PQCNC SIVB LS3 Labor Induction in Nulliparous Patients

7/28/2019 PQCNC SIVB LS3 Labor Induction in Nulliparous Patients

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Labor Induction in

Nulliparous Patients

PQCNC Spring Meeting

April 9, 2013


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Arthur Ollendorff, MDMedical Director

MAHEC OB/GYN Specialists

Asheville, NC

Clinical Professor of OB/GYN

University of North Carolina SOM

[email protected]


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Objectives

Summarize the statistics andevidence behind induction of labor

(IOL) Review the Community Care of North

Carolina (CCNC) Pregnancy Medical

Home pathway for induction of

nulliparous patients


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Induction of Labor

Rates have been increasing over thepast 20 years

Reasons are unclear but may includelPatient/Provider preferencel Increasing medical complications

among pregnant womenlAccess to care in certain areas


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0

5

10

15

20

25

30

35

1990 2000 2005 2008

IOL

C/S

US Births: Rates of Cesarean

Delivery and Induction of Labor

U.S. National Center for Health Statistics

Percent


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U.S. Induction Rate Change by

Gestational Age (1990-2005)

National Vital Statistics Reports; Vol 56, no 6.


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NC Births: Rates of Cesarean Delivery and

Induction of Labor (2007-2011)

0

5

10

15

20

25

30

35

2007 2008 2009 2011

IOL

C/S

The Baby Book. NC State Center for Health Statistics


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IOL Is Not a Bad Thing

Critical to distinguish elective frommedically indicated induction

lPatient counselinglPatient safetylData collection

Elective IOL is necessary at times butshould be used judiciously


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Obstetrics is a Balance


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In order to review any IOL

pathway

1. What are the medical indications forIOL?

2. What are the risks of IOL?3. What is a failed induction?4. How can we choose the patients

most likely to have a successful IOL?


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Medical Indications for IOL

There is some consensus and far lessdata to support the best practice for

induction of labor in certain clinicalsituations

There are some guidelines that existbased primarily on expert opinion


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Medical Indications for IOL

Abruptio placentae Chorioamnionitis Fetal demise Gestational hypertension Preeclampsia, eclampsia Premature rupture of membranes Post-term pregnancy Maternal medical conditions (eg, diabetes mellitus, renal

disease, chronic pulmonary disease, chronichypertension, antiphospholipid syndrome)

Fetal compromise (severe fetal growth restriction,isoimmunization, oligohydramnios)

Induction of Labor. ACOG Practice Bulletin No. 107. August 2009.


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Non-medical Indications for

IOL

Labor also may be induced logisticreasons

lrisk of rapid laborldistance from hospitallpsychosocial indications.

Induction of Labor. ACOG Practice Bulletin No. 107. August 2009.


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Indications and Timing for

Late Preterm Delivery

Spong et alObstetrics & Gynecology (2011) 118(2)

Condition GA

Chronic Hypertension 36-39 weeks

Mild Pre-eclampsia 37 weeks

Diabetes, well-controlled EIOL not advised

Diabetes, poorly controlled 34-39 weeks

Fetal congenital malformations 34-39 weeks

Oligohydramnios, isolated and persistent 36-37 weeks


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Latest ACOG Opinion (April 2013)

Non-medically Indicated Early-Term Deliveries. ACOGCommittee Opinion 561. April 2013


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What are the risks of IOL?

Cesarean delivery Prolonged labor Increased risk of chorioamnionitis Postpartum hemorrhage Tachysystole Neonatal morbidity


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Nullipara Rate of Cesarean Section:

Spontaneous vs. Induced Labor

0

2

4

6

8

10

12

14

16

18

20

Seyb Maslow Cammu Dublin

EIOL

Spontanous Labor

Frequen

cyofCesarean

Delivery(%)

Adapted from WA Grobman. Semin Perinatol 36:344-347


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What is a Failed Induction?

A. Not able to get patient into activelabor

B. Not achieving a vaginal deliveryC. Both


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Failed Induction

Defined as not able to achieve activelabor during the course of induction

A latent phase of as long as 18 hoursduring induction of labor in nulliparous

women allows the majority of these

women to achieve a vaginal delivery

Simon et al. Obstet Gynecol 2005; 105:7059


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Defining Arrest of Labor

Conventional Wisdom

4 cm defines active laborArrest of dilation after 2

hours of adequatecontractions in activephase

Second stage should lastno more than 3 hours

Newer Data Suggests

6 cm defines active labor Arrest of dilation after 4

hours of adequatecontractions in activephase

Second stage may last upto 4 hours

El-Sayed YY. Diagnosis and Management of Arrest Disorders:Duration to Wait. Semin Perinatol 2012; 36:374-378.


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Practical Considerations

Indication for InductionlProvider may rightfully be less patient

in a patient with severe pre-eclampsiathan for another indication

Method of InductionlFoley bulb will get a patient to 4-5 cm

fairly quickly but are they actually in

labor?


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Can We Predict Successful

IOL Candidates?

Patients with an unfavorable cervixhave a higher chance of Cesarean

delivery than those with a favorablecervix

Cervical ripening does not lower therisk of Cesarean delivery

lDecreases failed inductionlShortens time from induction to

delivery


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Bishop Score

Score of < 6 isunfavorable

Score of

8confers same

likelihood of

vaginal delivery

as spontaneouslabor


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Why Did CCNC PMH Develop

an Induction Guideline?

Judicious use of induction can helpmeet two of PMH goals

lReduction in Cesarean SectionlEliminate elective IOL prior to 39

weeks

It dovetails well with several othernational initiatives


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CherokeeGraham

Swain

Clay MaconJackson

Haywood

Madison

Buncombe

Henderson

McDowellRutherford

Polk

Burke

Cleveland

Watauga

CaldwellAlexander

CatawbaLincolnGaston

Ashe

Wilkes

AlleghanySurry

Yadkin

Iredell

Mecklenburg

Union

StanlyCabarrus

Rowan

Davie

Stokes

Forsyth

Davidson

Anson

Rockingham

Guilford

Randolph

Montgomery

Richmond

Caswell

Chatham

Orange

Person

LeeMoore

HokeScotland

Robeson

Cumberland

Harnett

Wake

Va

nce

Franklin

Warren

Johnston

Sampson

Bladen

ColumbusBrunswick

Pender

Duplin

Wayne

Wilson

Nash

HalifaxNorthhampton

Edgecombe

PittGreeneLenoir

Jones

Onslow Carteret

CravenPamlico

BeaufortHyde

Martin

Bertie

HertfordGates

WashingtonTyrrellDare

Alamance DurhamGranville

Ne

wHanover

Chowan

ar

Source:CCNCMarch2013

Legend

AccessCareNetworkSites CommunityCarePlanofEasternCarolina

AccessCareNetworkCoun?es CommunityHealthPartners

CommunityCareofWesternNorthCarolina NorthernPiedmontCommunityCare

CommunityCareoftheLowerCapeFear NorthwestCommunityCare

CarolinaCollabora?veCommunityCare PartnershipforCommunityCare

CommunityCareofWakeandJohnstonCoun?es CommunityCareoftheSandhills

CommunityCarePartnersofGreaterMecklenburg CommunityCareofSouthernPiedmont

CarolinaCommunityHealthPartnership


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CCNC Pregnancy Medical

Home Program

An outcome-driven initiative monitoredfor specific performance standards

lParticipating practices receivefinancial incentives and support fromthe local CCNC network

lPractices agree to work toward qualityimprovement goals


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Pregnancy Medical Home

Program Quality Goals

Reducing elective deliveries prior to 39weeks

Performing standardized initial riskscreening

l Collaborating with pregnancy caremanagement programs to serve high-risk

patients

Using 17P to prevent recurrent preterm birth Reducing primary Cesarean Section rate


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NC Pregnancy Medical

Pathways

Collaborative effort of the PregnancyMedical Home Physician Champions

l to promote evidence-based, bestpractice care statewide

Three pathways currently existlHypertensive Diseases in PregnancylScreening for Preterm Deliveryl Induction of Labor-Nullipara


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Choosing Wisely

An initiative by ABIM Foundation tohelp physicians and patients engage

in conversations to reduce overuse oftests and procedures

ACOG is a partner in this initiativel Identified Five Things Physicians and

Patients Should Question


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Disclaimer

Pregnancy Medical Home Care Pathways are intended to assistproviders of obstetrical care in the clinical management of

problems that can occur during pregnancy. They are intended tosupport the safest maternal and fetal outcomes for patients

receiving care at North Carolina Pregnancy Medical Homepractices. This pathway was developed after reviewing the Society

for Maternal-Fetal Medicine and the American College of

Obstetricians and Gynecologists resources such as practicebulletins, committee opinions, and Guidelines for Perinatal Care as

well as current obstetrical literature. PMH Care Pathways offer a

framework for the provision of obstetrical care, rather than aninflexible set of mandates. Clinicians should use their professional

knowledge and judgment when applying pathwayrecommendations to their management of individual patients.


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Highlights of the CCNC

Induction Pathway

Intended for nulliparous patients only Do not induce labor before 39 weeks

unless there is a medical indication Do not electively induce labor with an

unfavorable cervix before 41 weeks


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First Decision Point


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Second Decision Point


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Medical Indication Side


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Elective Indication Side


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ACOG Patient Safety

Checklist No. 5


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References used for CCNC IOL

Pathway

1. Induction of Labor. ACOG Practice Bulletin No. 107, August 20092. Fetal Lung Maturity. ACOG Practice Bulletin No. 97, September 2008.3. Spong CY, Mercer BM, DAlton M, et al. Timing of indicated late-

preterm and early-term birth. Obstet Gynecol 2011;118:323-33.

4.ACOG/ACP Guidelines for Perinatal Care, Sixth edition. WashingtonDC, November 2007.

5. Scheduling induction of labor. Patient Safety Checklist No. 5. AmericanCollege of Obstetricians and Gynecologists. Obstet Gynecol

2011;118:14734.

6. Grobman WA. Predictors of Induction Success, Semin Perinatol 2012;36:344-347

7. Swamy GK. Current Methods of Labor Induction. Semin Perinatol 2012;36:348-352.

8. El-Sayed YY. Diagnosis and Management of Arrest Disorders: Durationto Wait. Semin Perinatol 2012; 36:374-378.

Documents

PQCNC SIVB LS3 Labor Induction in Nulliparous Patients