Health Care Guideline:
Prevention, Diagnosis and Treatment of
Failure to Progress in Obstetrical Labor
General Implementation March 1998
Copyright © 1998 by Institute for Clinical Systems Integration
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Work Group Leader
Deborah Thorp, MD, HealthSystem Minnesota
Family Practice
Vicki Jacobsen, MD, Mayo Clinic
Nurse Midwife
Cherida McCall, CNM, HealthPartners
Beth Reinhart, CNM, Twin City Ob/Gyn, Ltd.
Michele Stegeman, CNM, HealthPartners
Susan Tighe, CNM, Twin City Ob/Gyn, Ltd.
Ob/Gyn
Dale Akkerman, MD, HealthSystem Minnesota
John Jefferies, MD, Mayo Clinic
Deborah Thorp, MD, HealthSystem Minnesota
Health Education
Dianne Eggen, RN, MPH, HealthPartners
Measurement Advisor
Rick Carlson, MS, HealthPartners
Buyers' Health Care Action Group Representative
Kathy Halvorson, RN, Honeywell
Facilitator
Teresa Rogstad, ICSI
This guideline is intended for a limited population. This guideline does not apply to inductions. All of the following parameters are necessary before application of the guideline is deemed appropriate:
Note that if there is any medical question about whether a patient fits these parameters, the guideline should not be applied to that patient.
Priority Aims For Medical Groups When Using This Guideline
1. To prevent unnecessary Cesarean sections associated with failure to progress.
Possible measures of accomplishing this aim:
a. Percent of births resulting in C-sections.
b. Percent of births to women included in this guideline resulting in C-sections.
2. To increase the use of procedures that assist in progress to vaginal birth.
Possible measures of accomplishing this aim:
a. Percent of women in the guideline who have SROM or early amniotomy.
b. Percent of women in the guideline with Failure to Progress diagnosis who have Oxytocin.
Clinical
Algorithm & Annotations
Hospital and/or clinic phone triage for the labor patient will include these questions. Triage staff will assess general questions from OB experience. Some questions may require more details for assessment. Generally the patient is encouraged to remain home as long as possible. The caregiver will manage any/all medical concerns according to accepted standards.
General Questions:
Specific Questions:
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Labor is defined as:
and at least two of the following:
Evidence supporting this conclusion is of class: R
Only patients who meet this definition of labor should be admitted for careful management of labor. Careful assessment of presenting patients is critical.
Patients who are not in labor should receive education which includes signs to look for, changes to assess, and reassurance that they can come back to the hospital when changes occur. A patient may be placed on "hold" status for observation. Hold patients require medical reassessment before leaving the hospital.
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Characteristics of care for a patient at time of admission to Labor & Delivery include:
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6. Amniotomy Unless Contraindicated
Amniotomy should be done early in labor unless spontaneous rupture has occurred or contraindications are present. Early amniotomy reduces the need for failure to progress protocol. It is part of the prevention of failure to progress. Contraindications include:
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7. < 1 cm Dilation x 2 consecutive hours?
Labor progress is measured in dilation of the cervix. The only way to make this assessment is to do cervical checks. Cervical checks should indicate at least 1 centimeter dilation per hour. Frequent cervical checks afford the best opportunity for prevention of failure to progress.
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8. Failure to Progress Diagnosis and Augmentation Protocol for Nullipara
Failure to Progress is defined as cervical changes of less than 1 cm per hour for 2 consecutive hours. Active management of labor reduces the rate of cesarean section for dystocia in nulliparas.
The sequence of management of labor includes:
1. Evaluation of the potential causes (check adequacy of labor with internal monitor). Adequate contractions are counted as a minimum of 200 montevideo units for a 2 hour time period.
2. Artificial Rupture Of Membranes if membranes are intact & there are no contraindications (see Annotation #6).
3. Ensure adequate analgesia as deemed appropriate by care provider:
4. Oxytocin augmentation according to hospital protocol (see common protocol as outlined in Discussion notes for step #8).
Contraindications include:
Electronic monitoring of fetal heart tones and uterine contractions is necessary when oxytocin is administered. Refer to ICSI Intrapartum Fetal Heart Rate Management guideline (Annotation #7) for criteria to guide discontinuance of oxytocin augmentation.
Because of the risk of uterine hyperstimulation an intrauterine pressure catheter should be used with any high dose oxytocin protocol.
5. Obtaining an obstetrical/surgical consult if necessary. C-section is done when patient is not making progress for 2 hours regardless of oxytocin dosage or duration of oxytocin after adequate contraction pattern has been achieved on maximum oxytocin dose appropriately used.
Conclusion Grade: II (see Conclusion Grading Worksheet in Discussion and References Appendix A.)
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When patient has reached Stage II labor a re-assessment at least every 30 minutes x2 is done to assess descent of the fetus and rotation of the fetus. If the patient is making appropriate progress the caregiver can anticipate vaginal delivery. Fetal descent should be 1 cm per hour.
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12. Management of Protraction Disorders
If the patient in Stage II Labor is not making progress, management of protraction disorders will include:
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15. Operative Vaginal Delivery Contraindicated?
When above measures fail the care giver will consider operative vaginal delivery including vacuum extraction or mid/low forceps delivery unless contraindicated. Contraindications include:
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After evaluating these options, caregiver will perform a cesarean section when necessary. Education for Vaginal Birth After Cesarean trial of labor is given before discharge. See ICSI VBAC Guideline.
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I. CLASS OF RESEARCH REPORTS
Primary Reports of New Data Collection:
Class A: Randomized, controlled trial
Class B: Prospective cohort study
Case-control study nested within a prospective cohort study
Class C: Non-randomized trial with concurrent or historical controls
Case-control study (except as above)
Retrospective cohort study
Study of sensitivity and specificity of a diagnostic test
Population-based descriptive study
Class D: Cross-sectional study
Case series
Case report
B. Reports that Synthesize or Reflect upon Collections of Primary Reports:
Class M: Meta-analysis
Decision analysis
Cost-benefit analysis
Cost-effectiveness study
Class R: Review article
Consensus statement
Consensus report
Class X: Medical Opinion
II. CONCLUSION GRADES
Key conclusions (as determined by the work group) are supported by a conclusion grading worksheet that summarizes the important studies pertaining to the conclusion. Conclusion grading worksheets are located at the end of the Discussion and References section. Individual studies are classed according to the system defined in Section I, above, and are assigned a designator of +, -, or ø to reflect the study quality. Conclusion grades are determined by the work group based on the following definitions:
Grade I: The evidence consists of results from studies of strong design for answering the question addressed. The results are both clinically important and consistent with minor exceptions at most. The results are free of serious doubts about generalizability, bias, and flaws in research design. Studies with negative results have sufficiently large samples to have adequate statistical power.
Grade II: The evidence consists of results from studies of strong design for answering the question addressed, but there is uncertainty attached to the conclusion because of inconsistencies among the results from different studies or because of doubts about generalizability, bias, research design flaws, or adequacy of sample size. Alternatively, the evidence consists solely of results from weaker designs for the question addressed, but the results have been confirmed in separate studies and are consistent with minor exceptions at most.
Grade III: The evidence consists of results from a limited number of studies of weak design for answering the question addressed. Evidence from studies of strong design is either unavailable because no studies of strong design have been done or because the studies that have been done are inconclusive due to lack of generalizability, bias, design flaws, or inadequate sample sizes.
Grade IV: The support for the conclusion consists solely of the statements of informed medical commentators based on their clinical experience, unsubstantiated by the results of any research studies.
The symbols +, -, ø and N/A found on the conclusion grading worksheets (See Discussion Appendix) are used to designate the quality of the primary research reports:
+ indicates that the report has clearly addressed issues of inclusion/exclusion, bias, generalizability, and data collection and analysis;
- indicates that these issues have not been adequately addressed;
ø indicates that the report is neither exceptionally strong or exceptionally weak;
N/A indicates that the report is not a primary reference and therefore the quality has not been assessed.
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