YVONNEW.CHENG,MD,PhD
MedicalDirector,DivisionofMaternal-FetalMedicine,DepartmentofObstetricsand
Gynecology,SutterHealth,CaliforniaPacificMedicalCenter,SanFrancisco,California;
DepartmentofSurgery,UniversityofCalifornia,Davis,Davis,California
NATHANS.FOX,MD
Maternal-FetalMedicineAssociates,PLLC,DepartmentofObstetrics,Gynecology,and
ReproductiveScience,IcahnSchoolofMedicineatMountSinai,NewYork,NewYork
ANNESSAKERNBERG,MD
DepartmentofObstetricsandGynecology,OregonHealth&ScienceUniversity,Portland,
Oregon
BETHLEOPOLD,MD
Resident,DepartmentofObstetricsandGynecology,ChristianaCareHealthSystem,
Newark,Delaware
iv Contributors
SARAHE.LITTLE,MD,MPH
AssistantProfessor,DivisionofMaternal-FetalMedicine,BrighamandWomen’s
Hospital,HarvardMedicalSchool,Boston,Massachusetts
STEPHANIEMELKA,MD
Maternal-FetalMedicineAssociates,PLLC,DepartmentofObstetrics,Gynecology,and
ReproductiveScience,IcahnSchoolofMedicineatMountSinai,NewYork,NewYork
JAMESMILLER,MD
Maternal-FetalMedicineAssociates,PLLC,DepartmentofObstetrics,Gynecology,and
ReproductiveScience,IcahnSchoolofMedicineatMountSinai,NewYork,NewYork
CHRISTINAA.PENFIELD,MD,MPH
ClinicalInstructorandMaternal-FetalMedicineFellow,DepartmentofObstetricsand
Gynecology,SchoolofMedicine,UniversityofCalifornia,Irvine,Orange,California
RACHELA.PILLIOD,MD
ClinicalFellow,DepartmentofObstetricsandGynecology,DivisionofMaternal-Fetal
Medicine,OregonHealth&ScienceUniversity,Portland,Oregon
NANDINIRAGHURAMAN,MD,MS
Maternal-FetalMedicineFellow,DepartmentofObstetricsandGynecology,Divisionof
Maternal-FetalMedicine,WashingtonUniversitySchoolofMedicineinSt.Louis,StLouis,
Missouri
JANINES.RHOADES,MD
DepartmentofObstetricsandGynecology,WashingtonUniversitySchoolofMedicinein
St.Louis,StLouis,Missouri
BETHANYSABOL,MD
DepartmentofObstetricsandGynecology,OregonHealth&ScienceUniversity,Portland,
Oregon
JAMESSARGENT,MD
ClinicalFellowinMaternal-FetalMedicine,DepartmentofObstetricsandGynecology,
OregonHealth&ScienceUniversity,Portland,Oregon
ANTHONYSCISCIONE,DO
DirectorofMaternal-FetalMedicineandtheOB/GynResidencyProgram,Departmentof
ObstetricsandGynecology,ChristianaCareHealthSystem,Newark,Delaware
DEBORAHA.WING,MD,MBA
Professor,DepartmentofObstetricsandGynecology,SchoolofMedicine,Universityof
California,Irvine,Orange,California
ManagementofLaborandDelivery
Contents
Foreword:AddressingCommonManagementDilemmasinLaborandDelivery xi
WilliamF.Rayburn
Preface:Evidence-BasedManagementofLaborandDelivery:WhatDoWeStill
NeedtoKnow? xiii
AaronB.Caughey
Evidence-BasedLaborandDeliveryManagement:CanWeSafelyReducethe
CesareanRate? 523
AaronB.Caughey
Thisarticleprovidesanoverviewoftheapproachesthatmightbeusedto
safely reduce the cesarean rate. Although cesarean delivery may be a
safe alternative to vaginal delivery, its use in 1 in 3 women giving birth
islikelytoohigh.Thedownstreamimpactofcesareandeliveryonfuture
pregnanciesislikelynotwellconsideredwhenthefirstcesareanisbeing
performed. Through quality improvement, environmental changes will
allow clinicians to adopt the range of practices described. However,
without such environmental changes, clinicians may not be able to
change their own practice patterns given environments in which they
practice.
DefiningandManagingNormalandAbnormalFirstStageofLabor 535
JanineS.RhoadesandAlisonG.Cahill
Moderndatahaveredefinedthenormalfirststageoflabor.Keydifferences
includethatthelatentphaseoflaborismuchslowerthanwaspreviously
thoughtandthetransitionfromlatenttoactivelabordoesnotoccuruntil
about 6 cm of cervical dilatation, regardless of parity or whether labor
was spontaneous or induced. Providers should have a low threshold to
useoneofthesafeandeffectiveinterventionstomanageabnormalpro-
gressioninthefirststageoflabor,includingoxytocin,internaltocodyna-
mometry,andamniotomy.
DefiningandManagingNormalandAbnormalSecondStageofLabor 547
YvonneW.ChengandAaronB.Caughey
TheAmericanCollegeofObstetriciansandGynecologists(ACOG)Prac-
ticeBulletinNo.49onDystociaandAugmentationofLabordefinesapro-
longedsecondstageasmorethan2hourswithoutor3hourswithepidural
analgesia in nulliparous women, and 1 hour without or 2 hours with
epiduralinmultiparouswomen.Thisdefinitiondiagnoses10%to14%of
nulliparousand3%to3.5%ofmultiparouswomenashavingaprolonged
second stage. Although current labor norms remained largely based on
dataestablishedbyFriedmaninthe1950s,modernobstetricpopulation
andpracticehaveevolvedwithtime.
vi Contents
LaborInductionTechniques:WhichIstheBest? 567
ChristinaA.PenfieldandDeborahA.Wing
Induction of labor is a common procedure undertaken whenever the
benefitsofpromptdeliveryoutweightherisksofexpectantmanagement.
Cervicalassessmentisessentialtodeterminetheoptimalapproach.Indi-
cationforinduction,clinicalpresentationandhistory,safety,cost,andpa-
tient preference may factor into the selection of methods. For the
unfavorable cervix, several pharmacologic and mechanical methods are
available,eachwithassociatedadvantagesanddisadvantages.Inwomen
with a favorable cervix, combined use of amniotomy and intravenous
oxytocinisgenerallythemosteffectiveapproach.Thegoaloflaborinduc-
tionistoensurethebestpossibleoutcomeformotherandnewborn.
IsThereaPlaceforOutpatientPreinductionCervicalRipening? 583
BethLeopoldandAnthonySciscione
Inductionoflaborcontinuestobeoneofthemostcommonlyperformed
tasks in obstetrics. If trials like the National Institute of Child Health and
Human Development’s ARRIVE trial show that delivery for all women at
39 weeks provides a significant advantage in pregnancy outcomes, the
number of women who require induction of labor will considerably in-
crease. Strategies to improve patient/family satisfaction, decrease
resourceallocationandcosts,andassuresafetyareparamount.Although
therearemanypotentialcandidates,itseemsthatoutpatientpreinduction
cervicalripeningwiththeFoleycathetermeetsthesecriteriainaproperly
selectedgroupoflow-riskwomen.
AugmentationofLabor:AReviewofOxytocinAugmentationandActive
ManagementofLabor 593
AnnessaKernbergandAaronB.Caughey
Laboraugmentationcanbeusedtohastenlabor,shortenthetimetode-
livery, and perhaps reduce the risk of cesarean delivery. Particularly in
womenwithlongerlaborsorlessfrequentcontractions,oxytocinaugmen-
tationseemstohavepositiveimpactsontheseoutcomes.Despitethis,the
evidence for augmentation alone on the risk of cesarean delivery is
unclear, with varying evidence. More recently, oxytocin protocols have
beenrecommendedtostandardizecareandensurepatientsafety.
ElectiveInductionofLabor:WhatistheImpact? 601
SarahE.Little
Elective induction of labor (ie, without a maternal or fetal indication) is
commonintheUnitedStates.Whenusingthecorrectcomparisongroup
(electiveinductionvsexpectantmanagement),inductionisnotassociated
withanincreasedriskofcesareandelivery.Moreover,electiveinduction
after39weeksseemstohavematernalbenefits(eg,lowerinfectionrates)
as well as a reduction in neonatal morbidity and the potential for a
decrease in term stillbirth. However, these risks, especially stillbirth, are
low in a healthy cohort and there are potential negative impacts on
maternalsatisfaction,breastfeeding,andcost/resourceusethatmustbe
considered.
Contents vii
UpdateonFetalMonitoring:OverviewofApproachesandManagementof
CategoryIITracings 615
NandiniRaghuramanandAlisonG.Cahill
Electronicfetalmonitoring(EFM)iswidelyusedtoassessfetalstatusin
labor.UseofintrapartumcontinuousEFMisassociatedwithalowerrisk
ofneonatalseizuresbutahigherriskofcesareanoroperativedelivery.
Category II fetal heart tracings are indeterminate in their ability to pre-
dict fetal acidemia. Certain patterns of decelerations and variability
within this category may be predictive of neonatal morbidity. Adjunct
tests of fetal well-being can be used during labor to further triage pa-
tients.Intrauterineresuscitationtechniquesshouldtargetthesuspected
etiology of intrapartum fetal hypoxia. Clinical factors play a role in the
interpretation of EFM.
TheEvolutionoftheLaborist 625
AllisonJ.AllenandAaronB.Caughey
The laborist movement was introduced as a means to improve the
quality of care patients receive in the labor suite and decrease physi-
cian burnout and malpractice claims. This model of care has rapidly
expanded, and there is evidence of its potential role in improving
labor outcomes. This article outlines the different models of laborist
care, reviews the evidence for its potential impact on labor outcomes,
and discusses the economic impact the employment of laborists
can have.
FetalMalpresentationandMalposition:DiagnosisandManagement 631
RachelA.PilliodandAaronB.Caughey
Fetal malpresentation and fetal malposition are frequently interchanged;
however, fetal malpresentation refers to a fetus with a fetal part other
thantheheadengagingthematernalpelvis.Fetalmalpositioninlaborin-
cludes occiput posterior and occiput transverse positions. Both fetal
malpositionandmalpresentationareassociatedwithsignificantmaternal
andneonatalmorbidity,whichhavesignificantimpactonpatientsandpro-
viders.Accuratediagnosisofbothconditionsisnecessaryforappropriate
management.Inthisarticle,terminology,incidence,diagnosis,andman-
agementarediscussed.
LaborandDeliveryofTwinPregnancies 645
StephanieMelka,JamesMiller,andNathanS.Fox
Obstetricians who care for twin pregnancies should be aware of the
challenges that may arise during the labor and delivery. With recogni-
tion of these issues and proper training, providers should be able to
help women with twin pregnancies achieve a safe delivery for them
and their babies. With the use of breech extraction of the second
twin and active management of the second stage of labor, women
with twin pregnancies can also achieve a high vaginal delivery rate of
both twins.
viii Contents
VaginalBirthAfterCesareanTrends:WhichWayIsthePendulumSwinging? 655
JamesSargentandAaronB.Caughey
Thecesareandeliveryratehasplateauedat32%;concurrently,afterpeak-
ing in the mid-1990s, trial of labor after cesarean (TOLAC) rates have
declined.Lessthan25%ofwomenwithapriorcesareandeliveryattempt
afutureTOLAC.ThisdecreasingtrendinTOLACiscausedbyinadequate
resourceavailability,malpracticeconcerns,andlackofknowledgeinpa-
tientsandprovidersregardingtheperceivedrisksandbenefits.Thisarticle
outlinesthefactorsinfluencingrecentvaginalbirthaftercesareantrendsin
additiontoreviewingthematernalandneonataloutcomesassociatedwith
TOLAC,specificallyinhigh-riskpopulations.
QualityImprovementandPatientSafetyonLaborandDelivery 667
BethanySabolandAaronB.Caughey
There has been an emphasis on redesigning our health care system to
eliminatemedicalerrorsandcreateacultureofsafety.TheAmericanCol-
legeofObstetricsandGynecologistsdefinesacultureofsafetyasanenvi-
ronmentinwhichallcareprovidersareempoweredtoidentifyerrors,near
misses, risky behaviors, and broader systems issues while engaging in
activecollaborationtoimproveandresolveprocessesandsystemfailures.
Thisarticlereviewskeycomponentsthatpromoteacultureofsafetyand
helpto implementsafer, moreeffective, evidence-basedqualitycareon
laboranddeliveryunits.
ManagementofLaborandDelivery ix
OBSTETRICS AND GYNECOLOGY CLINICS
FORTHCOMINGISSUES RECENTISSUES
March2018 September2017
ReproductiveGenetics EvaluationandManagementofVulvar
LorraineDugoff,Editor Disease
ArunaVenkatesan,Editor
June2018
MedicalDisordersinPregnancy June2017
JudithHibbardandErikaPeterson, ObstetricsandGynecology:Maintenance
Editors ofKnowledge
JaniceL.BaconandPaulG.Tomich,
September2018
Editors
PerinatalMentalHealth
ConstanceGuilleandRogerB.Newman, March2017
Editors HealthCareforUnderservedWomen
WandaKayNicholson,Editor
ISSUE OF RELATED INTEREST
ClinicsinPerinatology,June2017(Vol.44,No.2)
DeliveryinthePeriviablePeriod
BrianM.MercerandKeithJ.Barrington,Editors
Availableat:http://www.perinatology.theclinics.com/
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