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Management of Spontaneous Labour at Term in Healthy Women

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Management of Spontaneous Labour at Term in Healthy Women SOGC CLINICAL PRACTICE GUIDELINE No. 336, September 2016 Management of Spontaneous Labour at Term in Healthy Women This Clinical Practice Guideline has been prepared by the Barbara Parish, MD, Halifax NS Clinical Practice Obstetrics Committee, reviewed by the SPECIAL CONTRIBUTOR Family Physician Advisory, Maternal Fetal Medicine, Medico- Legal and Obstetrical Content Review Committees, and Roanne Preston, MD, Vancouver BC approved by the Board of the Society of Obstetricians and Gynaecologists of Canada. Jennifer Hutcheon, PhD, Vancouver BC Corinne Riddell, PhD, Montreal QC PRINCIPAL AUTHORS Disclosure statements have been received from all members of Lily Lee, RN, Vancouver BC the committee. Jessica Dy, MD, Ottawa ON The authors wish to acknowledge the expertise and support of the Hussam Azzam, MD, Thompson MB SOGC Obstetrical Content Review committee in completing this guideline. CLINICAL PRACTICE OBSTETRICS COMMITTEE MEMBERS Hussam Azzam (Chair), MD, Thompson MB Abstract Jon Barrett, MD, Toronto ON Objective: The purpose of this guideline is to provide guidance Anne Biringer, MD, Toronto ON for the intrapartum management of spontaneous labour, whether Kim Campbell, RM, Vancouver BC normal or abnormal, in term, healthy women, and to provide fi Louise Duperron, MD, Kirkland QC guidance in the management of rst and second stage dystocia to increase the likelihood of a vaginal birth and optimize birth Jessica Dy, MD, Ottawa ON outcomes. Ellen Giesbrecht, MD, Vancouver BC Evidence: Published literature was retrieved through searches of Lisa Graves, MD, Toronto ON PubMed and the Cochrane Library in October 2011 using appropriate, controlled vocabulary (e.g., labour pain; labour, Michael Helewa, MD, Winnipeg MB obstetric; dystocia) and key words (e.g., obstetric labor, perineal Ian Lange, MD, Calgary AB care, dysfunctional labor). When appropriate, results were restricted to systematic reviews, randomized control trials/controlled clinical Lily Lee, RN, Vancouver BC trials, and observational studies. Results were limited to the last 10 Suzanne Muise, MD, Bedford NS years. Searches were updated on a regular basis and incorporated in the guideline up to June 15, 2015. Values: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Key Words: management of labour, labour dystocia, first stage Preventive Health Care (Table 1). labour, second stage labour, third stage labour http://dx.doi.org/10.1016/j.jogc.2016.04.093 Summary Statements 1. The duration of the first stage of labour increases with maternal age and body mass index. (II-2) e J Obstet Gynaecol Can 2016;38(9):843 865 2. In low-risk nulliparous women in the active phase of labour (i.e., Copyright ª 2016 The Society of Obstetricians and Gynaecologists of equal to or greater than 4 cm dilatation), progress of cervical Canada/La Société des obstétriciens et gynécologues du Canada. dilatation greater than or equal to 0.5 cm/hour is considered Published by Elsevier Inc. All rights reserved. normal. (II-2) This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the publisher. SEPTEMBER JOGC SEPTEMBRE 2016 l 843 SOGC CLINICAL PRACTICE GUIDELINE Table 1. Key to evidence statements and grading of recommendations, using the ranking of the Canadian Task Force on Preventive Health Care Quality of evidence assessment* Classification of recommendations† I: Evidence obtained from at least one properly randomized A. There is good evidence to recommend the clinical preventive action controlled trial B. There is fair evidence to recommend the clinical preventive action II-1: Evidence from well-designed controlled trials without C. The existing evidence is conflicting and does not allow to make a randomization recommendation for or against use of the clinical preventive action; II-2: Evidence from well-designed cohort (prospective or retro- however, other factors may influence decision-making spective) or caseecontrol studies, preferably from more than D. There is fair evidence to recommend against the clinical preventive one centre or research group action II-3: Evidence obtained from comparisons between times or places E. There is good evidence to recommend against the clinical preven- with or without the intervention. Dramatic results in uncontrolled tive action experiments (such as the results of treatment with penicillin in L. There is insufficient evidence (in quantity or quality) to make a the 1940s) could also be included in the category recommendation; however, other factors may influence decision- III: Opinions of respected authorities, based on clinical experi- making ence, descriptive studies, or reports of expert committees *The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care. †Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care. 3. Each labour unit should have a guideline for opioid use during labour 3. Women should be informed of the benefits of upright positioning in that includes the method of action, average and maximum doses, labour and encouraged and assisted to assume whatever positions route of administration, possible maternal and fetal side effects, they find most comfortable. (I-B) precautions, and opioid antagonists and resuscitative measures for 4. Women who are at low risk of requiring general anesthesia should each drug. (III) have the choice to eat or drink as desired or tolerated in labour. (I-A) 4. Epidural analgesia provides the most effective pain relief for women 5. Continuous labour support is recommended for all women in active in labour. The timing of initiation of labour epidural is dependent on labour. Each labour unit should aim to provide the opportunity for ’ the woman s choice once the diagnosis of labour has been estab- each woman to receive continuous 1-to-1 labour support. (I-A) lished. (I) 6. Amniotomy and oxytocin, in addition to other measures, should be Recommendations considered once a diagnosis of dystocia has been made in either the first or second stage of labour. (I-B) 1. Health care providers should delay term labour admission to the birthing unit until active labour (i.e., equal to or greater than 4 cm 7. Women and health care providers should have information about dilatation) is established. (II-2A) coping strategies for early labour and mechanisms for accessing support from caregivers. (III-A) 2. Documentation and communication of labour progress are impor- tant aspects of labour management. Labour and delivery units 8. When appropriate, health care providers should support women in should establish local policy regarding labour documentation, their choice of analgesic options in labour. These may include including partogram use and its application in labour management. pharmacological and non-pharmacological measures. (III-A) (III-A) 9. Each woman should be provided with evidence-based information about labour analgesia options prior to the onset of labour and offered ample opportunity to discuss the risks and benefits of each option available at her planned site of delivery. (III-A) ABBREVIATIONS 10. The use of meperidine as labour analgesia should be avoided due to its long-acting active metabolites and negative effects on AMTSL active management of the third stage of labour neonatal behaviours. (II-2B) BMI body mass index 11. Low-dose epidural, when available, is preferred over high-dose CCT controlled cord traction epidural for labour analgesia and in promoting mobility in labour. (I-A) CLS continuous labour support 12. Women who receive an epidural should be encouraged to maintain mobility and flexibility in positions of comfort throughout labour. (I-B) CS Caesarean section 13. Once an epidural has been established, the infusion should be IUPC intrauterine pressure catheter continued until completion of the third stage of labour. (I-A) IV intravenous 14. Pushing, as a component of second stage progress, may commence OASIS obstetrical anal sphincter injuries when the cervix is fully dilated, the presenting part is confirmed to be PCEA patient-controlled epidural analgesia engaged, and the woman feels an urge to push. (III-A) PPH postpartum hemorrhage 15. Delayed pushing is preferred when the woman has no urge to push, particularly if the presenting part is above station þ2 and/or RCT randomized controlled trial in a non-occiput anterior position, assuming the fetus does not SOGC Society of Obstetricians and Gynaecologists of Canada display abnormal monitoring and the pregnant woman’s status is satisfactory. (I-A) TENS transcutaneous electrical nerve stimulation 844 l SEPTEMBER JOGC SEPTEMBRE 2016 Management of Spontaneous Labour at Term in Healthy Women 16. Delay of pushing according to parity and the presence or absence recommended that every obstetrical unit have an identified and of an epidural should follow the time limits described in the text accessible protocol that includes a starting dose, increment in- unless there are extenuating circumstances. (II-2B) terval, and maximum dose. Consistent use of 1 standard 17. The method of pushing, spontaneous or directed with Valsalva approach to oxytocin administration in any 1 obstetrical unit manoeuvre, should be chosen using the woman’s own preference. should be considered. (III-A) fi Directed pushing may assist with the nal expulsion of the head. (II-2B) 23. Operative delivery less than 2 hours after commencing pushing is 18. Avoid the use of routine episiotomy in spontaneous vaginal births. (I-A) not recommended, provided maternal status and fetal surveillance 19. Prophylactic oxytocics should be given after the delivery of the are normal. (III-D) baby.
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