New labor management guidelines and changes in cesarean delivery patterns

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Abstract

Background

In 2010 the Consortium on Safe Labor published labor curves. It was proposed that the rate of cesarean delivery could be lowered by avoiding the diagnosis of arrest of dilation before 6 cm. However, there is little information on the uptake of the guidelines and on changes in cesarean delivery rates that may have occurred.

Objective

The objective of the study was to test the following hypotheses: (1) among patients laboring at term, rates of arrest of dilation disorders have decreased, leading to a decrease in the rate of cesarean delivery; (2) in the second stage, pushing duration prior to diagnosis of arrest of descent has increased, also leading to a reduction in the rate of cesarean delivery for this indication. As a secondary aim, we investigated changes in maternal and neonatal morbidity.

Study Design

This was a secondary analysis of a prospective cohort study of all patients presenting at ≥37 weeks’ gestation from 2010 through 2014 with a nonanomalous vertex singleton and no prior history of cesarean delivery. Rates of cesarean delivery, arrest of dilation, and changes in rates of maternal and neonatal morbidity were calculated in crude and adjusted models. Cervical dilation at diagnosis of the arrest of dilation, time spent at the maximal dilation prior to diagnosis of arrest of dilation, and time in the second stage prior to the diagnosis of arrest of descent were compared over the study period.

Results

There were 7845 eligible patients. The cesarean delivery rate in 2010 was 15.8% and, in 2014, 17.7% (P trend = .51). In patients undergoing cesarean delivery for the arrest of dilation, the median cervical dilation at the time of cesarean delivery was at 5.5 cm in 2010 and 6.0 cm in 2014 (P trend = .94). In these patients, there was an increase in the time spent at last dilation: 3.8 hours in 2010 to 5.2 hours in 2014 (P trend = .02). There was no change in the frequency of patients diagnosed with the arrest of dilation at <6 cm: 51.4% in 2010 and 48.6% in 2014 (P trend = .56). However, in these patients, the median time spent at the last cervical dilation was 4.0 hours in 2010 and 6.7 hours in 2014 (P trend = .046). There were 206 cesarean deliveries for the arrest of descent. The median pushing time in these patients increased in multiparous patients from 1.1 hours in 2010 to 3.4 hours in 2014 (P trend = .009); in nulliparous patients these times were 2.7 hours in 2010 and 3.8 hours in 2014 (P trend = .09). There was a significant trend toward increasing adverse neonatal and maternal outcomes (P < .001 for each). The adjusted odds ratio for adverse maternal outcome for 2014 compared with 2010 was 1.66 (95% confidence interval, 1.27–2.17); however, considering only transfusion, hemorrhage, or infection, there was no difference (P trend = .96). The adjusted odds ratio of adverse neonatal outcome in 2014 compared with 2010 was 1.80 (95% confidence interval, 1.36–2.36).

Conclusion

Despite significant changes in labor management that have occurred over the initial years since publication of the new labor curves and associated guidelines, the primary cesarean delivery rate was not reduced and there has been an increase in maternal and neonatal morbidity in our institution. A randomized controlled trial is needed.

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