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ZSFG Labor Duration and Management Guideline BackgroundA third of all babies in the U.S. are born by cesarean delivery, a rate twice as high as what the World Health Organization deems appropriate for highly developed countries. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"xYAUvem3","properties":{"formattedCitation":"{\\rtf \\super 1\\nosupersub{}}","plainCitation":"1"},"citationItems":[{"id":27618,"uris":[""],"uri":[""],"itemData":{"id":27618,"type":"article-journal","title":"Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver national institute of child health and human development, society for maternal-fetal medicine, and American college of obstetricians and gynecologists workshop","container-title":"Obstetrics and gynecology","page":"1181","volume":"120","issue":"5","source":"Google Scholar","shortTitle":"Preventing the first cesarean delivery","author":[{"family":"Spong","given":"Catherine Y."},{"family":"Berghella","given":"Vincenzo"},{"family":"Wenstrom","given":"Katharine D."},{"family":"Mercer","given":"Brian M."},{"family":"Saade","given":"George R."}],"issued":{"date-parts":[["2012"]]}}}],"schema":""} 1 While cesarean delivery (CD) is a life-saving procedure in some situations, its overuse in the United States is currently contributing to undue morbidity and mortality for mothers and babies. CD are associated with a three-fold increase in severe maternal morbidities such as hemorrhage requiring hysterectomy or transfusions, uterine rupture, anesthetic complications, shock, cardiac arrest, acute renal failure, assisted ventilation, venous thromboembolism, major infection, and in-hospital wound or hematoma. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Cqsg4G6a","properties":{"formattedCitation":"{\\rtf \\super 2\\nosupersub{}}","plainCitation":"2"},"citationItems":[{"id":27619,"uris":[""],"uri":[""],"itemData":{"id":27619,"type":"article-journal","title":"Safe prevention of the primary cesarean delivery","container-title":"American Journal of Obstetrics and Gynecology","page":"179-193","volume":"210","issue":"3","source":"CrossRef","DOI":"10.1016/j.ajog.2014.01.026","ISSN":"00029378","language":"en","author":[{"family":"Caughey","given":"Aaron B."},{"family":"Cahill","given":"Alison G."},{"family":"Guise","given":"Jeanne-Marie"},{"family":"Rouse","given":"Dwight J."}],"issued":{"date-parts":[["2014",3]]}}}],"schema":""} 2 Furthermore, subsequent cesarean deliveries increase the risk of placental abnormalities in future pregnancies. By the third cesarean delivery, a woman has a 3% chance of placenta previa and there is a 40% chance that the placenta previa will be complicated by placenta accreta. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"baqBP34U","properties":{"formattedCitation":"{\\rtf \\super 2\\nosupersub{}}","plainCitation":"2"},"citationItems":[{"id":27619,"uris":[""],"uri":[""],"itemData":{"id":27619,"type":"article-journal","title":"Safe prevention of the primary cesarean delivery","container-title":"American Journal of Obstetrics and Gynecology","page":"179-193","volume":"210","issue":"3","source":"CrossRef","DOI":"10.1016/j.ajog.2014.01.026","ISSN":"00029378","language":"en","author":[{"family":"Caughey","given":"Aaron B."},{"family":"Cahill","given":"Alison G."},{"family":"Guise","given":"Jeanne-Marie"},{"family":"Rouse","given":"Dwight J."}],"issued":{"date-parts":[["2014",3]]}}}],"schema":""} 2 Labor dystocia is the top indication for primary cesarean deliveries. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"HtVzx80Z","properties":{"formattedCitation":"{\\rtf \\super 1\\nosupersub{}}","plainCitation":"1"},"citationItems":[{"id":27618,"uris":[""],"uri":[""],"itemData":{"id":27618,"type":"article-journal","title":"Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver national institute of child health and human development, society for maternal-fetal medicine, and American college of obstetricians and gynecologists workshop","container-title":"Obstetrics and gynecology","page":"1181","volume":"120","issue":"5","source":"Google Scholar","shortTitle":"Preventing the first cesarean delivery","author":[{"family":"Spong","given":"Catherine Y."},{"family":"Berghella","given":"Vincenzo"},{"family":"Wenstrom","given":"Katharine D."},{"family":"Mercer","given":"Brian M."},{"family":"Saade","given":"George R."}],"issued":{"date-parts":[["2012"]]}}}],"schema":""} 1 However, many of the interventions used to treat labor dystocia, such as oxytocin augmentation and artificial rupture of membranes, put women at risk for other morbidities and in some cases decreased patient satisfaction. This guideline is intended to aid health care providers in identifying those at risk for labor dystocia, and provide them with a template for judicious, safe and timely management of labor dystocia and arrest. Relevant DataActive Phase ArrestIn the setting of active phase arrest (APA), outcomes of vaginal delivery and cesarean delivery were compared. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"uZy3Jtb4","properties":{"formattedCitation":"{\\rtf \\super 3\\nosupersub{}}","plainCitation":"3"},"citationItems":[{"id":27620,"uris":[""],"uri":[""],"itemData":{"id":27620,"type":"article-journal","title":"Perinatal Outcomes in the Setting of Active Phase Arrest of Labor:","container-title":"Obstetrics & Gynecology","page":"1109-1115","volume":"112","issue":"5","source":"CrossRef","DOI":"10.1097/AOG.0b013e31818b46a2","ISSN":"0029-7844","shortTitle":"Perinatal Outcomes in the Setting of Active Phase Arrest of Labor","language":"en","author":[{"family":"Henry","given":"Dana E. M."},{"family":"Cheng","given":"Yvonne W."},{"family":"Shaffer","given":"Brian L."},{"family":"Kaimal","given":"Anjali J."},{"family":"Bianco","given":"Katherine"},{"family":"Caughey","given":"Aaron B."}],"issued":{"date-parts":[["2008",11]]}}}],"schema":""} 3 Abnormal active phase was diagnosed after greater than or equal to 4cm cervical dilation with no progress for at least 2 hours in the presence of adequate uterine contractions (≥ 200 Montevideo units per 10-minute period, as measured by an intrauterine pressure catheter). A sample of 1,014 women, 355 in the vaginal delivery group, 95 in the operative vaginal delivery group, and 584 in the cesarean delivery group yielded the following results: Neonatal Outcomes: No difference in rates of adverse neonatal outcomes between those who delivered vaginally and those who had a cesarean delivery Maternal Outcomes: Women with APA who had cesareans compared with women with APA who delivered vaginally, were at higher risk of Chorioamnionitis (OR 3.37 95% CI 2.21-5.15) Endometritis(OR 48.4, 95% CI 6.61-354) Postpartum hemorrhage (OR 5.18; 95% CI 3.42-7.85) Severe postpartum hemorrhage (OR 14.97, 95% CI 1.77-1.26) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"kJgYWwou","properties":{"formattedCitation":"{\\rtf \\super 3\\nosupersub{}}","plainCitation":"3"},"citationItems":[{"id":27620,"uris":[""],"uri":[""],"itemData":{"id":27620,"type":"article-journal","title":"Perinatal Outcomes in the Setting of Active Phase Arrest of Labor:","container-title":"Obstetrics & Gynecology","page":"1109-1115","volume":"112","issue":"5","source":"CrossRef","DOI":"10.1097/AOG.0b013e31818b46a2","ISSN":"0029-7844","shortTitle":"Perinatal Outcomes in the Setting of Active Phase Arrest of Labor","language":"en","author":[{"family":"Henry","given":"Dana E. M."},{"family":"Cheng","given":"Yvonne W."},{"family":"Shaffer","given":"Brian L."},{"family":"Kaimal","given":"Anjali J."},{"family":"Bianco","given":"Katherine"},{"family":"Caughey","given":"Aaron B."}],"issued":{"date-parts":[["2008",11]]}}}],"schema":""} 3 The researchers also studied the outcomes of 355 women with vaginal deliveries in the setting of APA compared to 12, 566 women without APA. The women with APA had:Maternal OutcomesHigher rate of Operative vaginal delivery (28% vs. 17%, p<0.001)Higher rate of chorioamnionitis (18% v. 8%, p<0.001)Higher rate of 3rd and 4th degree lacerations (16% vs. 9%, p<0.001)Higher rate of Postpartum hemorrhage (26% vs. 17%, p<0.001)Neonatal Outcomes:Higher rate of shoulder dystocia (4% vs. 2%, p<0.01)Higher rate of 5 minute Apgar scores <7 (5% vs. 2%, p<0.001)No difference in sepsis, NICU admission, clavicular fracture, Erb’s palsy or acidemia. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"35uBzD21","properties":{"formattedCitation":"{\\rtf \\super 3\\nosupersub{}}","plainCitation":"3"},"citationItems":[{"id":27620,"uris":[""],"uri":[""],"itemData":{"id":27620,"type":"article-journal","title":"Perinatal Outcomes in the Setting of Active Phase Arrest of Labor:","container-title":"Obstetrics & Gynecology","page":"1109-1115","volume":"112","issue":"5","source":"CrossRef","DOI":"10.1097/AOG.0b013e31818b46a2","ISSN":"0029-7844","shortTitle":"Perinatal Outcomes in the Setting of Active Phase Arrest of Labor","language":"en","author":[{"family":"Henry","given":"Dana E. M."},{"family":"Cheng","given":"Yvonne W."},{"family":"Shaffer","given":"Brian L."},{"family":"Kaimal","given":"Anjali J."},{"family":"Bianco","given":"Katherine"},{"family":"Caughey","given":"Aaron B."}],"issued":{"date-parts":[["2008",11]]}}}],"schema":""} 3Summary: Women who had active phase arrest had higher risks of maternal and neonatal outcomes compared to those who did not have the diagnosis. However, those who had active phase arrest and underwent a cesarean delivery had much higher risks than those who delivered vaginally. Waiting for a vaginal delivery rather than doing a cesarean decreases the risk of adverse maternal outcomes without causing any additional risk to the newborn. Number needed to treat (NNT): three women delivering vaginally rather than by cesarean would prevent one postpartum hemorrhage; 33 women delivering vaginally would prevent one blood transfusion.Prolonged Second StageNulliparous women:Multiple investigators have found that for nulliparous women, adverse neonatal outcomes are not associated with duration of second stage. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"dJSUWw9L","properties":{"formattedCitation":"{\\rtf \\super 2\\nosupersub{}}","plainCitation":"2"},"citationItems":[{"id":27619,"uris":[""],"uri":[""],"itemData":{"id":27619,"type":"article-journal","title":"Safe prevention of the primary cesarean delivery","container-title":"American Journal of Obstetrics and Gynecology","page":"179-193","volume":"210","issue":"3","source":"CrossRef","DOI":"10.1016/j.ajog.2014.01.026","ISSN":"00029378","language":"en","author":[{"family":"Caughey","given":"Aaron B."},{"family":"Cahill","given":"Alison G."},{"family":"Guise","given":"Jeanne-Marie"},{"family":"Rouse","given":"Dwight J."}],"issued":{"date-parts":[["2014",3]]}}}],"schema":""} 2 A secondary analysis compared neonatal and maternal outcomes of 4,126 nulliparous women with second stages of labor lasting greater than 3 hours with women who delivered in under 3 hours.Results:There were no increases in neonatal outcomes of prolonged second stage for:NICU admission5 minute Apgar scores<4umbilical cord pH<7intubationsepsissmall increase in brachial plexus injury (OR 1.78 CI 1.08-2.78) small absolute risk (3 in 1000)Maternal outcomes Longer 2nd stage associated with: higher rate chorioamnionitis (OR 1.60, CI 1.51-1.87)3rd or 4th degree laceration (OR 1.88, CI 1.62-1.99)uterine atony (OR 1.29, CI 1.51-1.45) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"28sRhcF2","properties":{"formattedCitation":"{\\rtf \\super 4\\nosupersub{}}","plainCitation":"4"},"citationItems":[{"id":27621,"uris":[""],"uri":[""],"itemData":{"id":27621,"type":"article-journal","title":"Second-stage labor duration in nulliparous women: relationship to maternal and perinatal outcomes","container-title":"American Journal of Obstetrics and Gynecology","page":"357.e1-357.e7","volume":"201","issue":"4","source":"CrossRef","DOI":"10.1016/j.ajog.2009.08.003","ISSN":"00029378","shortTitle":"Second-stage labor duration in nulliparous women","language":"en","author":[{"family":"Rouse","given":"Dwight J."},{"family":"Weiner","given":"Steven J."},{"family":"Bloom","given":"Steven L."},{"family":"Varner","given":"Michael W."},{"family":"Spong","given":"Catherine Y."},{"family":"Ramin","given":"Susan M."},{"family":"Caritis","given":"Steve N."},{"family":"Peaceman","given":"Alan M."},{"family":"Sorokin","given":"Yoram"},{"family":"Sciscione","given":"Anthony"},{"family":"Carpenter","given":"Marshall W."},{"family":"Mercer","given":"Brian M."},{"family":"Thorp","given":"John M."},{"family":"Malone","given":"Fergal D."},{"family":"Harper","given":"Margaret"},{"family":"Iams","given":"Jay D."},{"family":"Anderson","given":"Garland D."}],"issued":{"date-parts":[["2009",10]]}}}],"schema":""} 4 Multiparous women:A retrospective cohort study of 5158 women found that for multiparous women with 3 hours or more in second stage, there were increased risks of:Maternal Outcomes: 3rd and 4th degree laceration (OR 2.56; 95% CI [1.44-4.55]postpartum hemorrhage (OR 2.27; 95% CI [1.66-3.11]chorioamnionitis [OR 6.02; 95% CI [4.14-8.75]Neonatal Outcomes:5-minute Apgar score of less than 7 (OR 3.63; 95% CI [1.77-7.43] NICU admission (OR 2.08; 95% CI [1.15-3.77]Composite of neonatal morbidity (OR 1.85; 95% CI [1.23-2.77]Longer neonatal stay in the hospital (OR 1.67; 95% CI [1.11-2.51] ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"bjfZmlBb","properties":{"formattedCitation":"{\\rtf \\super 5\\nosupersub{}}","plainCitation":"5"},"citationItems":[{"id":27622,"uris":[""],"uri":[""],"itemData":{"id":27622,"type":"article-journal","title":"Duration of the second stage of labor in multiparous women: maternal and neonatal outcomes","container-title":"American Journal of Obstetrics and Gynecology","page":"585.e1-6","volume":"196","issue":"6","source":"PubMed","abstract":"OBJECTIVE: This study was undertaken to examine perinatal outcomes associated with the second stage of labor in multiparous women.\nSTUDY DESIGN: This is a retrospective cohort study of all term, cephalic, singleton births delivered by multiparous women between 1991 and 2001. Duration of the second stage of labor was stratified into hourly intervals: 0-1 hour, 1-2 hours, 2-3 hours, and 3 hours or longer. Perinatal outcomes were analyzed by using chi2 test and multivariable logistic regression models, by using P<.05 and 95% CI to indicate statistical significance.\nRESULTS: Compared with women who delivered between the 0- and 2-hour interval, women with a second stage more than 3 hours had higher risks of operative vaginal deliveries (odds ratio = 13.27; 95% CI [9.38-18.8]), cesarean deliveries (odds ratio = 6.00; [4.06-8.86]), and maternal morbidity including third- or fourth-degree perineal lacerations, postpartum hemorrhage, and chorioamnionitis. Their neonates had higher risks of 5-minute Apgar score less than 7 (odds ratio = 3.63; 95% CI [1.77-7.43]), meconium stained amniotic fluid (odds ratio = 1.44; 95% CI [1.07-1.94]), admission to intensive care nursery (odds ratio = 2.08; 95% CI [1.15-3.77]), composite neonatal morbidity (odds ratio = 1.85; 95% CI [1.23-2.77]), and longer neonatal stay in the hospital (odds ratio = 1.67; 95% CI [1.11-2.51]).\nCONCLUSION: Multiparous women with a second stage of 3 hours or greater are at increased risks for operative deliveries, peripartum morbidity, and undesirable neonatal outcomes. These outcomes should be considered in the management of multiparous women with a second stage of labor beyond 3 hours.","DOI":"10.1016/j.ajog.2007.03.021","ISSN":"1097-6868","note":"PMID: 17547906","shortTitle":"Duration of the second stage of labor in multiparous women","journalAbbreviation":"Am. J. Obstet. Gynecol.","language":"eng","author":[{"family":"Cheng","given":"Yvonne W."},{"family":"Hopkins","given":"Linda M."},{"family":"Laros","given":"Russell K."},{"family":"Caughey","given":"Aaron B."}],"issued":{"date-parts":[["2007",6]]},"PMID":"17547906"}}],"schema":""} 5 A population-based study including 2,156 multiparous women with prolonged second stage (defined as lasting more than 2 hours) found similar results but no difference in: neonatal sepsis trauma ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"sLZaD3BN","properties":{"formattedCitation":"{\\rtf \\super 6\\nosupersub{}}","plainCitation":"6"},"citationItems":[{"id":27624,"uris":[""],"uri":[""],"itemData":{"id":27624,"type":"article-journal","title":"Maternal and Perinatal Outcomes With Increasing Duration of the Second Stage of Labor:","container-title":"Obstetrics & Gynecology","page":"1248-1258","volume":"113","issue":"6","source":"CrossRef","DOI":"10.1097/AOG.0b013e3181a722d6","ISSN":"0029-7844","shortTitle":"Maternal and Perinatal Outcomes With Increasing Duration of the Second Stage of Labor","language":"en","author":[{"family":"Allen","given":"Victoria M."},{"family":"Baskett","given":"Thomas F."},{"family":"O’Connell","given":"Colleen M."},{"family":"McKeen","given":"Dolores"},{"family":"Allen","given":"Alexander C."}],"issued":{"date-parts":[["2009",6]]}}}],"schema":""} 6Chance of NSVD by lengths of second stage: at 3 hours:59%at 4 hours:27%at 5 hours: 9% ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"nkmrpw0S","properties":{"formattedCitation":"{\\rtf \\super 4\\nosupersub{}}","plainCitation":"4"},"citationItems":[{"id":27621,"uris":[""],"uri":[""],"itemData":{"id":27621,"type":"article-journal","title":"Second-stage labor duration in nulliparous women: relationship to maternal and perinatal outcomes","container-title":"American Journal of Obstetrics and Gynecology","page":"357.e1-357.e7","volume":"201","issue":"4","source":"CrossRef","DOI":"10.1016/j.ajog.2009.08.003","ISSN":"00029378","shortTitle":"Second-stage labor duration in nulliparous women","language":"en","author":[{"family":"Rouse","given":"Dwight J."},{"family":"Weiner","given":"Steven J."},{"family":"Bloom","given":"Steven L."},{"family":"Varner","given":"Michael W."},{"family":"Spong","given":"Catherine Y."},{"family":"Ramin","given":"Susan M."},{"family":"Caritis","given":"Steve N."},{"family":"Peaceman","given":"Alan M."},{"family":"Sorokin","given":"Yoram"},{"family":"Sciscione","given":"Anthony"},{"family":"Carpenter","given":"Marshall W."},{"family":"Mercer","given":"Brian M."},{"family":"Thorp","given":"John M."},{"family":"Malone","given":"Fergal D."},{"family":"Harper","given":"Margaret"},{"family":"Iams","given":"Jay D."},{"family":"Anderson","given":"Garland D."}],"issued":{"date-parts":[["2009",10]]}}}],"schema":""} 4According to a 2014 retrospective cohort study of 42,268 women who delivered vaginally and had normal neonatal outcomes, the 95th percentile duration of second stage labor with epidural anesthesia is more than two hours greater for both nullips and multips (as opposed to one hour) when compared to women in second stage labor without epidural use. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"TTDH9w48","properties":{"formattedCitation":"{\\rtf \\super 7\\nosupersub{}}","plainCitation":"7"},"citationItems":[{"id":27628,"uris":[""],"uri":[""],"itemData":{"id":27628,"type":"article-journal","title":"Second Stage of Labor and Epidural Use: A Larger Effect Than Previously Suggested","container-title":"Obstetrics & Gynecology","page":"527-535","volume":"123","issue":"3","source":"CrossRef","DOI":"10.1097/AOG.0000000000000134","ISSN":"0029-7844","shortTitle":"Second Stage of Labor and Epidural Use","language":"en","author":[{"family":"Cheng","given":"Yvonne W."},{"family":"Shaffer","given":"Brian L."},{"family":"Nicholson","given":"James M."},{"family":"Caughey","given":"Aaron B."}],"issued":{"date-parts":[["2014",3]]}}}],"schema":""} 7 Summary: In prolonged second stage for nulliparous women, there is higher risk of adverse maternal outcomes but no evidence of adverse neonatal outcomes. For multiparous women with prolonged second stage, there are increased risks for maternal and neonatal outcomes. As second stage progresses past the normal range, there is a decreasing chance of a successful vaginal delivery. New Insight from Contemporary Data on Normal Labor Curve????????????Traditionally, normal ranges for the duration of the stages of labor have been based on data from Friedman’s studies in the 1950’s. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"OCAfmAMj","properties":{"formattedCitation":"{\\rtf \\super 8\\nosupersub{}}","plainCitation":"8"},"citationItems":[{"id":27626,"uris":[""],"uri":[""],"itemData":{"id":27626,"type":"article-journal","title":"Primigravid labor; a graphicostatistical analysis","container-title":"Obstetrics and Gynecology","page":"567-589","volume":"6","issue":"6","source":"PubMed","ISSN":"0029-7844","note":"PMID: 13272981","journalAbbreviation":"Obstet Gynecol","language":"eng","author":[{"family":"Friedman","given":"E. A."}],"issued":{"date-parts":[["1955",12]]},"PMID":"13272981"}}],"schema":""} 8 Research from Zhang has updated our understanding of what is normal for contemporary women in terms of labor duration. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"wTQWlyNR","properties":{"formattedCitation":"{\\rtf \\super 9\\nosupersub{}}","plainCitation":"9"},"citationItems":[{"id":27625,"uris":[""],"uri":[""],"itemData":{"id":27625,"type":"article-journal","title":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes:","container-title":"Obstetrics & Gynecology","page":"1281-1287","volume":"116","issue":"6","source":"CrossRef","DOI":"10.1097/AOG.0b013e3181fdef6e","ISSN":"0029-7844","shortTitle":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes","language":"en","author":[{"family":"Zhang","given":"Jun"},{"family":"Landy","given":"Helain J."},{"family":"Ware Branch","given":"D."},{"family":"Burkman","given":"Ronald"},{"family":"Haberman","given":"Shoshana"},{"family":"Gregory","given":"Kimberly D."},{"family":"Hatjis","given":"Christos G."},{"family":"Ramirez","given":"Mildred M."},{"family":"Bailit","given":"Jennifer L."},{"family":"Gonzalez-Quintero","given":"Victor H."},{"family":"Hibbard","given":"Judith U."},{"family":"Hoffman","given":"Matthew K."},{"family":"Kominiarek","given":"Michelle"},{"family":"Learman","given":"Lee A."},{"family":"Van Veldhuisen","given":"Paul"},{"family":"Troendle","given":"James"},{"family":"Reddy","given":"Uma M."}],"issued":{"date-parts":[["2010",12]]}}}],"schema":""} 9 Likely the most significant new understanding is that, for most women, active labor doesn’t begin until six centimeters of cervical dilation, not three centimeters as thought by Friedman. According to Zhang et al,?half of women are not yet active at 4-5 cm dilation. Thus they recommend using 6 cm as the start of the active phase of labor. Another key take-away from this contemporary data is that for nulliparous women, labor accelerates at greater dilations but there is no clear inflection point as previously thought. In multiparas labor generally accelerates after 6 cm dilation. Additionally, Zhang and colleagues highlight that using the “average” as the parameter for guiding labor management decisions is not suitable for the management of the individual patient. Rather, women should be compared to the longest normal duration that is still associated with healthy birth outcomes (also known as 95th percentile values) for the first and second stages of labor. See Zhang’s labor curve chart in Appendix A for median and 95th percentile durations for cervical dilation.Labor Duration Definitions First Stage Latent Labor: Cervical dilation of 0-6 cm ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"8smwtox8","properties":{"formattedCitation":"{\\rtf \\super 9\\nosupersub{}}","plainCitation":"9"},"citationItems":[{"id":27625,"uris":[""],"uri":[""],"itemData":{"id":27625,"type":"article-journal","title":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes:","container-title":"Obstetrics & Gynecology","page":"1281-1287","volume":"116","issue":"6","source":"CrossRef","DOI":"10.1097/AOG.0b013e3181fdef6e","ISSN":"0029-7844","shortTitle":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes","language":"en","author":[{"family":"Zhang","given":"Jun"},{"family":"Landy","given":"Helain J."},{"family":"Ware Branch","given":"D."},{"family":"Burkman","given":"Ronald"},{"family":"Haberman","given":"Shoshana"},{"family":"Gregory","given":"Kimberly D."},{"family":"Hatjis","given":"Christos G."},{"family":"Ramirez","given":"Mildred M."},{"family":"Bailit","given":"Jennifer L."},{"family":"Gonzalez-Quintero","given":"Victor H."},{"family":"Hibbard","given":"Judith U."},{"family":"Hoffman","given":"Matthew K."},{"family":"Kominiarek","given":"Michelle"},{"family":"Learman","given":"Lee A."},{"family":"Van Veldhuisen","given":"Paul"},{"family":"Troendle","given":"James"},{"family":"Reddy","given":"Uma M."}],"issued":{"date-parts":[["2010",12]]}}}],"schema":""} 9 NormalDifficult to define due to challenge of determining the onset of labor. No range exists for the new latent labor definition of 0-6 cm per ZhangNulliparas (data exists only for 3-6cm): Median duration of 3.9 hours; 95th percentile: 17.7 hoursMultiparas (data exists only for 4-6cm) Median duration of 2.2 hours; 95th percentile: 10.7 hours ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"D0MmOy7b","properties":{"formattedCitation":"{\\rtf \\super 9\\nosupersub{}}","plainCitation":"9"},"citationItems":[{"id":27625,"uris":[""],"uri":[""],"itemData":{"id":27625,"type":"article-journal","title":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes:","container-title":"Obstetrics & Gynecology","page":"1281-1287","volume":"116","issue":"6","source":"CrossRef","DOI":"10.1097/AOG.0b013e3181fdef6e","ISSN":"0029-7844","shortTitle":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes","language":"en","author":[{"family":"Zhang","given":"Jun"},{"family":"Landy","given":"Helain J."},{"family":"Ware Branch","given":"D."},{"family":"Burkman","given":"Ronald"},{"family":"Haberman","given":"Shoshana"},{"family":"Gregory","given":"Kimberly D."},{"family":"Hatjis","given":"Christos G."},{"family":"Ramirez","given":"Mildred M."},{"family":"Bailit","given":"Jennifer L."},{"family":"Gonzalez-Quintero","given":"Victor H."},{"family":"Hibbard","given":"Judith U."},{"family":"Hoffman","given":"Matthew K."},{"family":"Kominiarek","given":"Michelle"},{"family":"Learman","given":"Lee A."},{"family":"Van Veldhuisen","given":"Paul"},{"family":"Troendle","given":"James"},{"family":"Reddy","given":"Uma M."}],"issued":{"date-parts":[["2010",12]]}}}],"schema":""} 9Per Friedman: <20 hours in the nullipara, and <14 hours in the multipara from 0-3cm ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"M7O2KEFv","properties":{"formattedCitation":"{\\rtf \\super 8\\nosupersub{}}","plainCitation":"8"},"citationItems":[{"id":27626,"uris":[""],"uri":[""],"itemData":{"id":27626,"type":"article-journal","title":"Primigravid labor; a graphicostatistical analysis","container-title":"Obstetrics and Gynecology","page":"567-589","volume":"6","issue":"6","source":"PubMed","ISSN":"0029-7844","note":"PMID: 13272981","journalAbbreviation":"Obstet Gynecol","language":"eng","author":[{"family":"Friedman","given":"E. 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M."}],"issued":{"date-parts":[["2010",12]]}}}],"schema":""} 9Prolonged/ slow slopeSlow progress from 6-10cm: Presence of labor progress, but duration outside the 95th percentile range of normal ( > 7 hours in a nullipara, or > 5 hours in a multipara) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"TVHrjuIT","properties":{"formattedCitation":"{\\rtf \\super 9\\nosupersub{}}","plainCitation":"9"},"citationItems":[{"id":27625,"uris":[""],"uri":[""],"itemData":{"id":27625,"type":"article-journal","title":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes:","container-title":"Obstetrics & Gynecology","page":"1281-1287","volume":"116","issue":"6","source":"CrossRef","DOI":"10.1097/AOG.0b013e3181fdef6e","ISSN":"0029-7844","shortTitle":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes","language":"en","author":[{"family":"Zhang","given":"Jun"},{"family":"Landy","given":"Helain J."},{"family":"Ware Branch","given":"D."},{"family":"Burkman","given":"Ronald"},{"family":"Haberman","given":"Shoshana"},{"family":"Gregory","given":"Kimberly D."},{"family":"Hatjis","given":"Christos G."},{"family":"Ramirez","given":"Mildred M."},{"family":"Bailit","given":"Jennifer L."},{"family":"Gonzalez-Quintero","given":"Victor H."},{"family":"Hibbard","given":"Judith U."},{"family":"Hoffman","given":"Matthew K."},{"family":"Kominiarek","given":"Michelle"},{"family":"Learman","given":"Lee A."},{"family":"Van Veldhuisen","given":"Paul"},{"family":"Troendle","given":"James"},{"family":"Reddy","given":"Uma M."}],"issued":{"date-parts":[["2010",12]]}}}],"schema":""} 9 Arrest Absence of labor progress/progressive cervical dilation for: 4 hours OR MORE of adequate UCs (MVUs >200)6 hours OR MORE with Pitocin and ruptured membranes (if possible) if UCs inadequate ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"DTLizyDY","properties":{"formattedCitation":"{\\rtf \\super 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ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"GIqcjNyQ","properties":{"formattedCitation":"{\\rtf \\super 7\\nosupersub{}}","plainCitation":"7"},"citationItems":[{"id":27628,"uris":[""],"uri":[""],"itemData":{"id":27628,"type":"article-journal","title":"Second Stage of Labor and Epidural Use: A Larger Effect Than Previously Suggested","container-title":"Obstetrics & Gynecology","page":"527-535","volume":"123","issue":"3","source":"CrossRef","DOI":"10.1097/AOG.0000000000000134","ISSN":"0029-7844","shortTitle":"Second Stage of Labor and Epidural Use","language":"en","author":[{"family":"Cheng","given":"Yvonne W."},{"family":"Shaffer","given":"Brian L."},{"family":"Nicholson","given":"James M."},{"family":"Caughey","given":"Aaron B."}],"issued":{"date-parts":[["2014",3]]}}}],"schema":""} 7 ProlongedPresence of descent, but duration outside normal range. Nulliparas: >3 hours without epidural, >4 hours with epiduralMultiparas: >2 hour without epidural, >3 hours with epidural ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"3CL3Hja4","properties":{"formattedCitation":"{\\rtf \\super 1\\nosupersub{}}","plainCitation":"1"},"citationItems":[{"id":27618,"uris":[""],"uri":[""],"itemData":{"id":27618,"type":"article-journal","title":"Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver national institute of child health and human development, society for maternal-fetal medicine, and American college of obstetricians and gynecologists workshop","container-title":"Obstetrics and gynecology","page":"1181","volume":"120","issue":"5","source":"Google Scholar","shortTitle":"Preventing the first cesarean delivery","author":[{"family":"Spong","given":"Catherine Y."},{"family":"Berghella","given":"Vincenzo"},{"family":"Wenstrom","given":"Katharine D."},{"family":"Mercer","given":"Brian M."},{"family":"Saade","given":"George R."}],"issued":{"date-parts":[["2012"]]}}}],"schema":""} 1ArrestNo descent after good pushing efforts for: Nulliparas: >3 hours without epidural, >4 hours with epiduralMultiparas: >2 hour without epidural, >3 hours with epiduralGeneral ConsiderationsTeam ConsiderationsConcerns regarding labor progress and need for potential intervention or operative delivery due to labor dystocia should be communicated frequently and openly to all team members. Care should be taken to address timing and resource utilization with situational awareness about other patient care activities at the Birth Center.Risk Factors for Dystocia Before and During LaborBased on ACOG Practice Bulletin Number 49 ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Br26pqLm","properties":{"formattedCitation":"{\\rtf \\super 10\\nosupersub{}}","plainCitation":"10"},"citationItems":[{"id":27669,"uris":[""],"uri":[""],"itemData":{"id":27669,"type":"article-journal","title":"ACOG Practice Bulletin Number 49, December 2003: Dystocia and Augmentation of Labor","container-title":"Obstetrics & Gynecology","page":"1445-1454","volume":"102","issue":"6","source":"CrossRef","DOI":"10.1016/j.obstetgynecol.2003.10.011","ISSN":"00297844","shortTitle":"ACOG Practice Bulletin Number 49, December 2003","language":"en","issued":{"date-parts":[["2003",12]]}}}],"schema":""} 10, except where it is noted otherwise. Risk Factors prior to laborRisk factors during laborNulliparityObesityPostterm pregnancyFetal weight > 4 kg Advanced maternal age DiabetesHypertensionInfertility treatmentPrevious perinatal deathAmniotic fluid abnormalitiesPremature rupture of membranesSleep deprivation ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"8yqLAIsd","properties":{"formattedCitation":"{\\rtf \\super 11\\nosupersub{}}","plainCitation":"11"},"citationItems":[{"id":27629,"uris":[""],"uri":[""],"itemData":{"id":27629,"type":"article-journal","title":"Sleep in late pregnancy predicts length of labor and type of delivery","container-title":"American Journal of Obstetrics and Gynecology","page":"2041-2046","volume":"191","issue":"6","source":"PubMed","abstract":"OBJECTIVE: The purpose of this study was to test the hypothesis that fatigue and sleep disturbance in late pregnancy are associated with labor duration and delivery type.\nSTUDY DESIGN: In a prospective observational study of 131 women in their ninth month of pregnancy, objective (48-hour wrist actigraphy) and subjective (sleep logs and questionnaires) measures were used to predict labor outcomes using analysis of variance and logistic regression.\nRESULTS: Controlling for infant birth weight, women who slept less than 6 hours at night had longer labors and were 4.5 times more likely to have cesarean deliveries. Women with severely disrupted sleep had longer labors and were 5.2 times more likely to have cesarean deliveries. Fatigue was unrelated to labor outcomes.\nCONCLUSION: Health care providers should prescribe 8 hours of bed time during pregnancy to assure adequate sleep and should include sleep quantity and quality in prenatal assessments as potential predictors of labor duration and delivery type.","DOI":"10.1016/j.ajog.2004.05.086","ISSN":"0002-9378","note":"PMID: 15592289","journalAbbreviation":"Am. J. Obstet. Gynecol.","language":"eng","author":[{"family":"Lee","given":"Kathryn A."},{"family":"Gay","given":"Caryl L."}],"issued":{"date-parts":[["2004",12]]},"PMID":"15592289"}}],"schema":""} 11Risk factors specific to second stage:Short maternal height (<5 ft)Induction of laborEpiduralChorioamnionitisPersistent occiput posterior positionCephalopelvic disproportionDehydration ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"jSfNBLPO","properties":{"formattedCitation":"{\\rtf \\super 12\\nosupersub{}}","plainCitation":"12"},"citationItems":[{"id":27631,"uris":[""],"uri":[""],"itemData":{"id":27631,"type":"article-journal","title":"Increased intravenous hydration of nulliparas in labor","container-title":"International Journal of Gynecology & Obstetrics","page":"213-215","volume":"118","issue":"3","source":"CrossRef","DOI":"10.1016/j.ijgo.2012.03.041","ISSN":"00207292","language":"en","author":[{"family":"Direkvand-Moghadam","given":"Ashraf"},{"family":"Rezaeian","given":"Mohsen"}],"issued":{"date-parts":[["2012",9]]}}}],"schema":""} 12Risk factors specific to second stage:Longer first stage of laborHigh station at complete cervical dilatation (higher than +2 station at complete)The P’s of Labor ProgressThe 7 P’s of Labor Progress: Remember to consider ALL of these areas when evaluating labor dystocia. Powers: contractions, pushingPassage: pelvic dimensions/shapePassenger: position, attitude, sizePosition & Movement (maternal)Psyche: copingPartner/ support: supportive partner, family, doulaProvider: your own beliefs, attitudes, practices, state of mind Etiologies and risk factors for dysfunctional labor Table adapted from Simpkin and Ancheta’s Labor Progress Handbook, Third Edition. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ng87os6T","properties":{"formattedCitation":"{\\rtf \\super 13\\nosupersub{}}","plainCitation":"13"},"citationItems":[{"id":27632,"uris":[""],"uri":[""],"itemData":{"id":27632,"type":"book","title":"The labor progress handbook","publisher":"Wiley-Blackwell","edition":"third edition","author":[{"family":"Simpkin","given":"Penny"},{"family":"Ancheta","given":"Ruth"}],"issued":{"date-parts":[["2013"]]}}}],"schema":""} 13Etiology DescriptionCommentsCervical dystociaPosterior unripe cervix at labor onset; scarred, fibrous cervix or “rigid os”; “tense cervix” or thick lower uterine segmentUnripe cervix may prolong latent phase. Surgical scarring, damage from disease, or structural abnormality may increase cervical resistanceEmotional dystociaMaternal distress or fear, exhaustion, severe painIncreased catecholamine production may inhibit contractionsFetal dystociaMalposition, asynclitism, large or deflexed head, lack of engagement Pendulous abdomen, size and shape of pelvis or fetal head may predispose fetus to malpositionIatrogenic dystociaMisdiagnosis of labor or second stage, elective induction (nulliparous), inappropriate oxytocin use, maternal immobility, drugs, dehydration, disturbanceMisdiagnosis or unneeded interventions or restrictions can slow or interfere with labor progress Pelvic dystociaMalformation, pelvic shape other than gynecoid, small dimensionsMaternal movement and upright positions increase pelvic dimensionsUterine dystociaInadequate or inefficient contractionsMay be secondary to fear, fasting, dehydration, supine position, cephalopelvic disproportion, lactic acidosis in myometrium, or structural abnormalities Management GuidelinesFirst Stage: Latent Labor 0-6 cmDefinition of Latent labor: The point at which the woman perceives regular uterine contractions up to the beginning of active phase. Difficult to define due to challenge of determining the onset of labor. No range exists for the new latent labor definition of 0-6 cm per ZhangNulliparas (data exists only for 3-6cm): Median duration of 3.9 hours; 95th percentile: 17.7 hoursMultiparas (data exists only for 4-6cm) Median duration of 2.2 hours; 95th percentile: 10.7 hours ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"vGzbQXy5","properties":{"formattedCitation":"{\\rtf \\super 9\\nosupersub{}}","plainCitation":"9"},"citationItems":[{"id":27625,"uris":[""],"uri":[""],"itemData":{"id":27625,"type":"article-journal","title":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes:","container-title":"Obstetrics & Gynecology","page":"1281-1287","volume":"116","issue":"6","source":"CrossRef","DOI":"10.1097/AOG.0b013e3181fdef6e","ISSN":"0029-7844","shortTitle":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes","language":"en","author":[{"family":"Zhang","given":"Jun"},{"family":"Landy","given":"Helain J."},{"family":"Ware Branch","given":"D."},{"family":"Burkman","given":"Ronald"},{"family":"Haberman","given":"Shoshana"},{"family":"Gregory","given":"Kimberly D."},{"family":"Hatjis","given":"Christos G."},{"family":"Ramirez","given":"Mildred M."},{"family":"Bailit","given":"Jennifer L."},{"family":"Gonzalez-Quintero","given":"Victor H."},{"family":"Hibbard","given":"Judith U."},{"family":"Hoffman","given":"Matthew K."},{"family":"Kominiarek","given":"Michelle"},{"family":"Learman","given":"Lee A."},{"family":"Van Veldhuisen","given":"Paul"},{"family":"Troendle","given":"James"},{"family":"Reddy","given":"Uma M."}],"issued":{"date-parts":[["2010",12]]}}}],"schema":""} 9Per Friedman: <20 hours in the nullipara, and <14 hours in the multipara from 0-3cm ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Kke35jyd","properties":{"formattedCitation":"{\\rtf \\super 8\\nosupersub{}}","plainCitation":"8"},"citationItems":[{"id":27626,"uris":[""],"uri":[""],"itemData":{"id":27626,"type":"article-journal","title":"Primigravid labor; a graphicostatistical analysis","container-title":"Obstetrics and Gynecology","page":"567-589","volume":"6","issue":"6","source":"PubMed","ISSN":"0029-7844","note":"PMID: 13272981","journalAbbreviation":"Obstet Gynecol","language":"eng","author":[{"family":"Friedman","given":"E. A."}],"issued":{"date-parts":[["1955",12]]},"PMID":"13272981"}}],"schema":""} 8Management: Management is based on maternal coping, membrane status, fetal status, parity, and infectious disease risk.For ALL patients:Involve patient and family in care plan and shared decision making.Encourage continuous labor support. Continuous labor support has been shown to shorten labor and promote physiologic birth. (See Appendix B: Continuous Labor Support) Delay hospital admission until active phase: Recommended admission criteria: admit at 4-5 cm IF exams have revealed cervical change of > 0.5 cm/hr over time OR at 6 cm regardless of preceding rate of cervical change. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"jY5FFJRR","properties":{"formattedCitation":"{\\rtf \\super 14\\nosupersub{}}","plainCitation":"14"},"citationItems":[{"id":27633,"uris":[""],"uri":[""],"itemData":{"id":27633,"type":"article-journal","title":"Outcomes of Nulliparous Women With Spontaneous Labor Onset Admitted to Hospitals in Preactive Versus Active Labor","container-title":"Journal of Midwifery & Women's Health","page":"28-34","volume":"59","issue":"1","source":"CrossRef","DOI":"10.1111/jmwh.12160","ISSN":"15269523","language":"en","author":[{"family":"Neal","given":"Jeremy L."},{"family":"Lamp","given":"Jane M."},{"family":"Buck","given":"Jacalyn S."},{"family":"Lowe","given":"Nancy K."},{"family":"Gillespie","given":"Shannon L."},{"family":"Ryan","given":"Sharon L."}],"issued":{"date-parts":[["2014",1]]}}}],"schema":""} 14If sending home, counsel re: early labor management at home, coping strategies, danger signs, and when to return to the hospital. Women sent home in early labor reported that they would have felt more reassured if they had received detailed specific written instructions and a follow up phone call. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"jJvu8yVh","properties":{"formattedCitation":"{\\rtf \\super 15\\nosupersub{}}","plainCitation":"15"},"citationItems":[{"id":27634,"uris":[""],"uri":[""],"itemData":{"id":27634,"type":"article-journal","title":"Perceptions of Care in Women Sent Home in Latent Labor:","container-title":"MCN, The American Journal of Maternal/Child Nursing","page":"115-121","volume":"39","issue":"2","source":"CrossRef","DOI":"10.1097/NMC.0000000000000015","ISSN":"0361-929X","shortTitle":"Perceptions of Care in Women Sent Home in Latent Labor","language":"en","author":[{"family":"Hosek","given":"Claire"},{"family":"Faucher","given":"Mary Ann"},{"family":"Lankford","given":"Janice"},{"family":"Alexander","given":"James"}],"issued":{"date-parts":[["2014"]]}}}],"schema":""} 15RestEncourage nutrition/hydrationEncourage upright positions (standing, walking, kneeling, sitting) (See Appendix C: Upright Positioning During Labor)Water immersion: One hour of immersion in water was associated with shorter labors even when initiated in latent labor. (See Appendix D: Water Immersion) Avoid amniotomy (See Appendix E: Amniotomy)Latent Labor- Prolonged: No range exists for the new latent labor definition of 0-6 cmNulliparas: >18 hours from 3-6cmMultiparas: >10.7 hrs from 4-6cm ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"iAZUQLy4","properties":{"formattedCitation":"{\\rtf \\super 9\\nosupersub{}}","plainCitation":"9"},"citationItems":[{"id":27625,"uris":[""],"uri":[""],"itemData":{"id":27625,"type":"article-journal","title":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes:","container-title":"Obstetrics & Gynecology","page":"1281-1287","volume":"116","issue":"6","source":"CrossRef","DOI":"10.1097/AOG.0b013e3181fdef6e","ISSN":"0029-7844","shortTitle":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes","language":"en","author":[{"family":"Zhang","given":"Jun"},{"family":"Landy","given":"Helain J."},{"family":"Ware Branch","given":"D."},{"family":"Burkman","given":"Ronald"},{"family":"Haberman","given":"Shoshana"},{"family":"Gregory","given":"Kimberly D."},{"family":"Hatjis","given":"Christos G."},{"family":"Ramirez","given":"Mildred M."},{"family":"Bailit","given":"Jennifer L."},{"family":"Gonzalez-Quintero","given":"Victor H."},{"family":"Hibbard","given":"Judith U."},{"family":"Hoffman","given":"Matthew K."},{"family":"Kominiarek","given":"Michelle"},{"family":"Learman","given":"Lee A."},{"family":"Van Veldhuisen","given":"Paul"},{"family":"Troendle","given":"James"},{"family":"Reddy","given":"Uma M."}],"issued":{"date-parts":[["2010",12]]}}}],"schema":""} 9Per Friedman: >20 hours in the nullipara, >14 hours in the multipara from 0-3 cm ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"qZyj6kex","properties":{"formattedCitation":"{\\rtf \\super 8\\nosupersub{}}","plainCitation":"8"},"citationItems":[{"id":27626,"uris":[""],"uri":[""],"itemData":{"id":27626,"type":"article-journal","title":"Primigravid labor; a graphicostatistical analysis","container-title":"Obstetrics and Gynecology","page":"567-589","volume":"6","issue":"6","source":"PubMed","ISSN":"0029-7844","note":"PMID: 13272981","journalAbbreviation":"Obstet Gynecol","language":"eng","author":[{"family":"Friedman","given":"E. A."}],"issued":{"date-parts":[["1955",12]]},"PMID":"13272981"}}],"schema":""} 8Management: For patients with risk factors or trending towards dystocia:Membrane Sweeping (See Appendix F: Membrane Sweeping)Breast/nipple stimulation (See SFGH Birth Center Policy 2.24)Encourage upright positions (standing, walking, kneeling, sitting) (See Appendix C: Upright Positioning During Labor)Three options for prolonged latent labor:1. Expectant Management: Observe, ambulate, or send home. 2. Sedation: Consider therapeutic rest (see triage order set for dosing recommendations)3. Stimulation of labor: Stimulation is reasonable to consider in women with a ripe cervix or in women who have failed therapeutic rest and have presented for multiple triage visits: consider various methods of induction/ augmentation. For more information on oxytocin, see SFGH oxytocin policy. Most women with prolonged latent phase will enter active phase with expectant management alone. Those that don’t will often either 1) stop contracting, or 2) reach active phase with amniotomy or oxytocin or both. Thus prolonged latent phase is not an indication for cesarean delivery. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"c3kO7gyp","properties":{"formattedCitation":"{\\rtf \\super 2\\nosupersub{}}","plainCitation":"2"},"citationItems":[{"id":27619,"uris":[""],"uri":[""],"itemData":{"id":27619,"type":"article-journal","title":"Safe prevention of the primary cesarean delivery","container-title":"American Journal of Obstetrics and Gynecology","page":"179-193","volume":"210","issue":"3","source":"CrossRef","DOI":"10.1016/j.ajog.2014.01.026","ISSN":"00029378","language":"en","author":[{"family":"Caughey","given":"Aaron B."},{"family":"Cahill","given":"Alison G."},{"family":"Guise","given":"Jeanne-Marie"},{"family":"Rouse","given":"Dwight J."}],"issued":{"date-parts":[["2014",3]]}}}],"schema":""} 2If patient is being induced, consider failed induction if unable to generate UC’s q3 minutes after at least 24 hours of pitocin with ruptured membranes, if feasible. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2WZbX98","properties":{"formattedCitation":"{\\rtf \\super 1\\nosupersub{}}","plainCitation":"1"},"citationItems":[{"id":27618,"uris":[""],"uri":[""],"itemData":{"id":27618,"type":"article-journal","title":"Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver national institute of child health and human development, society for maternal-fetal medicine, and American college of obstetricians and gynecologists workshop","container-title":"Obstetrics and gynecology","page":"1181","volume":"120","issue":"5","source":"Google Scholar","shortTitle":"Preventing the first cesarean delivery","author":[{"family":"Spong","given":"Catherine Y."},{"family":"Berghella","given":"Vincenzo"},{"family":"Wenstrom","given":"Katharine D."},{"family":"Mercer","given":"Brian M."},{"family":"Saade","given":"George R."}],"issued":{"date-parts":[["2012"]]}}}],"schema":""} 1First Stage: Active Labor 6-10 cmDefinition: Point at which the labor curve becomes steep, with steady and rapid cervical change. Exact point in labor varies considerably from person to person. Normal Active Labor: Nulliparas: Median duration of 2.1 hours; 95th percentile: 7 hoursMultiparas: Median duration of 1.5 hours; 95th percentile: 5.1 hours ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"hgNnYjZ3","properties":{"formattedCitation":"{\\rtf \\super 9\\nosupersub{}}","plainCitation":"9"},"citationItems":[{"id":27625,"uris":[""],"uri":[""],"itemData":{"id":27625,"type":"article-journal","title":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes:","container-title":"Obstetrics & Gynecology","page":"1281-1287","volume":"116","issue":"6","source":"CrossRef","DOI":"10.1097/AOG.0b013e3181fdef6e","ISSN":"0029-7844","shortTitle":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes","language":"en","author":[{"family":"Zhang","given":"Jun"},{"family":"Landy","given":"Helain J."},{"family":"Ware Branch","given":"D."},{"family":"Burkman","given":"Ronald"},{"family":"Haberman","given":"Shoshana"},{"family":"Gregory","given":"Kimberly D."},{"family":"Hatjis","given":"Christos G."},{"family":"Ramirez","given":"Mildred M."},{"family":"Bailit","given":"Jennifer L."},{"family":"Gonzalez-Quintero","given":"Victor H."},{"family":"Hibbard","given":"Judith U."},{"family":"Hoffman","given":"Matthew K."},{"family":"Kominiarek","given":"Michelle"},{"family":"Learman","given":"Lee A."},{"family":"Van Veldhuisen","given":"Paul"},{"family":"Troendle","given":"James"},{"family":"Reddy","given":"Uma M."}],"issued":{"date-parts":[["2010",12]]}}}],"schema":""} 9Management: For ALL patientsInvolve patient and family in care plan and shared decision making.Encourage continuous labor support. Continuous labor support has been shown to shorten labor and promote physiologic birth. (See Appendix B: Continuous Labor Support) Supportive care:Hydration: Encourage PO fluids (not exclusively water) and offer IV fluids if PO fluid intake is low. Beware of overuse of IV hydration, consider maintaining total IV fluid intake below 125 an hour unless clinically indicated. Nourishment: Offer small portions of food that sound appealing to the laboring mother. Eg: fruit, yogurt, crackers, cheese, popsicles, sandwich. An average of 81 calories kcal/hr prevents the development of ketosis during labor. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"H8JO5Dz5","properties":{"formattedCitation":"{\\rtf \\super 16\\nosupersub{}}","plainCitation":"16"},"citationItems":[{"id":27640,"uris":[""],"uri":[""],"itemData":{"id":27640,"type":"article-journal","title":"Eating in labour. A randomised controlled trial assessing the risks and benefits","container-title":"Anaesthesia","page":"329-334","volume":"54","issue":"4","source":"PubMed","abstract":"The aim of this study was to determine whether permitting women in labour to eat a light diet would: (i) alter their metabolic profile, (ii) influence the outcome of labour, and (iii) increase residual gastric volume and consequent risk of pulmonary aspiration. Women were randomised to receive either a light diet (eating group, n = 48) or water only (starved group, n = 46) during labour. The light diet prevented the rise in plasma beta-hydroxybutyrate (p = 2.3 x 10(-5)) and nonesterified fatty acids (p = 9.3 x 10(-7)) seen in the starved group. Plasma glucose (p = 0.003) and insulin (p = 0.017) rose in the eating group but there was no difference in plasma lactate (p = 0.167) between the groups. There were no differences between the groups with respect to duration of first or second stage of labour, oxytocin requirements, mode of delivery, Apgar scores or umbilical artery and venous blood samples. Relative gastric volumes estimated by ultrasound measurement of gastric antral cross-sectional area were larger (p = 0.001) in the eating group. This was supported by the observation that those from this group who vomited, vomited significantly larger volumes than those in the starved group (p = 0.001). We conclude that eating in labour prevents the development of ketosis but significantly increases residual gastric volume.","ISSN":"0003-2409","note":"PMID: 10455830","journalAbbreviation":"Anaesthesia","language":"eng","author":[{"family":"Scrutton","given":"M. J."},{"family":"Metcalfe","given":"G. A."},{"family":"Lowy","given":"C."},{"family":"Seed","given":"P. T."},{"family":"O'Sullivan","given":"G."}],"issued":{"date-parts":[["1999",4]]},"PMID":"10455830"}}],"schema":""} 16 Encourage movement and frequent position changes. Encourage upright positions (standing, walking, kneeling, sitting) (See Appendix B: Upright Positioning During Labor)Provide psychological supportOptional Interventions:Acupressure of SP6 and/or L14 point (See Appendix G: Acupressure)Active Labor- Prolonged/ Slow SlopeSlow progress after 6 cm dilation: Presence of labor progress, but duration outside the 95th percentile range of normal (> 7 hours in a nullip, or > 5 hours in a multipara). ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"vsblDpSl","properties":{"formattedCitation":"{\\rtf \\super 9\\nosupersub{}}","plainCitation":"9"},"citationItems":[{"id":27625,"uris":[""],"uri":[""],"itemData":{"id":27625,"type":"article-journal","title":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes:","container-title":"Obstetrics & Gynecology","page":"1281-1287","volume":"116","issue":"6","source":"CrossRef","DOI":"10.1097/AOG.0b013e3181fdef6e","ISSN":"0029-7844","shortTitle":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes","language":"en","author":[{"family":"Zhang","given":"Jun"},{"family":"Landy","given":"Helain J."},{"family":"Ware Branch","given":"D."},{"family":"Burkman","given":"Ronald"},{"family":"Haberman","given":"Shoshana"},{"family":"Gregory","given":"Kimberly D."},{"family":"Hatjis","given":"Christos G."},{"family":"Ramirez","given":"Mildred M."},{"family":"Bailit","given":"Jennifer L."},{"family":"Gonzalez-Quintero","given":"Victor H."},{"family":"Hibbard","given":"Judith U."},{"family":"Hoffman","given":"Matthew K."},{"family":"Kominiarek","given":"Michelle"},{"family":"Learman","given":"Lee A."},{"family":"Van Veldhuisen","given":"Paul"},{"family":"Troendle","given":"James"},{"family":"Reddy","given":"Uma M."}],"issued":{"date-parts":[["2010",12]]}}}],"schema":""} 9 Consider all possible etiologies when troubleshootingInvolve the patient and family in the care plan and shared decision making.Emotional dystocia: Assess mom’s level of coping. Is she distressed, afraid, exhausted, in severe pain?Assess mother’s emotional/psychological well being through open-ended questions and active listening, and provide appropriate reassurance and education. Between contractions ask questions like:What was going through your mind during that last contraction?How are you feeling right now?Do you have any idea why your labor has slowed down?Is there anything that you feel needs to happen before you have your baby? Refocus and comfort patient: shower/bath, massage/soothing touch, aromatherapyPain relief: Ideally starting with non-pharm methods and escalating as needed. Encourage continuous labor support. Continuous labor support has been shown to shorten labor and promote physiologic birth. (See Appendix B: Continuous Labor Support) Cervical dystocia: Persistent anterior cervical lip, swollen cervix, or rigid os?With freedom of movement mom will often assume positions that help to reduce cervical lip and swollen cervix. Gravity neutral or anti-gravity positions like hands and knees and open knee chest will help to lift the fetal head away and reduce pressure on the cervix. To help redistribute the pressure on the cervix and promote more even dilation, try the following: side-lying, semi-prone, standing. Water immersion reduces gravitational force and can help relieve pressure on the cervix. If patience, position change, and water immersion fail, try manual reduction of a persistent cervical lip. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"J42bTjex","properties":{"formattedCitation":"{\\rtf \\super 13\\nosupersub{}}","plainCitation":"13"},"citationItems":[{"id":27632,"uris":[""],"uri":[""],"itemData":{"id":27632,"type":"book","title":"The labor progress handbook","publisher":"Wiley-Blackwell","edition":"third edition","author":[{"family":"Simpkin","given":"Penny"},{"family":"Ancheta","given":"Ruth"}],"issued":{"date-parts":[["2013"]]}}}],"schema":""} 13Uterine dystocia: Assess for inadequate or inefficient contractionsConsider IV fluids if not already running. IV hydration is shown to shorten active labor by 1 hr. and 2nd stage by 15 min. Also decreases need for oxytocin augmentation (50% w/ PO fluids vs. 20% w/ IVF) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"qLMP2uAC","properties":{"formattedCitation":"{\\rtf \\super 12\\nosupersub{}}","plainCitation":"12"},"citationItems":[{"id":27631,"uris":[""],"uri":[""],"itemData":{"id":27631,"type":"article-journal","title":"Increased intravenous hydration of nulliparas in labor","container-title":"International Journal of Gynecology & Obstetrics","page":"213-215","volume":"118","issue":"3","source":"CrossRef","DOI":"10.1016/j.ijgo.2012.03.041","ISSN":"00207292","language":"en","author":[{"family":"Direkvand-Moghadam","given":"Ashraf"},{"family":"Rezaeian","given":"Mohsen"}],"issued":{"date-parts":[["2012",9]]}}}],"schema":""} 12 Breast/nipple stimulation (See SFGH Birth Center Policy 2.24)Ensure adequate forcesEnsure adequate forces: MVU of 200 is thought to be adequate (ACOG) or, if no IUPC, UCs every 2-3 min x 80-90 sec that palpate strongConsider IUPC placementConsider oxytocin augmentation Consider membrane sweeping in conjunction with oxytocin augmentation (See Appendix E: Membrane Sweeping)Fetal dystocia: Assess for malposition, CPD, and macrosomiaReposition fetus: Upright and forward leaning positions, walk/movement, pelvic rock, lunge, hands and knees. Suggest frequent position change (q 30 min.) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"DEyenghC","properties":{"formattedCitation":"{\\rtf \\super 13\\nosupersub{}}","plainCitation":"13"},"citationItems":[{"id":27632,"uris":[""],"uri":[""],"itemData":{"id":27632,"type":"book","title":"The labor progress handbook","publisher":"Wiley-Blackwell","edition":"third edition","author":[{"family":"Simpkin","given":"Penny"},{"family":"Ancheta","given":"Ruth"}],"issued":{"date-parts":[["2013"]]}}}],"schema":""} 13 (See Appendix C: Upright Positioning During Labor)If the preceding measures do not improve fetal position and/or dilation: Assess fetal position by ultrasound, if OP and > 7cm dilated, consider manual rotation. (See Appendix F: Occiput Posterior Position, See Appendix G: Manual Rotation)Iatrogenic dystocia: Has active labor been diagnosed too early? Pelvic dystocia: This is a diagnosis of exclusion and should not be made prior to investigating all other causes.Note: Operative delivery is not indicated for prolonged labor as long as maternal/fetal status is reassuring. When evaluating labor progress consider effacement, station, and rotation in addition to cervical dilation. Active Phase ArrestAbsence of labor progress/progressive cervical dilation for:4 hours OR MORE of adequate UCs (MVUs >200)6 hours OR MORE if UCs inadequate ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"r2SrRS7F","properties":{"formattedCitation":"{\\rtf \\super 1\\nosupersub{}}","plainCitation":"1"},"citationItems":[{"id":27618,"uris":[""],"uri":[""],"itemData":{"id":27618,"type":"article-journal","title":"Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver national institute of child health and human development, society for maternal-fetal medicine, and American college of obstetricians and gynecologists workshop","container-title":"Obstetrics and gynecology","page":"1181","volume":"120","issue":"5","source":"Google Scholar","shortTitle":"Preventing the first cesarean delivery","author":[{"family":"Spong","given":"Catherine Y."},{"family":"Berghella","given":"Vincenzo"},{"family":"Wenstrom","given":"Katharine D."},{"family":"Mercer","given":"Brian M."},{"family":"Saade","given":"George R."}],"issued":{"date-parts":[["2012"]]}}}],"schema":""} 1If Active Phase Arrest:Involve patient and family in care plan and shared decision making.Management options include:Augmentation: Consider oxytocin augmentation and “tincture of time”. Can consider amniotomy as an alternative or adjunct to oxytocinIUPC may be useful in diagnosing adequate forces but is not necessary to titrate Pitocin. In cases of active phase arrest, waiting for a vaginal delivery rather than doing a cesarean decreases the risk of adverse maternal outcomes without causing any additional risk to the newborn. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"OosU3g6Q","properties":{"formattedCitation":"{\\rtf \\super 3\\nosupersub{}}","plainCitation":"3"},"citationItems":[{"id":27620,"uris":[""],"uri":[""],"itemData":{"id":27620,"type":"article-journal","title":"Perinatal Outcomes in the Setting of Active Phase Arrest of Labor:","container-title":"Obstetrics & Gynecology","page":"1109-1115","volume":"112","issue":"5","source":"CrossRef","DOI":"10.1097/AOG.0b013e31818b46a2","ISSN":"0029-7844","shortTitle":"Perinatal Outcomes in the Setting of Active Phase Arrest of Labor","language":"en","author":[{"family":"Henry","given":"Dana E. M."},{"family":"Cheng","given":"Yvonne W."},{"family":"Shaffer","given":"Brian L."},{"family":"Kaimal","given":"Anjali J."},{"family":"Bianco","given":"Katherine"},{"family":"Caughey","given":"Aaron B."}],"issued":{"date-parts":[["2008",11]]}}}],"schema":""} 3Cesarean: Consider if pt. meets arrest criteria and rupture of membranes has already occurred. Second Stage LaborDefinition: Time of complete cervical dilatation to birth of the neonate. Normal Second Stage*Nulliparas: <3 hours WITHOUT epidural, <4 hours WITH epiduralMultiparas: <2 hours WITHOUT epidural, <3 hours WITH epidural ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"2JC0QgYg","properties":{"formattedCitation":"{\\rtf \\super 1\\nosupersub{}}","plainCitation":"1"},"citationItems":[{"id":27618,"uris":[""],"uri":[""],"itemData":{"id":27618,"type":"article-journal","title":"Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver national institute of child health and human development, society for maternal-fetal medicine, and American college of obstetricians and gynecologists workshop","container-title":"Obstetrics and gynecology","page":"1181","volume":"120","issue":"5","source":"Google Scholar","shortTitle":"Preventing the first cesarean delivery","author":[{"family":"Spong","given":"Catherine Y."},{"family":"Berghella","given":"Vincenzo"},{"family":"Wenstrom","given":"Katharine D."},{"family":"Mercer","given":"Brian M."},{"family":"Saade","given":"George R."}],"issued":{"date-parts":[["2012"]]}}}],"schema":""} 1*New data suggests that 95% of nullips with epidurals will deliver safely within 5 hours and 19 minutes and 95% of multips will deliver safely within 5 hours. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"VJeZ9Cbi","properties":{"formattedCitation":"{\\rtf \\super 7\\nosupersub{}}","plainCitation":"7"},"citationItems":[{"id":27628,"uris":[""],"uri":[""],"itemData":{"id":27628,"type":"article-journal","title":"Second Stage of Labor and Epidural Use: A Larger Effect Than Previously Suggested","container-title":"Obstetrics & Gynecology","page":"527-535","volume":"123","issue":"3","source":"CrossRef","DOI":"10.1097/AOG.0000000000000134","ISSN":"0029-7844","shortTitle":"Second Stage of Labor and Epidural Use","language":"en","author":[{"family":"Cheng","given":"Yvonne W."},{"family":"Shaffer","given":"Brian L."},{"family":"Nicholson","given":"James M."},{"family":"Caughey","given":"Aaron B."}],"issued":{"date-parts":[["2014",3]]}}}],"schema":""} 7General management:Ensure adequate hydrationEncourage upright and comfortable positioning Allow for the physiologic resting phase and passive descent. Delayed pushing: allow mother to rest until strong urge to push is noted—usually 1-2 hoursEspecially beneficial for: epidural w/ no urge to push, fetal head above +2 station at onset of 2nd stage, women w/ limited strength or motivation to push. Delayed pushing decreased pushing time by 20 mins while increasing duration of 2nd stage by 54 mins. No difference in operative vaginal delivery rate. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"bWFwC8qB","properties":{"formattedCitation":"{\\rtf \\super 17\\nosupersub{}}","plainCitation":"17"},"citationItems":[{"id":27642,"uris":[""],"uri":[""],"itemData":{"id":27642,"type":"article-journal","title":"Immediate Compared With Delayed Pushing in the Second Stage of Labor: A Systematic Review and Meta-Analysis","container-title":"Obstetrics & Gynecology","page":"660-668","volume":"120","issue":"3","source":"CrossRef","DOI":"10.1097/AOG.0b013e3182639fae","ISSN":"0029-7844","shortTitle":"Immediate Compared With Delayed Pushing in the Second Stage of Labor","language":"en","author":[{"family":"Tuuli","given":"Methodius G."},{"family":"Frey","given":"Heather A."},{"family":"Odibo","given":"Anthony O."},{"family":"Macones","given":"George A."},{"family":"Cahill","given":"Alison G."}],"issued":{"date-parts":[["2012",9]]}}}],"schema":""} 17 Evaluate progress early and frequently: expect some progress each hour of active pushing. Prolonged Second Stage: Presence of descent, but duration outside normal range. Nulliparas: >3 hours WITHOUT epidural, >4 hours WITH epidural Multiparas: >2 hours WITHOUT epidural, >3 hours WITH epidural ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"6GDf0OR7","properties":{"formattedCitation":"{\\rtf \\super 1\\nosupersub{}}","plainCitation":"1"},"citationItems":[{"id":27618,"uris":[""],"uri":[""],"itemData":{"id":27618,"type":"article-journal","title":"Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver national institute of child health and human development, society for maternal-fetal medicine, and American college of obstetricians and gynecologists workshop","container-title":"Obstetrics and gynecology","page":"1181","volume":"120","issue":"5","source":"Google Scholar","shortTitle":"Preventing the first cesarean delivery","author":[{"family":"Spong","given":"Catherine Y."},{"family":"Berghella","given":"Vincenzo"},{"family":"Wenstrom","given":"Katharine D."},{"family":"Mercer","given":"Brian M."},{"family":"Saade","given":"George R."}],"issued":{"date-parts":[["2012"]]}}}],"schema":""} 1It may be prudent to begin assessing and addressing potential causes of slow progress once second stage has extended past the half-way point of the upper limit of normal: Nulliparas: >1.5 hours WITHOUT epidural, >2 hours WITH epiduralMultiparas: >1 hour WITHOUT epidural, >1.5 hours WITH epidural In general, consider all of the same factors listed for prolonged active first stage labor, with the following exceptions and specifications: Uterine dystocia:Encourage walking or position changesConsider augmentation with breast/nipple stimulation or oxytocinIUPC likely not useful in pushing phase, but may consider during passive descent if concerned about uterine hypocontractility.Fetal dystocia: Assess for malposition, CPD, and macrosomiaEncourage upright, forward leaning, pelvic-opening positions. (See Appendix B: Upright Positioning During Labor)Check fetal position with ultrasound, and consider manual rotation of the occiput posterior fetus. (See Appendix H: Occiput Posterior Position, See Appendix I: Manual Rotation)Ineffective Pushing: Consider decreasing maternal anesthesia, although evidence re: effectiveness of this is inconclusive. If pain is interfering, consider increasing analgesia at least temporarily to refocus Arrest of descent: No descent after good pushing efforts for:Nulliparas: >3 hours without epidural, >4 hours with epiduralMultiparas: >2 hour without epidural, >3 hours with epiduralIf arrest of second stage:Consider all the same factors as were noted in the above section on prolonged second stageConsider operative delivery. Be aware of risk factors for shoulder dystocia.A specific absolute maximum length of time spent in the second stage of labor beyond which all women should undergo operative delivery has not been identified as long as fetal heart rate pattern are normal and some degree of progress is made. ---ACOG, 2003, 2014 (Strong recommendation, low- quality evidence) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"pbocpqkq","properties":{"formattedCitation":"{\\rtf \\super 2\\nosupersub{}}","plainCitation":"2"},"citationItems":[{"id":27619,"uris":[""],"uri":[""],"itemData":{"id":27619,"type":"article-journal","title":"Safe prevention of the primary cesarean delivery","container-title":"American Journal of Obstetrics and Gynecology","page":"179-193","volume":"210","issue":"3","source":"CrossRef","DOI":"10.1016/j.ajog.2014.01.026","ISSN":"00029378","language":"en","author":[{"family":"Caughey","given":"Aaron B."},{"family":"Cahill","given":"Alison G."},{"family":"Guise","given":"Jeanne-Marie"},{"family":"Rouse","given":"Dwight J."}],"issued":{"date-parts":[["2014",3]]}}}],"schema":""} 2It is important to assess fetal position in the setting of abnormal fetal descent and manual rotation of the OP fetus is a reasonable option to consider before moving onto operative delivery or cesarean delivery. ---ACOG, 2014 (Strong recommendation, moderate quality evidence) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"px6n1xiN","properties":{"formattedCitation":"{\\rtf \\super 2\\nosupersub{}}","plainCitation":"2"},"citationItems":[{"id":27619,"uris":[""],"uri":[""],"itemData":{"id":27619,"type":"article-journal","title":"Safe prevention of the primary cesarean delivery","container-title":"American Journal of Obstetrics and Gynecology","page":"179-193","volume":"210","issue":"3","source":"CrossRef","DOI":"10.1016/j.ajog.2014.01.026","ISSN":"00029378","language":"en","author":[{"family":"Caughey","given":"Aaron B."},{"family":"Cahill","given":"Alison G."},{"family":"Guise","given":"Jeanne-Marie"},{"family":"Rouse","given":"Dwight J."}],"issued":{"date-parts":[["2014",3]]}}}],"schema":""} 2Appendix A: Normal Labor CurveDuration of Labor in Hours by Parity in Spontaneous Onset of Labor: Contemporary Patterns of Spontaneous Labor with Normal Neonatal Outcomes ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"wYXoxd1O","properties":{"formattedCitation":"{\\rtf \\super 9\\nosupersub{}}","plainCitation":"9"},"citationItems":[{"id":27625,"uris":[""],"uri":[""],"itemData":{"id":27625,"type":"article-journal","title":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes:","container-title":"Obstetrics & Gynecology","page":"1281-1287","volume":"116","issue":"6","source":"CrossRef","DOI":"10.1097/AOG.0b013e3181fdef6e","ISSN":"0029-7844","shortTitle":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes","language":"en","author":[{"family":"Zhang","given":"Jun"},{"family":"Landy","given":"Helain J."},{"family":"Ware Branch","given":"D."},{"family":"Burkman","given":"Ronald"},{"family":"Haberman","given":"Shoshana"},{"family":"Gregory","given":"Kimberly D."},{"family":"Hatjis","given":"Christos G."},{"family":"Ramirez","given":"Mildred M."},{"family":"Bailit","given":"Jennifer L."},{"family":"Gonzalez-Quintero","given":"Victor H."},{"family":"Hibbard","given":"Judith U."},{"family":"Hoffman","given":"Matthew K."},{"family":"Kominiarek","given":"Michelle"},{"family":"Learman","given":"Lee A."},{"family":"Van Veldhuisen","given":"Paul"},{"family":"Troendle","given":"James"},{"family":"Reddy","given":"Uma M."}],"issued":{"date-parts":[["2010",12]]}}}],"schema":""} 9Cervical Dilation (cm)Parity 0Parity 1Parity 2+3-41.8 (8.1) 4-51.3 (6.4)1.4 (7.3)1.4 (7.0)5-60.8 (3.2)0.8 (3.4)0.8 (3.4)6-70.6 (2.2)0.5 (1.9)0.5 (1.8)7-80.5 (1.6)0.4 (1.3)0.4 (1.2)8-90.5 (1.4)0.3 (1.0)0.3 (0.9)9-100.5 (1.8)0.3 (0.9)0.3 (0.8)2nd stage with epidural1.1 (3.6)0.4 (2.0)0.3 (1.6)2nd stage without epidural0.6 (2.8)0.2 (1.3)0.1 (1.1)Key: Data are median (95th percentile)Source: Zhang, 2010 ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"YZ3tfD50","properties":{"formattedCitation":"{\\rtf \\super 9\\nosupersub{}}","plainCitation":"9"},"citationItems":[{"id":27625,"uris":[""],"uri":[""],"itemData":{"id":27625,"type":"article-journal","title":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes:","container-title":"Obstetrics & Gynecology","page":"1281-1287","volume":"116","issue":"6","source":"CrossRef","DOI":"10.1097/AOG.0b013e3181fdef6e","ISSN":"0029-7844","shortTitle":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes","language":"en","author":[{"family":"Zhang","given":"Jun"},{"family":"Landy","given":"Helain J."},{"family":"Ware Branch","given":"D."},{"family":"Burkman","given":"Ronald"},{"family":"Haberman","given":"Shoshana"},{"family":"Gregory","given":"Kimberly D."},{"family":"Hatjis","given":"Christos G."},{"family":"Ramirez","given":"Mildred M."},{"family":"Bailit","given":"Jennifer L."},{"family":"Gonzalez-Quintero","given":"Victor H."},{"family":"Hibbard","given":"Judith U."},{"family":"Hoffman","given":"Matthew K."},{"family":"Kominiarek","given":"Michelle"},{"family":"Learman","given":"Lee A."},{"family":"Van Veldhuisen","given":"Paul"},{"family":"Troendle","given":"James"},{"family":"Reddy","given":"Uma M."}],"issued":{"date-parts":[["2010",12]]}}}],"schema":""} 9Average Labor CurveSource: Zhang, 2010 ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"8KldiUxK","properties":{"formattedCitation":"{\\rtf \\super 9\\nosupersub{}}","plainCitation":"9"},"citationItems":[{"id":27625,"uris":[""],"uri":[""],"itemData":{"id":27625,"type":"article-journal","title":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes:","container-title":"Obstetrics & Gynecology","page":"1281-1287","volume":"116","issue":"6","source":"CrossRef","DOI":"10.1097/AOG.0b013e3181fdef6e","ISSN":"0029-7844","shortTitle":"Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes","language":"en","author":[{"family":"Zhang","given":"Jun"},{"family":"Landy","given":"Helain J."},{"family":"Ware Branch","given":"D."},{"family":"Burkman","given":"Ronald"},{"family":"Haberman","given":"Shoshana"},{"family":"Gregory","given":"Kimberly D."},{"family":"Hatjis","given":"Christos G."},{"family":"Ramirez","given":"Mildred M."},{"family":"Bailit","given":"Jennifer L."},{"family":"Gonzalez-Quintero","given":"Victor H."},{"family":"Hibbard","given":"Judith U."},{"family":"Hoffman","given":"Matthew K."},{"family":"Kominiarek","given":"Michelle"},{"family":"Learman","given":"Lee A."},{"family":"Van Veldhuisen","given":"Paul"},{"family":"Troendle","given":"James"},{"family":"Reddy","given":"Uma M."}],"issued":{"date-parts":[["2010",12]]}}}],"schema":""} 9Appendix B: Continuous Labor Support Continuous labor support is an evidence-based intervention shown to shorten labor, along with other benefits. In 2013 The Cochrane Collaboration conducted a review of the literature on continuous support for laboring women. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"22o8G3zy","properties":{"formattedCitation":"{\\rtf \\super 18\\nosupersub{}}","plainCitation":"18"},"citationItems":[{"id":27643,"uris":[""],"uri":[""],"itemData":{"id":27643,"type":"chapter","title":"Continuous support for women during childbirth","container-title":"Cochrane Database of Systematic Reviews","publisher":"John Wiley & Sons, Ltd","publisher-place":"Chichester, UK","source":"CrossRef","event-place":"Chichester, UK","URL":"","language":"en","editor":[{"literal":"The Cochrane Collaboration"}],"author":[{"family":"Hodnett","given":"Ellen D"},{"family":"Gates","given":"Simon"},{"family":"Hofmeyr","given":"G Justus"},{"family":"Sakala","given":"Carol"}],"issued":{"date-parts":[["2013",7,15]]},"accessed":{"date-parts":[["2016",2,19]]}}}],"schema":""} 18 The review included twenty-two trials involving 15,288 women. This systematic review found that continuous labor support is associated with the following benefits:?Greater incidence of spontaneous vaginal birth (RR 1.08, 95% confidence interval (CI) 1.04 to 1.12).Lower rates of intrapartum analgesia (RR 0.90, 95% CI 0.84 to 0.96).?Greater maternal satisfaction (RR 0.69, 95% CI 0.59 to 0.79).?Shorter labor (MD -0.58 hours, 95% CI -0.85 to -0.31).Lower rates of cesarean (RR 0.78, 95%CI 0.67 to 0.91).Lower rates of instrumental vaginal birth (fixed-effect, RR 0.90, 95% CI 0.85 to 0.96).Lower rates of regional analgesia (RR 0.93, 95% CI 0.88 to 0.99).Fewer cases of low five-minute Apgar scores (fixed-effect, RR 0.69, 95% CI 0.50 to 0.95).?Labor support didn't appear to affect any other intrapartum interventions, maternal or neonatal complications, or breastfeeding. The review found that continuous support had the greatest positive effect when provided by a person outside of the laboring woman's family or social group, and not a member of the hospital staff. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"BUYDWlUT","properties":{"formattedCitation":"{\\rtf \\super 18\\nosupersub{}}","plainCitation":"18"},"citationItems":[{"id":27643,"uris":[""],"uri":[""],"itemData":{"id":27643,"type":"chapter","title":"Continuous support for women during childbirth","container-title":"Cochrane Database of Systematic Reviews","publisher":"John Wiley & Sons, Ltd","publisher-place":"Chichester, UK","source":"CrossRef","event-place":"Chichester, UK","URL":"","language":"en","editor":[{"literal":"The Cochrane Collaboration"}],"author":[{"family":"Hodnett","given":"Ellen D"},{"family":"Gates","given":"Simon"},{"family":"Hofmeyr","given":"G Justus"},{"family":"Sakala","given":"Carol"}],"issued":{"date-parts":[["2013",7,15]]},"accessed":{"date-parts":[["2016",2,19]]}}}],"schema":""} 18 Appendix C: Upright Positioning during Labor It is common for women to labor in bed, yet there is no evidence indicating that this is beneficial for women or neonates. In countries not influenced by western society, women are more likely to progress through the first stage of labor in upright positions and more free to change positions without evidence of harm to themselves or to their baby. Position changes and upright posturing are ways in which women cope with labor pain. Given the freedom and permission, many pregnant women will change positions since no position is comfortable for a long time. In many health facilities, many protocols and procedures pose barriers to pregnant women being mobile. The World Health Organization states that a woman should have the opportunity to assume any position she wishes, in or out of bed, during the course of labor. She should not be restricted to bed, and certainly not to the supine position, but should have the freedom to adopt upright postures such as sitting, standing, or walking, without interference by caregivers, especially during the first stage of labor. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"qw4LPS8v","properties":{"formattedCitation":"{\\rtf \\super 19\\nosupersub{}}","plainCitation":"19"},"citationItems":[{"id":27645,"uris":[""],"uri":[""],"itemData":{"id":27645,"type":"article","title":"Care in normal birth: A practical guide","publisher":"World Health Organization, Maternal and Newborn Health/Safe Motherhood Unit","source":"Google Scholar","abstract":"This document presents universal guidelines for the routine care of women during uncomplicated labour and childbirth. Reflecting the consensus reached by an international group of experts, the report responds to the proliferation of practices designed to start, augment, accelerate, regulate or monitor the physiological process of labour in industrialized and developing countries alike. Recommendations for routine care are based on a critical review of what research has to say about the effectiveness and safety of 59 common procedures and practices.","URL":"","call-number":"WHO/FRH/MSM/96.24","author":[{"family":"World Health Organization, Maternal and Newborn Health/Safe Motherhood Unit","given":""}],"issued":{"date-parts":[["1996"]]},"accessed":{"date-parts":[["2016",2,19]]}}}],"schema":""} 19 First Stage of Labor:In a systematic review of randomized and quasi randomized trials comparing women randomized to upright position (walking, sitting, standing, kneeling) and recumbent position (supine, semi-recumbent and lateral) during the first stage of labor, upright position was associated with:A reduction in the first stage of labor duration by approximately one hour and 22 minutes (MD -1.36, 95% CI -2.22 to -0.51; 15 studies, 2503 women)Reduction in cesarean delivery (RR 0.71, 95% CI 0.54 to 0.94; 14 studies, 2682 women)Less use of epidural (RR 0.81, 95% CI 0.66 to 0.99, nine studies, 2107 women)One trial reported that babies of mothers who were?upright?were less likely to be admitted to the neonatal intensive care unit, (RR 0.20, 95% CI 0.04 to 0.89, 200 women) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"w5hXjZIw","properties":{"formattedCitation":"{\\rtf \\super 20\\nosupersub{}}","plainCitation":"20"},"citationItems":[{"id":27646,"uris":[""],"uri":[""],"itemData":{"id":27646,"type":"chapter","title":"Maternal positions and mobility during first stage labour","container-title":"Cochrane Database of Systematic Reviews","publisher":"John Wiley & Sons, Ltd","publisher-place":"Chichester, UK","source":"CrossRef","event-place":"Chichester, UK","URL":"","language":"en","editor":[{"literal":"The Cochrane Collaboration"}],"author":[{"family":"Lawrence","given":"Annemarie"},{"family":"Lewis","given":"Lucy"},{"family":"Hofmeyr","given":"G Justus"},{"family":"Styles","given":"Cathy"}],"issued":{"date-parts":[["2013",10,9]]},"accessed":{"date-parts":[["2016",2,19]]}}}],"schema":""} 20 In a study of 58 women who alternately assumed the sitting and supine?positions?for 15 minutes during cervical dilatation from 6 to 8 centimeters, women experienced significantly reduced lower back pain in the sitting position. This applies to continuous pain as well as pain with contractions. (p<.001) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Yx9Q7BPl","properties":{"formattedCitation":"{\\rtf \\super 21\\nosupersub{}}","plainCitation":"21"},"citationItems":[{"id":27647,"uris":[""],"uri":[""],"itemData":{"id":27647,"type":"article-journal","title":"The relationship between the parturient's positions and perceptions of labor pain intensity","container-title":"Nursing Research","page":"47-51","volume":"52","issue":"1","source":"PubMed","abstract":"BACKGROUND: While the effect of the maternal position on reducing labor pain has been studied, the data presented to date have not been conclusive.\nOBJECTIVES: To determine if maternal position reduced the intensity of labor pain during cervical dilatation from 6 to 8 centimeters.\nMETHOD: Pain intensity was measured using the visual analogue scale (VAS) on 39 primiparous and 19 multiparous women (N = 58) who alternately assumed the sitting and supine positions for 15 minutes during cervical dilatation from 6 to 8 centimeters.\nRESULTS: The pain scores for the sitting position were significantly lower than those for the supine position. The Wilcoxon signed-ranks test showed the VAS scores for the (a) total labor pain (\"total\" being defined as both abdominal and lumbar pain) during contraction (p =.011), (b) continuous total labor pain (p =.001), (c) lumbar pain during contraction (p <.001), and (d) continuous lumbar pain (p <.001) in the sitting position (significantly lower than in supine position). The diminished pain scores were greater than 13 millimeters, which is the minimum clinically significant change in patient pain severity as measured with the 100 millimeter VAS. The largest decrease occurred in lower back pain. No significant differences were found for abdominal pain scores in either the sitting or supine positions.\nCONCLUSION: The sitting position offers an effective method to relieve lower back labor pain during cervical dilatation from 6 to 8 centimeters. Similar relief was experienced for women who reported pain only on contraction as well as those with continuous pain.","ISSN":"0029-6562","note":"PMID: 12552175","journalAbbreviation":"Nurs Res","language":"eng","author":[{"family":"Adachi","given":"Kumiko"},{"family":"Shimada","given":"Mieko"},{"family":"Usui","given":"Akira"}],"issued":{"date-parts":[["2003",2]]},"PMID":"12552175"}}],"schema":""} 21 Second Stage of Labor:In a systematic review of randomized and quasi randomized controlled trials comparing upright or lateral position and supine and lithotomy position during the second stage of labor for women without epidural anesthesia, the upright group experienced:a reduction in assisted deliveries [risk ratio (RR) 0.78; 95% CI 0.68 to 0.90; 19 trials, 6024 women]a reduction in episiotomies [average RR 0.79, 95% CI 0.70 to 0.90, 12 trials, 4541 women]fewer abnormal fetal heart rate patterns [RR 0.46; 95% CI 0.22 to 0.93; two trials, 617 women]no difference in cesarean delivery [RR 0.97; 95% CI 0.59 to 1.59; 13 trials, 4824 women]non-significant reduction in the duration of the second stage [(MD) -3.71 minutes; 95% confidence interval (CI) -8.78 to 1.37 minutes; 10 trials, 3485 women]increased second degree perineal tears [RR 1.35; 95% CI 1.20 to 1.51, 14 trials, 5367 women]increased estimated blood loss greater than 500 ml [RR 1.65; 95% CI 1.32 to 2.60; 13 trials, 5158 women] ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"bCk8bg40","properties":{"formattedCitation":"{\\rtf \\super 22\\nosupersub{}}","plainCitation":"22"},"citationItems":[{"id":27649,"uris":[""],"uri":[""],"itemData":{"id":27649,"type":"chapter","title":"Position in the second stage of labour for women without epidural anaesthesia","container-title":"Cochrane Database of Systematic Reviews","publisher":"John Wiley & Sons, Ltd","publisher-place":"Chichester, UK","source":"CrossRef","event-place":"Chichester, UK","URL":"","language":"en","editor":[{"literal":"The Cochrane Collaboration"}],"author":[{"family":"Gupta","given":"Janesh K"},{"family":"Hofmeyr","given":"G Justus"},{"family":"Shehmar","given":"Manjeet"}],"issued":{"date-parts":[["2012",5,16]]},"accessed":{"date-parts":[["2016",2,19]]}}}],"schema":""} 22 In women with epidural anesthesia in the second stage of labor, the upright group experienced:No significant difference in operative birth (RR 0.97; 95% CI 0.76 to 1.29; five trials, 874 women)No significant difference in duration of the second stage of labor (mean difference -22.98 minutes; 95% CI -99.09 to 53.13; two trials, 322 women) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"BGRdcwGE","properties":{"formattedCitation":"{\\rtf \\super 23\\nosupersub{}}","plainCitation":"23"},"citationItems":[{"id":27650,"uris":[""],"uri":[""],"itemData":{"id":27650,"type":"chapter","title":"Position in the second stage of labour for women with epidural anaesthesia","container-title":"Cochrane Database of Systematic Reviews","publisher":"John Wiley & Sons, Ltd","publisher-place":"Chichester, UK","source":"CrossRef","event-place":"Chichester, UK","URL":"","language":"en","editor":[{"literal":"The Cochrane Collaboration"}],"author":[{"family":"Kemp","given":"Emily"},{"family":"Kingswood","given":"Claire J"},{"family":"Kibuka","given":"Marion"},{"family":"Thornton","given":"Jim G"}],"issued":{"date-parts":[["2013",1,31]]},"accessed":{"date-parts":[["2016",2,19]]}}}],"schema":""} 23 Appendix D: Water immersionAnxiety and pain may trigger a stress response leading to reduced uterine activity and labor dystocia. Shoulder-deep warm water immersion is found to improve maternal sense of control and privacy, lower rates of labor augmentation, epidural anesthesia, and possibly a reduction in the first stage of labor. A woman who feels in control of her childbirth experiences greater emotional wellbeing postpartum. When compared to women with immediate augmentation (oxytocin and amniotomy), women with slow labor randomized to water immersion (≤4 hours) experienced: greater satisfaction with freedom of movement (91% v 63%) greater feeling of privacy (96% v 81%) lower rates of augmentation (RR 0.74, 95% CI 0.59 to 0.88, NNT 4) lower rates of epidural anesthesia (RR 0.71, 95% CI 0.49 to 1.01, NNT 5) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"riS6at8g","properties":{"formattedCitation":"{\\rtf \\super 24\\nosupersub{}}","plainCitation":"24"},"citationItems":[{"id":27635,"uris":[""],"uri":[""],"itemData":{"id":27635,"type":"article-journal","title":"Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour","container-title":"BMJ (Clinical research ed.)","page":"314","volume":"328","issue":"7435","source":"PubMed","abstract":"OBJECTIVES: To evaluate the impact of labouring in water during first stage of labour on rates of epidural analgesia and operative delivery in nulliparous women with dystocia.\nDESIGN: Randomised controlled trial.\nSETTING: University teaching hospital in southern England.\nPARTICIPANTS: 99 nulliparous women with dystocia (cervical dilation rate < 1 cm/hour in active labour) at low risk of complications. Interventions Immersion in water in birth pool or standard augmentation for dystocia (amniotomy and intravenous oxytocin).\nMAIN OUTCOME MEASURES: Primary: epidural analgesia and operative delivery rates. Secondary: augmentation rates with amniotomy and oxytocin, length of labour, maternal and neonatal morbidity including infections, maternal pain score, and maternal satisfaction with care.\nRESULTS: Women randomised to immersion in water had a lower rate of epidural analgesia than women allocated to augmentation (47% v 66%, relative risk 0.71 (95% confidence interval 0.49 to 1.01), number needed to treat for benefit (NNT) 5). They showed no difference in rates of operative delivery (49% v 50%, 0.98 (0.65 to 1.47), NNT 98), but significantly fewer received augmentation (71% v 96%, 0.74 (0.59 to 0.88), NNT 4) or any form of obstetric intervention (amniotomy, oxytocin, epidural, or operative delivery) (80% v 98%, 0.81 (0.67 to 0.92), NNT 5). More neonates of women in the water group were admitted to the neonatal unit (6 v 0, P = 0.013), but there was no difference in Apgar score, infection rates, or umbilical cord pH.\nCONCLUSIONS: Labouring in water under midwifery care may be an option for slow progress in labour, reducing the need for obstetric intervention, and offering an alternative pain management strategy.","DOI":"10.1136/bmj.37963.606412.EE","ISSN":"1756-1833","note":"PMID: 14744822\nPMCID: PMC338094","journalAbbreviation":"BMJ","language":"eng","author":[{"family":"Cluett","given":"Elizabeth R."},{"family":"Pickering","given":"Ruth M."},{"family":"Getliffe","given":"Kathryn"},{"family":"St George Saunders","given":"Nigel James"}],"issued":{"date-parts":[["2004",2,7]]},"PMID":"14744822","PMCID":"PMC338094"}}],"schema":""} 24 (n=99)*Six neonates born to women in the water labor group were admitted to the neonatal unit compared with none in the augmentation group (P = 0.013). With the exception of an infant with cardiac defects, all these neonates, were reunited with their mothers within 48 hours and experienced no subsequent problems. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"hb4WgrJ1","properties":{"formattedCitation":"{\\rtf \\super 24\\nosupersub{}}","plainCitation":"24"},"citationItems":[{"id":27635,"uris":[""],"uri":[""],"itemData":{"id":27635,"type":"article-journal","title":"Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour","container-title":"BMJ (Clinical research ed.)","page":"314","volume":"328","issue":"7435","source":"PubMed","abstract":"OBJECTIVES: To evaluate the impact of labouring in water during first stage of labour on rates of epidural analgesia and operative delivery in nulliparous women with dystocia.\nDESIGN: Randomised controlled trial.\nSETTING: University teaching hospital in southern England.\nPARTICIPANTS: 99 nulliparous women with dystocia (cervical dilation rate < 1 cm/hour in active labour) at low risk of complications. Interventions Immersion in water in birth pool or standard augmentation for dystocia (amniotomy and intravenous oxytocin).\nMAIN OUTCOME MEASURES: Primary: epidural analgesia and operative delivery rates. Secondary: augmentation rates with amniotomy and oxytocin, length of labour, maternal and neonatal morbidity including infections, maternal pain score, and maternal satisfaction with care.\nRESULTS: Women randomised to immersion in water had a lower rate of epidural analgesia than women allocated to augmentation (47% v 66%, relative risk 0.71 (95% confidence interval 0.49 to 1.01), number needed to treat for benefit (NNT) 5). They showed no difference in rates of operative delivery (49% v 50%, 0.98 (0.65 to 1.47), NNT 98), but significantly fewer received augmentation (71% v 96%, 0.74 (0.59 to 0.88), NNT 4) or any form of obstetric intervention (amniotomy, oxytocin, epidural, or operative delivery) (80% v 98%, 0.81 (0.67 to 0.92), NNT 5). More neonates of women in the water group were admitted to the neonatal unit (6 v 0, P = 0.013), but there was no difference in Apgar score, infection rates, or umbilical cord pH.\nCONCLUSIONS: Labouring in water under midwifery care may be an option for slow progress in labour, reducing the need for obstetric intervention, and offering an alternative pain management strategy.","DOI":"10.1136/bmj.37963.606412.EE","ISSN":"1756-1833","note":"PMID: 14744822\nPMCID: PMC338094","journalAbbreviation":"BMJ","language":"eng","author":[{"family":"Cluett","given":"Elizabeth R."},{"family":"Pickering","given":"Ruth M."},{"family":"Getliffe","given":"Kathryn"},{"family":"St George Saunders","given":"Nigel James"}],"issued":{"date-parts":[["2004",2,7]]},"PMID":"14744822","PMCID":"PMC338094"}}],"schema":""} 24 Review of 8 randomized controlled trials comparing water immersion during first stage of labor with no water immersion:Water immersion is associated with: a shorter first stage of labor (mean difference –32.4 minutes; 95% CI, from –58.7 to –6.13, 7 trials, n=1461)lower rates of epidural/spinal/paracervical anesthesia/analgesia (RR 0.90; 95% CI 0.82 to 0.99, six trials, n=2499)lower rates of any analgesia use (RR 0.72, 95% CI 0.46 to 1.12, 5 trials, n=653) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"DNmNMVAX","properties":{"formattedCitation":"{\\rtf \\super 25\\nosupersub{}}","plainCitation":"25"},"citationItems":[{"id":27638,"uris":[""],"uri":[""],"itemData":{"id":27638,"type":"article-journal","title":"Immersion in water in labour and birth","container-title":"The Cochrane Database of Systematic Reviews","page":"CD000111","issue":"2","source":"PubMed","abstract":"BACKGROUND: Enthusiasts suggest that labouring in water and waterbirth increase maternal relaxation, reduce analgesia requirements and promote a midwifery model of care. Sceptics cite the possibility of neonatal water inhalation and maternal/neonatal infection.\nOBJECTIVES: To assess the evidence from randomised controlled trials about immersion in water during labour and waterbirth on maternal, fetal, neonatal and caregiver outcomes.\nSEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2008).\nSELECTION CRITERIA: Randomised controlled trials comparing any bath tub/pool with no immersion during labour and/or birth.\nDATA COLLECTION AND ANALYSIS: We assessed trial eligibility and quality and extracted data independently. One review author entered data and another checked for accuracy.\nMAIN RESULTS: This review includes 11 trials (3146 women); eight related to the first stage of labour, one to the first and second stages, one to early versus late immersion in the first stage of labour, and another to the second stage. We identified no trials evaluating different baths/pools, or the management of third stage of labour.Results for the first stage of labour showed there was a significant reduction in the epidural/spinal/paracervical analgesia/anaesthesia rate amongst women allocated to water immersion compared to controls (478/1254 versus 529/1245; odds ratio (OR) 0.82, 95% confidence interval (CI) 0.70 to 0.98, six trials). There was no difference in assisted vaginal deliveries (OR 0.84, 95% CI 0.66 to 1.06, seven trials), caesarean sections (OR 1.23, 95% CI 0.86 to 1.75, eight trials), perineal trauma or maternal infection. There were no differences for Apgar score less than seven at five minutes (OR 1.59, 95% CI 0.63 to 4.01, five trials), neonatal unit admissions (OR 1.06, 95% CI 0.70 to 1.62, three trials), or neonatal infection rates (OR 2.01, 95% CI 0.50 to 8.07, five trials).A lack of data for some comparisons prevented robust conclusions. Further research is needed.\nAUTHORS' CONCLUSIONS: Evidence suggests that water immersion during the first stage of labour reduces the use of epidural/spinal analgesia. There is limited information for other outcomes related to water use during the first and second stages of labour, due to intervention and outcome variability. There is no evidence of increased adverse effects to the fetus/neonate or woman from labouring in water or waterbirth. The fact that use of water immersion in labour and birth is now a widely available care option for women threatens the feasibility of a large, multicentre randomised controlled trial.","DOI":"10.1002/14651858.CD000111.pub3","ISSN":"1469-493X","note":"PMID: 19370552\nPMCID: PMC3982045","journalAbbreviation":"Cochrane Database Syst Rev","language":"eng","author":[{"family":"Cluett","given":"Elizabeth R."},{"family":"Burns","given":"Ethel"}],"issued":{"date-parts":[["2009"]]},"PMID":"19370552","PMCID":"PMC3982045"}}],"schema":""} 25There was no significant difference in:assisted vaginal deliveries (RR 0.86; 95% CI 0.71 to 1.05, seven trials, n=2628)cesarean deliveries (RR 1.21; 95% CI 0.87 to 1.68, eight trials, n=2712)use of oxytocin infusion (RR 0.64; 95%CI 0.32 to 1.28, five trials, n=1125)perineal trauma (RR 1.16; 95% CI 0.99 to 1.35, five trials, n=1337)maternal infection (RR 0.99; 95% CI 0.50 to 1.96, five trials, n=647),Apgar score less than seven at five minutes (RR 1.58; 95% CI 0.63 to 3.93, five trials, n=1834) neonatal unit admissions (RR 1.06; 95% CI 0.71 to 1.57, three trials, n=1260)neonatal infection rates (RR 2.00; 95% CI 0.50 to 7.94, five trials, n= 1295, 6 infections in immersion groups, 3 infections in non-immersion groups) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"b45foMYX","properties":{"formattedCitation":"{\\rtf \\super 25\\nosupersub{}}","plainCitation":"25"},"citationItems":[{"id":27638,"uris":[""],"uri":[""],"itemData":{"id":27638,"type":"article-journal","title":"Immersion in water in labour and birth","container-title":"The Cochrane Database of Systematic Reviews","page":"CD000111","issue":"2","source":"PubMed","abstract":"BACKGROUND: Enthusiasts suggest that labouring in water and waterbirth increase maternal relaxation, reduce analgesia requirements and promote a midwifery model of care. Sceptics cite the possibility of neonatal water inhalation and maternal/neonatal infection.\nOBJECTIVES: To assess the evidence from randomised controlled trials about immersion in water during labour and waterbirth on maternal, fetal, neonatal and caregiver outcomes.\nSEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2008).\nSELECTION CRITERIA: Randomised controlled trials comparing any bath tub/pool with no immersion during labour and/or birth.\nDATA COLLECTION AND ANALYSIS: We assessed trial eligibility and quality and extracted data independently. One review author entered data and another checked for accuracy.\nMAIN RESULTS: This review includes 11 trials (3146 women); eight related to the first stage of labour, one to the first and second stages, one to early versus late immersion in the first stage of labour, and another to the second stage. We identified no trials evaluating different baths/pools, or the management of third stage of labour.Results for the first stage of labour showed there was a significant reduction in the epidural/spinal/paracervical analgesia/anaesthesia rate amongst women allocated to water immersion compared to controls (478/1254 versus 529/1245; odds ratio (OR) 0.82, 95% confidence interval (CI) 0.70 to 0.98, six trials). There was no difference in assisted vaginal deliveries (OR 0.84, 95% CI 0.66 to 1.06, seven trials), caesarean sections (OR 1.23, 95% CI 0.86 to 1.75, eight trials), perineal trauma or maternal infection. There were no differences for Apgar score less than seven at five minutes (OR 1.59, 95% CI 0.63 to 4.01, five trials), neonatal unit admissions (OR 1.06, 95% CI 0.70 to 1.62, three trials), or neonatal infection rates (OR 2.01, 95% CI 0.50 to 8.07, five trials).A lack of data for some comparisons prevented robust conclusions. Further research is needed.\nAUTHORS' CONCLUSIONS: Evidence suggests that water immersion during the first stage of labour reduces the use of epidural/spinal analgesia. There is limited information for other outcomes related to water use during the first and second stages of labour, due to intervention and outcome variability. There is no evidence of increased adverse effects to the fetus/neonate or woman from labouring in water or waterbirth. The fact that use of water immersion in labour and birth is now a widely available care option for women threatens the feasibility of a large, multicentre randomised controlled trial.","DOI":"10.1002/14651858.CD000111.pub3","ISSN":"1469-493X","note":"PMID: 19370552\nPMCID: PMC3982045","journalAbbreviation":"Cochrane Database Syst Rev","language":"eng","author":[{"family":"Cluett","given":"Elizabeth R."},{"family":"Burns","given":"Ethel"}],"issued":{"date-parts":[["2009"]]},"PMID":"19370552","PMCID":"PMC3982045"}}],"schema":""} 25 One limitation of research on water immersion during labor thus far is the lack of standardization of length of time for water immersion. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"fu9EZS9h","properties":{"formattedCitation":"{\\rtf \\super 25\\nosupersub{}}","plainCitation":"25"},"citationItems":[{"id":27638,"uris":[""],"uri":[""],"itemData":{"id":27638,"type":"article-journal","title":"Immersion in water in labour and birth","container-title":"The Cochrane Database of Systematic Reviews","page":"CD000111","issue":"2","source":"PubMed","abstract":"BACKGROUND: Enthusiasts suggest that labouring in water and waterbirth increase maternal relaxation, reduce analgesia requirements and promote a midwifery model of care. Sceptics cite the possibility of neonatal water inhalation and maternal/neonatal infection.\nOBJECTIVES: To assess the evidence from randomised controlled trials about immersion in water during labour and waterbirth on maternal, fetal, neonatal and caregiver outcomes.\nSEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2008).\nSELECTION CRITERIA: Randomised controlled trials comparing any bath tub/pool with no immersion during labour and/or birth.\nDATA COLLECTION AND ANALYSIS: We assessed trial eligibility and quality and extracted data independently. One review author entered data and another checked for accuracy.\nMAIN RESULTS: This review includes 11 trials (3146 women); eight related to the first stage of labour, one to the first and second stages, one to early versus late immersion in the first stage of labour, and another to the second stage. We identified no trials evaluating different baths/pools, or the management of third stage of labour.Results for the first stage of labour showed there was a significant reduction in the epidural/spinal/paracervical analgesia/anaesthesia rate amongst women allocated to water immersion compared to controls (478/1254 versus 529/1245; odds ratio (OR) 0.82, 95% confidence interval (CI) 0.70 to 0.98, six trials). There was no difference in assisted vaginal deliveries (OR 0.84, 95% CI 0.66 to 1.06, seven trials), caesarean sections (OR 1.23, 95% CI 0.86 to 1.75, eight trials), perineal trauma or maternal infection. There were no differences for Apgar score less than seven at five minutes (OR 1.59, 95% CI 0.63 to 4.01, five trials), neonatal unit admissions (OR 1.06, 95% CI 0.70 to 1.62, three trials), or neonatal infection rates (OR 2.01, 95% CI 0.50 to 8.07, five trials).A lack of data for some comparisons prevented robust conclusions. Further research is needed.\nAUTHORS' CONCLUSIONS: Evidence suggests that water immersion during the first stage of labour reduces the use of epidural/spinal analgesia. There is limited information for other outcomes related to water use during the first and second stages of labour, due to intervention and outcome variability. There is no evidence of increased adverse effects to the fetus/neonate or woman from labouring in water or waterbirth. The fact that use of water immersion in labour and birth is now a widely available care option for women threatens the feasibility of a large, multicentre randomised controlled trial.","DOI":"10.1002/14651858.CD000111.pub3","ISSN":"1469-493X","note":"PMID: 19370552\nPMCID: PMC3982045","journalAbbreviation":"Cochrane Database Syst Rev","language":"eng","author":[{"family":"Cluett","given":"Elizabeth R."},{"family":"Burns","given":"Ethel"}],"issued":{"date-parts":[["2009"]]},"PMID":"19370552","PMCID":"PMC3982045"}}],"schema":""} 25 Appendix E: AmniotomyEffects of early amniotomy on duration of labor and rates of cesarean delivery remain unclear. According to a 2013 Cochrane review of 14 trials with 8033 women, preventative use of amniotomy and oxytocin may or may not be associated with a reduced rate of cesarean delivery. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"0HZgOioX","properties":{"formattedCitation":"{\\rtf \\super 26\\nosupersub{}}","plainCitation":"26"},"citationItems":[{"id":27651,"uris":[""],"uri":[""],"itemData":{"id":27651,"type":"chapter","title":"Early amniotomy and early oxytocin for prevention of, or therapy for, delay in first stage spontaneous labour compared with routine care","container-title":"Cochrane Database of Systematic Reviews","publisher":"John Wiley & Sons, Ltd","publisher-place":"Chichester, UK","source":"CrossRef","event-place":"Chichester, UK","URL":"","language":"en","editor":[{"literal":"The Cochrane Collaboration"}],"author":[{"family":"Wei","given":"Shuqin"},{"family":"Wo","given":"Bi Lan"},{"family":"Qi","given":"Hui-Ping"},{"family":"Xu","given":"Hairong"},{"family":"Luo","given":"Zhong-Cheng"},{"family":"Roy","given":"Chantal"},{"family":"Fraser","given":"William D"}],"issued":{"date-parts":[["2013",8,7]]},"accessed":{"date-parts":[["2016",2,19]]}}}],"schema":""} 26 Results are unclear because although the RR was 0.87, the confidence interval included the null effect (95% CI 0.79 to 1.01). Routine early amniotomy used in combination with early oxytocin was shown to shorten the duration of labor [average mean difference (MD) - 1.28 hours; 95% CI -1.97 to -0.59; eight trials; 4816 women]. When using amniotomy to treat labor dystocia, reviewers state that, “the severity of delay which was sufficient to justify interventions remains to be defined”. Reviewers saw no effects on other indicators measured regarding maternal and neonatal morbidity. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"0rYFLTNu","properties":{"formattedCitation":"{\\rtf \\super 26\\nosupersub{}}","plainCitation":"26"},"citationItems":[{"id":27651,"uris":[""],"uri":[""],"itemData":{"id":27651,"type":"chapter","title":"Early amniotomy and early oxytocin for prevention of, or therapy for, delay in first stage spontaneous labour compared with routine care","container-title":"Cochrane Database of Systematic Reviews","publisher":"John Wiley & Sons, Ltd","publisher-place":"Chichester, UK","source":"CrossRef","event-place":"Chichester, UK","URL":"","language":"en","editor":[{"literal":"The Cochrane Collaboration"}],"author":[{"family":"Wei","given":"Shuqin"},{"family":"Wo","given":"Bi Lan"},{"family":"Qi","given":"Hui-Ping"},{"family":"Xu","given":"Hairong"},{"family":"Luo","given":"Zhong-Cheng"},{"family":"Roy","given":"Chantal"},{"family":"Fraser","given":"William D"}],"issued":{"date-parts":[["2013",8,7]]},"accessed":{"date-parts":[["2016",2,19]]}}}],"schema":""} 26Appendix F: Membranes SweepingMembrane sweeping is thought to increase local prostaglandin release to stimulate labor. It is performed by inserting a finger past the internal os and rotating it to detach fetal membranes from the lower uterine segment. Contraindications to membrane sweeping: low lying placenta or placenta previacervicitispreterm status, unless the patient is being induced for a medical indication Evidence:Membrane sweeping in conjunction with induction: A randomized trial compared 274 women scheduled for induction at term to membrane sweeping or no membrane sweeping at the initiation of induction. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"K8RMZOFw","properties":{"formattedCitation":"{\\rtf \\super 27\\nosupersub{}}","plainCitation":"27"},"citationItems":[{"id":27652,"uris":[""],"uri":[""],"itemData":{"id":27652,"type":"article-journal","title":"Membrane sweeping at initiation of formal labor induction: a randomized controlled trial","container-title":"Obstetrics and Gynecology","page":"569-577","volume":"107","issue":"3","source":"PubMed","abstract":"OBJECTIVE: To determine the benefit of membrane sweeping at initiation of labor induction in conjunction with formal methods of labor induction.\nMETHODS: Two hundred seventy-four women at term with a singleton fetus in cephalic presentation and intact membranes were randomly assigned to receive membrane sweeping or no membrane sweeping at initiation of formal labor induction with either dinoprostone pessary or amniotomy. Outcome measures included mode of delivery, induction-to-delivery interval, dinosprostone dose, any oxytocin use and duration of oxytocin use in labor, visual analog score for pain associated with sweeping, and visual analog score for satisfaction with the birth process.\nRESULTS: Two hundred sixty-four women (136 sweep and 128 no sweep) had their data analyzed. Ten women (4 sweep and 6 no sweep) were excluded because of exclusion criteria infringements. Swept women had higher spontaneous vaginal delivery rate (69% compared with 56%, P = .041), shorter induction to delivery interval (mean 14 compared with 19 hours, P = .003), fewer that required oxytocin use (46% compared with 59%, P = .037), shorter duration of oxytocin infusion (mean 2.6 compared with 4.3 hours, P = .001) and improved visual analog score for birth process satisfaction (mean 4.0 compared with 4.7, P = .015). The reduction in dinoprostone dose used (mean 1.2 compared with 1.3, P = .082) was not significant. Postsweeping visual analog score for pain (mean 4.7 compared with 3.5, P < .001) was significantly increased.\nCONCLUSION: Membrane sweeping at initiation of labor induction increased the spontaneous vaginal delivery rate, reduced oxytocic drug use, shortened induction to delivery interval, and improved patient satisfaction.\nLEVEL OF EVIDENCE: I.","DOI":"10.1097/01.AOG.0000200094.89388.70","ISSN":"1873-233X","note":"PMID: 16507926","shortTitle":"Membrane sweeping at initiation of formal labor induction","journalAbbreviation":"Obstet Gynecol","language":"eng","author":[{"family":"Tan","given":"Peng Chiong"},{"family":"Jacob","given":"Reena"},{"family":"Omar","given":"Siti Zawiah"}],"issued":{"date-parts":[["2006",3]]},"PMID":"16507926"}}],"schema":""} 27 The aim was to determine whether membrane sweeping increases the likelihood of spontaneous vaginal delivery. Results: Membrane sweeping was associated with:Higher spontaneous vaginal delivery rate (69% vs 56%, P=.041)Shorter induction-to-delivery interval (mean 14 vs 19 hours, P=.003)Fewer requirements for oxytocin (46% vs 59%, P=.037)Shorter duration of oxytocin infusion (mean 2.6 vs 4.3 hours, P=.001) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"7znnhX7Q","properties":{"formattedCitation":"{\\rtf \\super 27\\nosupersub{}}","plainCitation":"27"},"citationItems":[{"id":27652,"uris":[""],"uri":[""],"itemData":{"id":27652,"type":"article-journal","title":"Membrane sweeping at initiation of formal labor induction: a randomized controlled trial","container-title":"Obstetrics and Gynecology","page":"569-577","volume":"107","issue":"3","source":"PubMed","abstract":"OBJECTIVE: To determine the benefit of membrane sweeping at initiation of labor induction in conjunction with formal methods of labor induction.\nMETHODS: Two hundred seventy-four women at term with a singleton fetus in cephalic presentation and intact membranes were randomly assigned to receive membrane sweeping or no membrane sweeping at initiation of formal labor induction with either dinoprostone pessary or amniotomy. Outcome measures included mode of delivery, induction-to-delivery interval, dinosprostone dose, any oxytocin use and duration of oxytocin use in labor, visual analog score for pain associated with sweeping, and visual analog score for satisfaction with the birth process.\nRESULTS: Two hundred sixty-four women (136 sweep and 128 no sweep) had their data analyzed. Ten women (4 sweep and 6 no sweep) were excluded because of exclusion criteria infringements. Swept women had higher spontaneous vaginal delivery rate (69% compared with 56%, P = .041), shorter induction to delivery interval (mean 14 compared with 19 hours, P = .003), fewer that required oxytocin use (46% compared with 59%, P = .037), shorter duration of oxytocin infusion (mean 2.6 compared with 4.3 hours, P = .001) and improved visual analog score for birth process satisfaction (mean 4.0 compared with 4.7, P = .015). The reduction in dinoprostone dose used (mean 1.2 compared with 1.3, P = .082) was not significant. Postsweeping visual analog score for pain (mean 4.7 compared with 3.5, P < .001) was significantly increased.\nCONCLUSION: Membrane sweeping at initiation of labor induction increased the spontaneous vaginal delivery rate, reduced oxytocic drug use, shortened induction to delivery interval, and improved patient satisfaction.\nLEVEL OF EVIDENCE: I.","DOI":"10.1097/01.AOG.0000200094.89388.70","ISSN":"1873-233X","note":"PMID: 16507926","shortTitle":"Membrane sweeping at initiation of formal labor induction","journalAbbreviation":"Obstet Gynecol","language":"eng","author":[{"family":"Tan","given":"Peng Chiong"},{"family":"Jacob","given":"Reena"},{"family":"Omar","given":"Siti Zawiah"}],"issued":{"date-parts":[["2006",3]]},"PMID":"16507926"}}],"schema":""} 27 Prevention of post-term pregnancies: A systematic review involving 22 trials and 2797 women showed that there is reduced frequency of pregnancy continuing beyond 41 weeks (RR 0.59, 95% CI 0.46 to 0.74) and 42 weeks (RR 0.28, 95% CI 0.15 to 0.50) when membranes are swept for women at term. To avoid one formal induction of labor, sweeping of membranes must be performed in eight women (NNT = 8). There was no evidence of a difference in the risk of maternal or neonatal infection. Rate of cesarean delivery is similar between the membrane sweeping group and the group without membrane sweeping (RR 0.90, 95% CI 0.70-1.15). ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"h29bcDgs","properties":{"formattedCitation":"{\\rtf \\super 28\\nosupersub{}}","plainCitation":"28"},"citationItems":[{"id":27654,"uris":[""],"uri":[""],"itemData":{"id":27654,"type":"article-journal","title":"Membrane sweeping for induction of labour","container-title":"The Cochrane Database of Systematic Reviews","page":"CD000451","issue":"1","source":"PubMed","abstract":"BACKGROUND: Sweeping of the membranes, also named stripping of the membranes, is a relatively simple technique usually performed without admission to hospital. During vaginal examination, the clinician's finger is introduced into the cervical os. Then, the inferior pole of the membranes is detached from the lower uterine segment by a circular movement of the examining finger. This intervention has the potential to initiate labour by increasing local production of prostaglandins and, thus, reduce pregnancy duration or pre-empt formal induction of labour with either oxytocin, prostaglandins or amniotomy. This is one of a series of reviews of methods of cervical ripening and labour induction using standardised methodology.\nOBJECTIVES: To determine the effects of membrane sweeping for third trimester induction of labour.\nSEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register (6 July 2004) and bibliographies of relevant papers.\nSELECTION CRITERIA: Clinical trials comparing membrane sweeping used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed above it on a predefined list of labour induction methods.\nDATA COLLECTION AND ANALYSIS: A strategy was developed to deal with the large volume and complexity of trial data relating to labour induction. This involved a two-stage method of data extraction.\nMAIN RESULTS: Twenty-two trials (2797 women) were included, 20 comparing sweeping of membranes with no treatment, three comparing sweeping with prostaglandins and one comparing sweeping with oxytocin (two studies reported more than one comparison). Risk of caesarean section was similar between groups (relative risk (RR) 0.90, 95% confidence interval (CI) 0.70 to 1.15). Sweeping of the membranes, performed as a general policy in women at term, was associated with reduced duration of pregnancy and reduced frequency of pregnancy continuing beyond 41 weeks (RR 0.59, 95% CI 0.46 to 0.74) and 42 weeks (RR 0.28, 95% CI 0.15 to 0.50). To avoid one formal induction of labour, sweeping of membranes must be performed in eight women (NNT = 8). There was no evidence of a difference in the risk of maternal or neonatal infection. Discomfort during vaginal examination and other adverse effects (bleeding, irregular contractions) were more frequently reported by women allocated to sweeping. Studies comparing sweeping with prostaglandin administration are of limited sample size and do not provide evidence of benefit.\nAUTHORS' CONCLUSIONS: Routine use of sweeping of membranes from 38 weeks of pregnancy onwards does not seem to produce clinically important benefits. When used as a means for induction of labour, the reduction in the use of more formal methods of induction needs to be balanced against women's discomfort and other adverse effects.","DOI":"10.1002/14651858.CD000451.pub2","ISSN":"1469-493X","note":"PMID: 15674873","journalAbbreviation":"Cochrane Database Syst Rev","language":"eng","author":[{"family":"Boulvain","given":"M."},{"family":"Stan","given":"C."},{"family":"Irion","given":"O."}],"issued":{"date-parts":[["2005"]]},"PMID":"15674873"}}],"schema":""} 28Appendix G: AcupressureAcupressure is a low-risk intervention with multiple demonstrated benefits for laboring women, including pain relief, reduced anxiety, shorter labors, and decreased risk of cesarean delivery. Acupressure is a Traditional Chinese Medicine (TCM) treatment modality that is thought to exert its effects by: promoting the circulation of blood, energy and qi, balancing yin and yang, and promoting the secretion of neurotransmitters. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"15u3k63p5r","properties":{"formattedCitation":"{\\rtf \\super 29,30\\nosupersub{}}","plainCitation":"29,30"},"citationItems":[{"id":27656,"uris":[""],"uri":[""],"itemData":{"id":27656,"type":"chapter","title":"Acupuncture or acupressure for pain management in labour","container-title":"Cochrane Database of Systematic Reviews","publisher":"John Wiley & Sons, Ltd","publisher-place":"Chichester, UK","source":"CrossRef","event-place":"Chichester, UK","URL":"","language":"en","editor":[{"literal":"The Cochrane Collaboration"}],"author":[{"family":"Smith","given":"Caroline A"},{"family":"Collins","given":"Carmel T"},{"family":"Crowther","given":"Caroline A"},{"family":"Levett","given":"Kate M"}],"issued":{"date-parts":[["2011",7,6]]},"accessed":{"date-parts":[["2016",2,19]]}},"label":"page"},{"id":27657,"uris":[""],"uri":[""],"itemData":{"id":27657,"type":"article-journal","title":"Effects of LI4 and BL 67 acupressure on labor pain and uterine contractions in the first stage of labor","container-title":"The journal of nursing research: JNR","page":"251-260","volume":"11","issue":"4","source":"PubMed","abstract":"Acupressure is said to promote the circulation of blood and qi, the harmony of yin and yang, and the secretion of neurotransmitters, thus maintaining the normal functions of the human body and providing comfort. However, there has been little research-based evidence to support the positive effects of acupressure in the area of obstetric nursing. The purpose of this study is to determine the effect of LI4 and BL67 acupressure on labor pain and uterine contractions during the first stage of labor. An experimental study with a pretest and posttest control group design was utilized. A total of 127 parturient women were randomly assigned to three groups. Each group received only one of the following treatments, LI4 and BL67 acupressure, light skin stroking, or no treatment/conversation only. Data collected from the VAS and external fetal monitoring strips were used for analysis. Findings indicated that there was a significant difference in decreased labor pain during the active phase of the first stage of labor among the three groups. There was no significant difference in effectiveness of uterine contractions during the first stage of labor among the three groups. Results of the study confirmed the effect of LI4 and BL67 acupressure in lessening labor pain during the active phase of the first stage of labor. There were no verified effects on uterine contractions.","ISSN":"1682-3141","note":"PMID: 14685931","journalAbbreviation":"J Nurs Res","language":"eng","author":[{"family":"Chung","given":"Ue-Lin"},{"family":"Hung","given":"Li-Chiao"},{"family":"Kuo","given":"Su-Chen"},{"family":"Huang","given":"Chun-Liang"}],"issued":{"date-parts":[["2003",12]]},"PMID":"14685931"},"label":"page"}],"schema":""} 29,30In 2011 The Cochrane Collaboration conducted a review of randomized clinical trials on the use of acupuncture and acupressure in laboring women. The review found that when compared to placebo, acupressure reduced pain intensity (SMD -0.55, 95% CI -0.92 to -0.19, one trial, 120 women, with a combined control; SMD - 0.42, 95% CI -0.65 to -0.18, two trials, 322 women). ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"kMyXF4TB","properties":{"formattedCitation":"{\\rtf \\super 29\\nosupersub{}}","plainCitation":"29"},"citationItems":[{"id":27656,"uris":[""],"uri":[""],"itemData":{"id":27656,"type":"chapter","title":"Acupuncture or acupressure for pain management in labour","container-title":"Cochrane Database of Systematic Reviews","publisher":"John Wiley & Sons, Ltd","publisher-place":"Chichester, UK","source":"CrossRef","event-place":"Chichester, UK","URL":"","language":"en","editor":[{"literal":"The Cochrane Collaboration"}],"author":[{"family":"Smith","given":"Caroline A"},{"family":"Collins","given":"Carmel T"},{"family":"Crowther","given":"Caroline A"},{"family":"Levett","given":"Kate M"}],"issued":{"date-parts":[["2011",7,6]]},"accessed":{"date-parts":[["2016",2,19]]}}}],"schema":""} 29 See the following discussion for evidence on the effects of specific acupressure points, as well as instructions for how to use them with laboring women. San-Yin-Jiao/ “SP6”Results of two randomized clinical trials comparing the effects of 30 min. of SP6 acupressure compared with SP6 touch: Reduced pain“There were significant differences between the groups in subjective labor pain scores at all time points following the intervention: immediately after the intervention (F=6.646,p 0.012); 30 minutes after the intervention (F=5.657, p 0.021); and 60 minutes after the intervention (F= 6.783, p 0.012).” Shortened laborShorter total length of labor from 3 cm to complete dilation (n = 75, t=-2.864, p = 0.006) Reduced risk of cesarean delivery (CD)CD rate for acupressure group was 12.8%, SP6 touch group 29.8%, and control group was 22.4% (p=0.049). CD rates were significantly different between the SP6 acupressure and non-SP6 acupressure group (p=0.035). ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"OOuB1weh","properties":{"formattedCitation":"{\\rtf \\super 31\\nosupersub{}}","plainCitation":"31"},"citationItems":[{"id":27659,"uris":[""],"uri":[""],"itemData":{"id":27659,"type":"article-journal","title":"Effects of SP6 acupressure on labor pain and length of delivery time in women during labor","container-title":"Journal of Alternative and Complementary Medicine (New York, N.Y.)","page":"959-965","volume":"10","issue":"6","source":"PubMed","abstract":"OBJECTIVE: The purpose of this study was to evaluate the effects of SP6 acupressure on labor pain and delivery time in women in labor.\nDESIGN: Randomized clinical trial.\nSETTING/LOCATION: Delivery room in a university hospital.\nPARTICIPANTS: Seventy-five (75) women in labor were randomly assigned to either the SP6 acupressure (n = 36) or SP6 touch control (n = 39) group. The participants were matched according to parity, cervical dilation, labor stage, rupture of amniotic membrane, and husband's presence during labor. There were no additional oxytocin augmentation or administration of analgesics during the study period.\nINTERVENTION: The 30-minute acupressure or touch on SP6 acupoint was performed.\nOUTCOME MEASURES: Labor pain was measured four times using a structured questionnaire, a subjective labor pain scale (visual-analogue scale [VAS]): before intervention, immediately after the intervention, and 30 and 60 minutes after the intervention. Length of delivery time was calculated in two stages: from 3 cm cervical dilation to full cervical dilatation, and full cervical dilatation to the delivery.\nRESULTS: There were significant differences between the groups in subjective labor pain scores at all time points following the intervention: immediately after the intervention (p = 0.012); 30 minutes after the intervention (p = 0.021); and 60 minutes after the intervention (p = 0.012). The total labor time (3 cm dilatation to delivery) was significantly shorter in the SP6 acupressure intervention group than in the control group (p = 0.006).\nCONCLUSIONS: These findings showed that SP6 acupressure was effective for decreasing labor pain and shortening the length of delivery time. SP6 acupressure can be an effective nursing management for women in labor.","DOI":"10.1089/acm.2004.10.959","ISSN":"1075-5535","note":"PMID: 15673989","journalAbbreviation":"J Altern Complement Med","language":"eng","author":[{"family":"Lee","given":"Mi Kyeong"},{"family":"Chang","given":"Soon Bok"},{"family":"Kang","given":"Duck-Hee"}],"issued":{"date-parts":[["2004",12]]},"PMID":"15673989"}}],"schema":""} 31How To Use SP6: SP6 is located 4 finger breadths (using patient’s fingers) above the tip of the inner malleous, just posterior to the border of the tibia (see image below). During contractions apply bilateral and simultaneous firm pressure to SP6 for 30min. 76200019050Large Intestine 4 (LI4) and Bladder 67 (BL67)Results of a randomized clinical trial, n= 100, with women at 3-4 cm of cervical dilation and regular uterine contractions comparing LI4 acupressure with LI4 touch: Reduced pain for up to 2 hours:There were significant differences between the groups in subjective labor pain scores immediately and 20, 60, and 120 minutes after intervention (P ≤ .001), using a 10 point pain scale (0 meaning no pain, 10 meaning unbearable pain).20 minutes post intervention: acupressure group: 6.5 vs control group: 8.26 (p value 0.001)60 minutes post intervention: acupressure group: 7.12 vs control group: 8.92 (p value 0.001)120 minutes post intervention: acupressure group: 8.57 vs control group: 9.83 (p value 0.001)Shorter first and second stage labor durationFirst stage: acupressure group: mean 2.44 hours, control group: mean 3.09 hoursSecond Stage: acupressure group: mean 20.51 mins, control group: mean 28.5 minsSignificant difference in perception of labor pain assessed 24 h after birth using a 10 point pain scale (0 meaning no pain, 10 meaning unbearable pain): acupressure group: mean 6.3, control group: mean 8.3, p value = 0.0001Greater maternal satisfaction acupressure group: 5.76 vs control group: 5.36 ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"y2SRgezc","properties":{"formattedCitation":"{\\rtf \\super 32\\nosupersub{}}","plainCitation":"32"},"citationItems":[{"id":27661,"uris":[""],"uri":[""],"itemData":{"id":27661,"type":"article-journal","title":"Effects of LI4 Acupressure on Labor Pain in the First Stage of Labor","container-title":"Journal of Midwifery & Women's Health","page":"133-138","volume":"57","issue":"2","source":"CrossRef","DOI":"10.1111/j.1542-2011.2011.00138.x","ISSN":"15269523","language":"en","author":[{"family":"Hamidzadeh","given":"Azam"},{"family":"Shahpourian","given":"Farangis"},{"family":"Orak","given":"Roohangiz Jamshidi"},{"family":"Montazeri","given":"Akram Sadat"},{"family":"Khosravi","given":"Ahmad"}],"issued":{"date-parts":[["2012",3]]}}}],"schema":""} 32Results of a clinical trial randomizing laboring women to one of three groups: LI4 and BL67 acupressure, light skin stroking, or no treatment/conversation only (n=127): Decreased pain during active phase of labor: There was a significant difference in decreased labor pain between the acupressure and control groups (W = 5.607, p = .017). W is the Wilcoxon rank sum statistic.No effect on uterine contractions ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"SD9XmLXN","properties":{"formattedCitation":"{\\rtf \\super 30\\nosupersub{}}","plainCitation":"30"},"citationItems":[{"id":27657,"uris":[""],"uri":[""],"itemData":{"id":27657,"type":"article-journal","title":"Effects of LI4 and BL 67 acupressure on labor pain and uterine contractions in the first stage of labor","container-title":"The journal of nursing research: JNR","page":"251-260","volume":"11","issue":"4","source":"PubMed","abstract":"Acupressure is said to promote the circulation of blood and qi, the harmony of yin and yang, and the secretion of neurotransmitters, thus maintaining the normal functions of the human body and providing comfort. However, there has been little research-based evidence to support the positive effects of acupressure in the area of obstetric nursing. The purpose of this study is to determine the effect of LI4 and BL67 acupressure on labor pain and uterine contractions during the first stage of labor. An experimental study with a pretest and posttest control group design was utilized. A total of 127 parturient women were randomly assigned to three groups. Each group received only one of the following treatments, LI4 and BL67 acupressure, light skin stroking, or no treatment/conversation only. Data collected from the VAS and external fetal monitoring strips were used for analysis. Findings indicated that there was a significant difference in decreased labor pain during the active phase of the first stage of labor among the three groups. There was no significant difference in effectiveness of uterine contractions during the first stage of labor among the three groups. Results of the study confirmed the effect of LI4 and BL67 acupressure in lessening labor pain during the active phase of the first stage of labor. There were no verified effects on uterine contractions.","ISSN":"1682-3141","note":"PMID: 14685931","journalAbbreviation":"J Nurs Res","language":"eng","author":[{"family":"Chung","given":"Ue-Lin"},{"family":"Hung","given":"Li-Chiao"},{"family":"Kuo","given":"Su-Chen"},{"family":"Huang","given":"Chun-Liang"}],"issued":{"date-parts":[["2003",12]]},"PMID":"14685931"}}],"schema":""} 30How To Use LI4: LI4 is located in the soft fleshy web between the thumb and forefinger. Apply firm pressure to LI4 for the duration of each contraction, over 20 minutes at the onset of active labor. Appendix H: Occiput Posterior Position At onset of labor 15-30% of fetuses are occiput posterior (OP) in relation to the maternal pelvis, and 1/3 are OP sometime during labor. Most OP fetuses rotate on their own, leaving only 3-8% being OP at birth. On the whole, OP position is underdiagnosed. Identifying persistently OP fetuses is important because the position is associated with: Increase in prolonged pregnancy (12% v 7% p<.001)oxytocin induction (31% v 16% p<.001) and oxytocin augmentation (52% v 32% p<.001)Prolonged labor lasting more than 12 hours (12% v 1.7% p<.001)Increase in operative vaginal birth (84% v 40% p<.001) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"OH9DECMZ","properties":{"formattedCitation":"{\\rtf \\super 33\\nosupersub{}}","plainCitation":"33"},"citationItems":[{"id":27662,"uris":[""],"uri":[""],"itemData":{"id":27662,"type":"article-journal","title":"Influence of persistent occiput posterior position on delivery outcome","container-title":"Obstetrics and Gynecology","page":"1027-1031","volume":"98","issue":"6","source":"PubMed","abstract":"OBJECTIVE: To evaluate the influence of intrapartum persistent occiput posterior position of the fetal head on delivery outcome and anal sphincter injury, with reference to the association with epidural analgesia.\nMETHODS: We conducted a prospective observational study of 246 women with persistent occiput posterior position in labor during a 2-year period, compared with 13,543 contemporaneous vaginal deliveries with occiput anterior position.\nRESULTS: The incidence of persistent occiput posterior position was significantly greater among primiparas (2.4%) than multiparas (1.3%; P <.001; 95% confidence interval 1.4, 2.4) and was associated with significantly higher incidences of prolonged pregnancy, induction of labor, oxytocin augmentation of labor, epidural use, and prolonged labor. Only 29% of primiparas and 55% of multiparas with persistent occiput posterior position achieved spontaneous vaginal delivery, and the malposition was associated with 12% of all cesarean deliveries performed because of dystocia. Persistent occiput posterior position was also associated with a sevenfold higher incidence of anal sphincter disruption. Despite a high overall incidence of use of epidural analgesia (47% versus 3%), the institutional incidence of persistent occiput posterior position was lower than that reported 25 years ago.\nCONCLUSION: Persistent occiput posterior position contributed disproportionately to cesarean and instrumental delivery, with fewer than half of the occiput posterior labors ending in spontaneous delivery and the position accounting for 12% of all cesarean deliveries for dystocia. Persistent occiput posterior position leads to a sevenfold increase in the incidence of anal sphincter injury. Use of epidural analgesia was not related to the malposition.","ISSN":"0029-7844","note":"PMID: 11755548","journalAbbreviation":"Obstet Gynecol","language":"eng","author":[{"family":"Fitzpatrick","given":"M."},{"family":"McQuillan","given":"K."},{"family":"O'Herlihy","given":"C."}],"issued":{"date-parts":[["2001",12]]},"PMID":"11755548"}}],"schema":""} 33 OP position is also found to be associated with increased postpartum hemorrhage and increased 3rd and 4th degree perineal lacerations. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"pYTVOvef","properties":{"formattedCitation":"{\\rtf \\super 34\\nosupersub{}}","plainCitation":"34"},"citationItems":[{"id":27664,"uris":[""],"uri":[""],"itemData":{"id":27664,"type":"article-journal","title":"Manual rotation to reduce caesarean delivery in persistent occiput posterior or transverse position","container-title":"The Journal of Maternal-Fetal & Neonatal Medicine","page":"65-72","volume":"24","issue":"1","source":"CrossRef","DOI":"10.3109/14767051003710276","ISSN":"1476-7058, 1476-4954","language":"en","author":[{"family":"Shaffer","given":"Brian L."},{"family":"Cheng","given":"Yvonne W."},{"family":"Vargas","given":"Juan E."},{"family":"Caughey","given":"Aaron B."}],"issued":{"date-parts":[["2011",1]]}}}],"schema":""} 34 Neonatal outcomes associated with OP position vs OA position: 5-minute Apgar score less than 7 ( OR 1.50, 95% CI 1.17-1.91)acidemic umbilical cord gases (OR 2.05, 95% CI 1.52-2.77)meconium-stained amniotic fluid (OR 1.29, 95% CI 1.17-1.42)birth trauma (OR 1.77, 95% CI 1.22-2.57)admission to the intensive care nursery (OR 1.57, 95% CI 1.28-1.92)longer?neonatal?stay in the hospital (OR 2.69, 95% CI 2.22-3.25) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"QRqRum0d","properties":{"formattedCitation":"{\\rtf \\super 35\\nosupersub{}}","plainCitation":"35"},"citationItems":[{"id":27665,"uris":[""],"uri":[""],"itemData":{"id":27665,"type":"article-journal","title":"The association between persistent occiput posterior position and neonatal outcomes","container-title":"Obstetrics and Gynecology","page":"837-844","volume":"107","issue":"4","source":"PubMed","abstract":"OBJECTIVE: To examine the effect of persistent occiput posterior position on neonatal outcome.\nMETHODS: This is a retrospective cohort study of 31,392 term, cephalic, singleton births. Women with neonates born in persistent occiput posterior position at delivery were compared to those with occiput anterior position. Women with occiput transverse position were excluded. The association between occiput posterior position and neonatal outcomes, including 5-minute Apgar scores, umbilical cord gases, meconium-stained amniotic fluid, meconium aspiration syndrome, birth trauma, admission to the intensive care nursery, and length of stay were examined using chi(2) and Student t tests. Potential confounders (maternal age, ethnicity, parity, gestational age, epidural anesthesia, labor induction, length of labor, meconium, chorioamnionitis, birth weight, and year of delivery) were controlled for by using multivariable logistic regression and linear regression analyses.\nRESULTS: There were 2,591 (8.2%) neonates delivered in occiput posterior position of the total cohort of 31,392 deliveries. Compared with occiput anterior, neonates delivered in occiput posterior position had higher risks for adverse outcomes, including 5-minute Apgar score less than 7 (odds ratio [OR] 1.50, 95% confidence interval [CI] 1.17-1.91), acidemic umbilical cord gases (OR 2.05, 95% CI 1.52-2.77), meconium-stained amniotic fluid (OR 1.29, 95% CI 1.17-1.42), birth trauma (OR 1.77, 95% CI 1.22-2.57), admission to the intensive care nursery (OR 1.57, 95% CI 1.28-1.92), and longer neonatal stay in the hospital (OR 2.69, 95% CI 2.22-3.25).\nCONCLUSION: Persistent occiput posterior position at delivery is associated with higher risks of adverse neonatal outcomes compared with neonates delivered in the occiput anterior position. This information may be important in counseling women who experience persistent occiput posterior position in labor.\nLEVEL OF EVIDENCE: II-2.","DOI":"10.1097/01.AOG.0000206217.07883.a2","ISSN":"0029-7844","note":"PMID: 16582120","journalAbbreviation":"Obstet Gynecol","language":"eng","author":[{"family":"Cheng","given":"Yvonne W."},{"family":"Shaffer","given":"Brian L."},{"family":"Caughey","given":"Aaron B."}],"issued":{"date-parts":[["2006",4]]},"PMID":"16582120"}}],"schema":""} 35 Clinical signs of a fetus in occiput posterior position include: premature urge to push, prolonged labor, and contraction coupling. Low back pain has been long thought to be associated with the occiput posterior position, but this feature may or may not be present and is not be a reliable indicator of OP. Ultrasound is the most accurate method for diagnosing OP position. Transabdominal ultrasound is reasonably accurate with an error rate of 6-8%, but can be difficult if the fetal head is deeply engaged. Transperineal ultrasound likely has highest accuracy, but is more intrusive. This method involves placing the transducer transverse on the vulva midway between the perineum and clitoris. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"FsiLEBs9","properties":{"formattedCitation":"{\\rtf \\super 36\\nosupersub{}}","plainCitation":"36"},"citationItems":[{"id":27667,"uris":[""],"uri":[""],"itemData":{"id":27667,"type":"article-journal","title":"Comparison of transvaginal sonography with digital examination and transabdominal sonography for the determination of fetal head position in the second stage of labor","container-title":"American Journal of Obstetrics and Gynecology","page":"381-386","volume":"193","issue":"2","source":"PubMed","abstract":"OBJECTIVE: Precise determination of fetal head position in labor is a prerequisite for safe instrumental deliveries, and essential for the assessment of labor progress. Recent studies have cast serious doubts on the accuracy of the time-honored digital vaginal examination (DVE) in comparison to transabdominal ultrasound scans (TUS). However, transabdominal imaging is technically difficult with a deeply engaged fetal head in the second stage of labor. We examined the accuracy and time requirements of transvaginal scans (TVS) in the second stage of labor for determination of fetal head position.\nSTUDY DESIGN: Sixty laboring women in the second stage of labor with a deeply engaged fetal head were examined by experienced nurse midwives and senior residents. Fetal head position was recorded as \"time on a 12-hour clock.\" Subsequently, TUS and TVS were independently performed by a skilled sonographer. Accuracy and time requirements for all 3 examinations were recorded.\nRESULTS: Fetal head position could be determined in all cases by TVS, but not in 7 cases and 9 cases by DVE and TUS, respectively (P < .03; P < .008). A discrepancy of 60 degrees or more between the DVE and TUS or TVS was found in 13/60 cases (21.7%) and 14/60 cases (23.3%), respectively. A > or = 90 degrees discrepancy was found in 9/60 cases (15%) and 12/60 cases (20%), respectively (P < .02 for comparison of TUS and TVS). In 5 cases, the digital examination erroneously perceived an occiput posterior position as occiput anterior. No significant differences in fetal head position were detected between TUS and TVS, when the examination was technically feasible. The mean time (+/-SD) required for determining fetal head position was shortest for TVS (8.7 +/- 5.8 seconds) in comparison to DVE (22.7 +/- 14.6 seconds; P < .0001) or TAS (31.7 +/- 19.1 seconds; P < .0001).\nCONCLUSION: Transvaginal sonography was the most successful and accurate method for determination of fetal head position in the second stage of labor, and required the least time for performance. We believe that TVS should be routinely performed in the labor room setting for the determination of fetal head position.","DOI":"10.1016/j.ajog.2004.12.011","ISSN":"0002-9378","note":"PMID: 16098859","journalAbbreviation":"Am. J. Obstet. Gynecol.","language":"eng","author":[{"family":"Zahalka","given":"Neriman"},{"family":"Sadan","given":"Oscar"},{"family":"Malinger","given":"Gustav"},{"family":"Liberati","given":"Marco"},{"family":"Boaz","given":"Mona"},{"family":"Glezerman","given":"Marek"},{"family":"Rotmensch","given":"Sigi"}],"issued":{"date-parts":[["2005",8]]},"PMID":"16098859"}}],"schema":""} 36 Appendix I: Manual RotationManual rotation is a safe and effective option for correcting persistent occiput posterior position (OP). 73% of attempts result in a successful rotation. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"fteWqA3G","properties":{"formattedCitation":"{\\rtf \\super 34\\nosupersub{}}","plainCitation":"34"},"citationItems":[{"id":27664,"uris":[""],"uri":[""],"itemData":{"id":27664,"type":"article-journal","title":"Manual rotation to reduce caesarean delivery in persistent occiput posterior or transverse position","container-title":"The Journal of Maternal-Fetal & Neonatal Medicine","page":"65-72","volume":"24","issue":"1","source":"CrossRef","DOI":"10.3109/14767051003710276","ISSN":"1476-7058, 1476-4954","language":"en","author":[{"family":"Shaffer","given":"Brian L."},{"family":"Cheng","given":"Yvonne W."},{"family":"Vargas","given":"Juan E."},{"family":"Caughey","given":"Aaron B."}],"issued":{"date-parts":[["2011",1]]}}}],"schema":""} 34 An RCT of 731 women who had manual rotation (MR) compared to 3000 who did not undergo MR showed MR to be associated with the following pared to expectant management, women with manual rotation were less likely to have: cesarean delivery [(aOR) 0.12; 95% CI (0.09-0.16)], severe perineal laceration [aOR 0.64; 95% CI (0.47-0.88)], postpartum hemorrhage [aOR 0.75; 95% CI (0.62-0.98)], chorioamnionitis [aOR 0.68; (0.50-0.92)]. The number of rotations attempted to avert one CD was 4. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"GqkgFtRx","properties":{"formattedCitation":"{\\rtf \\super 34\\nosupersub{}}","plainCitation":"34"},"citationItems":[{"id":27664,"uris":[""],"uri":[""],"itemData":{"id":27664,"type":"article-journal","title":"Manual rotation to reduce caesarean delivery in persistent occiput posterior or transverse position","container-title":"The Journal of Maternal-Fetal & Neonatal Medicine","page":"65-72","volume":"24","issue":"1","source":"CrossRef","DOI":"10.3109/14767051003710276","ISSN":"1476-7058, 1476-4954","language":"en","author":[{"family":"Shaffer","given":"Brian L."},{"family":"Cheng","given":"Yvonne W."},{"family":"Vargas","given":"Juan E."},{"family":"Caughey","given":"Aaron B."}],"issued":{"date-parts":[["2011",1]]}}}],"schema":""} 34Risks: Women who had a trial of rotation had an increased risk of cervical laceration [aOR 2.46; (1.1-5.4)].*aOR: adjusted odds ratioTips for manual rotation: There is no data to guide how to do it, or when to do it. If vertex is +3 station it is very difficult. 0 to +1 station is better Cervical dilation of 7 cm or more is thought to be ideal Membranes must be ruptured Use ultrasound to confirm OP position and to locate the fetal spine to guide the direction of your rotation of the fetal head. Need for anesthesia is very individual. Many women tolerate it well without anesthesia *Document informed verbal consent and include the following: Risks of the procedure: cervical laceration and cord prolapse (if done vigorously or if there is a large de-station of the fetal head). Procedure is not associated with fetal distress. The procedure may be uncomfortable, and anesthesia is optional. Procedure is highly successful (73%), but failure is a possibility. Two proposed methods for manual rotation1. Spread fingers over posterior parietal bone, cradle head with fingers (maybe thumb on top side of head), slightly lift the head upward (“de-station the head”) and rotate the head just before a contraction. Hold it there during a contraction while mom pushes to fix it into the new position. Best used if cervix is greater than 7-8 cm dilated. 2. Two fingers on sagittal suture, “like fingertip pull-up in rock climbing”. This is best for when the cervix is not completely dilated, or there is a concern about cervical laceration.References ADDIN ZOTERO_BIBL {"custom":[]} CSL_BIBLIOGRAPHY 1. Spong CY, Berghella V, Wenstrom KD, Mercer BM, Saade GR. Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver national institute of child health and human development, society for maternal-fetal medicine, and American college of obstetricians and gynecologists workshop. Obstet Gynecol. 2012;120(5):1181.2. Caughey AB, Cahill AG, Guise J-M, Rouse DJ. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol. 2014;210(3):179-193. doi:10.1016/j.ajog.2014.01.026.3. Henry DEM, Cheng YW, Shaffer BL, Kaimal AJ, Bianco K, Caughey AB. Perinatal Outcomes in the Setting of Active Phase Arrest of Labor: Obstet Gynecol. 2008;112(5):1109-1115. doi:10.1097/AOG.0b013e31818b46a2.4. Rouse DJ, Weiner SJ, Bloom SL, et al. Second-stage labor duration in nulliparous women: relationship to maternal and perinatal outcomes. Am J Obstet Gynecol. 2009;201(4):357.e1-e357.e7. doi:10.1016/j.ajog.2009.08.003.5. Cheng YW, Hopkins LM, Laros RK, Caughey AB. Duration of the second stage of labor in multiparous women: maternal and neonatal outcomes. Am J Obstet Gynecol. 2007;196(6):585.e1-e6. doi:10.1016/j.ajog.2007.03.021.6. Allen VM, Baskett TF, O’Connell CM, McKeen D, Allen AC. Maternal and Perinatal Outcomes With Increasing Duration of the Second Stage of Labor: Obstet Gynecol. 2009;113(6):1248-1258. doi:10.1097/AOG.0b013e3181a722d6.7. Cheng YW, Shaffer BL, Nicholson JM, Caughey AB. Second Stage of Labor and Epidural Use: A Larger Effect Than Previously Suggested. Obstet Gynecol. 2014;123(3):527-535. doi:10.1097/AOG.0000000000000134.8. Friedman EA. Primigravid labor; a graphicostatistical analysis. Obstet Gynecol. 1955;6(6):567-589.9. Zhang J, Landy HJ, Ware Branch D, et al. Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes: Obstet Gynecol. 2010;116(6):1281-1287. doi:10.1097/AOG.0b013e3181fdef6e.10. ACOG Practice Bulletin Number 49, December 2003: Dystocia and Augmentation of Labor. Obstet Gynecol. 2003;102(6):1445-1454. doi:10.1016/j.obstetgynecol.2003.10.011.11. Lee KA, Gay CL. Sleep in late pregnancy predicts length of labor and type of delivery. Am J Obstet Gynecol. 2004;191(6):2041-2046. doi:10.1016/j.ajog.2004.05.086.12. Direkvand-Moghadam A, Rezaeian M. Increased intravenous hydration of nulliparas in labor. Int J Gynecol Obstet. 2012;118(3):213-215. doi:10.1016/j.ijgo.2012.03.041.13. Simpkin P, Ancheta R. The Labor Progress Handbook. third edition. Wiley-Blackwell; 2013.14. Neal JL, Lamp JM, Buck JS, Lowe NK, Gillespie SL, Ryan SL. Outcomes of Nulliparous Women With Spontaneous Labor Onset Admitted to Hospitals in Preactive Versus Active Labor. J Midwifery Womens Health. 2014;59(1):28-34. doi:10.1111/jmwh.12160.15. Hosek C, Faucher MA, Lankford J, Alexander J. Perceptions of Care in Women Sent Home in Latent Labor: MCN Am J Matern Nurs. 2014;39(2):115-121. doi:10.1097/NMC.0000000000000015.16. Scrutton MJ, Metcalfe GA, Lowy C, Seed PT, O’Sullivan G. Eating in labour. A randomised controlled trial assessing the risks and benefits. Anaesthesia. 1999;54(4):329-334.17. Tuuli MG, Frey HA, Odibo AO, Macones GA, Cahill AG. Immediate Compared With Delayed Pushing in the Second Stage of Labor: A Systematic Review and Meta-Analysis. Obstet Gynecol. 2012;120(3):660-668. doi:10.1097/AOG.0b013e3182639fae.18. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. In: The Cochrane Collaboration, ed. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2013. . Accessed February 19, 2016.19. World Health Organization, Maternal and Newborn Health/Safe Motherhood Unit. Care in normal birth: A practical guide. 1996. . Accessed February 19, 2016.20. Lawrence A, Lewis L, Hofmeyr GJ, Styles C. Maternal positions and mobility during first stage labour. In: The Cochrane Collaboration, ed. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2013. . Accessed February 19, 2016.21. Adachi K, Shimada M, Usui A. The relationship between the parturient’s positions and perceptions of labor pain intensity. Nurs Res. 2003;52(1):47-51.22. Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for women without epidural anaesthesia. In: The Cochrane Collaboration, ed. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2012. . Accessed February 19, 2016.23. Kemp E, Kingswood CJ, Kibuka M, Thornton JG. Position in the second stage of labour for women with epidural anaesthesia. In: The Cochrane Collaboration, ed. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2013. . Accessed February 19, 2016.24. Cluett ER, Pickering RM, Getliffe K, St George Saunders NJ. Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour. BMJ. 2004;328(7435):314. doi:10.1136/bmj.37963.606412.EE.25. Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database Syst Rev. 2009;(2):CD000111. doi:10.1002/14651858.CD000111.pub3.26. Wei S, Wo BL, Qi H-P, et al. Early amniotomy and early oxytocin for prevention of, or therapy for, delay in first stage spontaneous labour compared with routine care. In: The Cochrane Collaboration, ed. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2013. . Accessed February 19, 2016.27. Tan PC, Jacob R, Omar SZ. Membrane sweeping at initiation of formal labor induction: a randomized controlled trial. Obstet Gynecol. 2006;107(3):569-577. doi:10.1097/01.AOG.0000200094.89388.70.28. Boulvain M, Stan C, Irion O. Membrane sweeping for induction of labour. Cochrane Database Syst Rev. 2005;(1):CD000451. doi:10.1002/14651858.CD000451.pub2.29. Smith CA, Collins CT, Crowther CA, Levett KM. Acupuncture or acupressure for pain management in labour. In: The Cochrane Collaboration, ed. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2011. . Accessed February 19, 2016.30. Chung U-L, Hung L-C, Kuo S-C, Huang C-L. Effects of LI4 and BL 67 acupressure on labor pain and uterine contractions in the first stage of labor. J Nurs Res JNR. 2003;11(4):251-260.31. Lee MK, Chang SB, Kang D-H. Effects of SP6 acupressure on labor pain and length of delivery time in women during labor. J Altern Complement Med N Y N. 2004;10(6):959-965. doi:10.1089/acm.2004.10.959.32. Hamidzadeh A, Shahpourian F, Orak RJ, Montazeri AS, Khosravi A. Effects of LI4 Acupressure on Labor Pain in the First Stage of Labor. J Midwifery Womens Health. 2012;57(2):133-138. doi:10.1111/j.1542-2011.2011.00138.x.33. Fitzpatrick M, McQuillan K, O’Herlihy C. Influence of persistent occiput posterior position on delivery outcome. Obstet Gynecol. 2001;98(6):1027-1031.34. Shaffer BL, Cheng YW, Vargas JE, Caughey AB. Manual rotation to reduce caesarean delivery in persistent occiput posterior or transverse position. J Matern Fetal Neonatal Med. 2011;24(1):65-72. doi:10.3109/14767051003710276.35. Cheng YW, Shaffer BL, Caughey AB. The association between persistent occiput posterior position and neonatal outcomes. Obstet Gynecol. 2006;107(4):837-844. doi:10.1097/01.AOG.0000206217.07883.a2.36. Zahalka N, Sadan O, Malinger G, et al. Comparison of transvaginal sonography with digital examination and transabdominal sonography for the determination of fetal head position in the second stage of labor. Am J Obstet Gynecol. 2005;193(2):381-386. doi:10.1016/j.ajog.2004.12.011. ................
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