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.

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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

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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. (I-A) 24. When the second stage exceeds the recommended time limits (see 20. In term and preterm infants who do not require neonatal resusci- text), consideration should be given to expediting delivery. tation, delayed umbilical cord clamping for 60 seconds is recom- Extending these time limits may be appropriate in the presence of mended irrespective of the mode of delivery. (I-B) continued descent of the head, satisfactory maternal and fetal status, and imminent vaginal birth. (II-2B) 21. Dystocia should not be diagnosed prior to the onset of the active fi phase of the rst stage of labour or before the cervix is at least 4 cm 25. High-dose oxytocin regimens have been shown to decrease dilated. (II-2D) labour duration compared with low-dose regimens. The lowest 22. Oxytocin augmentation should be titrated to avoid tachysystole dose needed to produce normal progress is recommended to or excessive uterine activity and to produce a uterine contraction reduce the risk of tachysystole or excessive uterine activity pattern of 4 to 5 contractions in 10 minutes (200 Montevideo and to create a uterine contraction pattern of 3 to 5 con- units). A minimum of 4 to 6 hours of adequate uterine activity tractions or 200 or more Montevideo units every 10 minutes. may be required to achieve the desired response. (I-A) It is (I-A)

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INTRODUCTION The diagnosis of the active phase of labour requires an assessment of both uterine activity and cervical status. abour management supports the natural physiological Description of cervical status should include dilatation, Lprocess of birth while identifying potential concerns. effacement, station, consistency, and position.4 The purpose of this guideline is to provide guidance for the intrapartum management of normal and abnormal labour, to increase the likelihood of a vaginal birth, and to optimize Labour Time Frames maternal and fetal outcomes. Promotion of normal birth The mean duration and longest acceptable duration of involves a balance between non-intervention and the labour and the “normal” rates of cervical dilatation were 5 judicious use of technologies that support safe outcomes historically established by Friedman in the early 1950s. for both the mother and baby. These were based on a mixed population of women who were in either spontaneous or induced labour and with This guideline focuses on the management of spontaneous fetuses in the vertex and breech presentations and were labour in healthy women at term, with a singleton vertex established before the introduction of epidural analgesia.6 fetus with no maternal or fetal risk factors. In addition, the 7 guideline discusses the management of dystocia in the first More recently, Zhang et al. studied 1162 nulliparous and second stages of labour in the same population. women with a single term fetus in the vertex presentation in spontaneous labour who delivered vaginally and Definitions of Labour demonstrated a markedly different curve than that of

Labour: first stage Regular uterine contractions accompanied by cervical dilatation and/or effacement. The first stage of labour includes the latent and active phases. Latent phase Presence of uterine activity resulting in progressive effacement and dilatation of the cervix proceeding to active phase. It is complete when a nulliparous woman reaches 4 cm dilatation and a parous woman reaches 4 to 5 cm. Cervical length is generally less than 1 cm. Active phase Presence of a pattern of contractions leading to cervical effacement and dilatation at 4 cm or greater in a nulliparous woman or 4 to 5 cm dilatation in a parous woman. Labour: second stage Full dilatation to delivery of the baby. Passive second stage Full dilatation but without active pushing. Active second stage Full dilatation with active pushing. Labour: third stage Immediately after delivery of the baby to delivery of the placenta. Labour: fourth stage Immediately after delivery of the placenta to 1 hour postpartum. Dystocia Delayed or arrested progress in labour, irrespective of cause. In active first stage Greater than 4 hours of < 0.5 cm/hour dilatation or no dilatation over 2 hours.1 In active second stage Greater than 1 hour of active pushing without descent of the presenting part.2 Obstructed labour No cervical dilatation or descent over 2 hours despite evidence of strong contractions (caput, molding, or measured using an IUPC).

PART I: NORMAL LABOUR Friedman’s. Almost half of the women included in Zhang’s study received regional anesthesia and oxytocin augmen- Diagnosis of Labour tation. Although both labour curves depict a relatively slow The diagnosis of the active phase of labour is the single 3 rate of cervical dilatation during the latent phase, the most important factor in labour management. The onset transition from the latent to active phase is less obvious in fi of labour is de ned as regular, painful uterine contractions Zhang’s labour curve (Figure 1). Cervical dilatation from 4 resulting in progressive cervical effacement and dilatation. to 10 cm took 5.5 hours in Zhang’s curve instead of 2.5 The onset of the latent phase is often difficult to define. hours in Friedman’s curve, and the rate of cervical change Women frequently present to the hospital in the latent was noted to be more gradual. In Zhang’s curve, women in phase of labour. Health education for women and families the lowest fifth percentile for rate of cervical dilatation about when to come to the hospital, what symptoms are experienced dilatation less than 1 cm/hour. Several studies, important, and what symptoms require urgent action is an including data from a large retrospective cohort from the important component of care during pregnancy. Consortium of Safe Labor, further confirmed the findings

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Figure 1. Comparison of Friedman’s curve and Zhang’s Maternal factors 7 contemporary labour curve. Power contractions maternal expulsive efforts

During labour, palpation of uterine contractions is recom- mended to assess the uterine activity. Assessment of the strength of contractions by palpation and/or external tocody- namometry does have limitations. Manual palpation provides a subjective estimate of intensity and can be more difficult to assess when obesity is a factor. External tocodynamometry cannot accurately detect contraction strength. Using an IUPC is the only accurate method to assess the intensity of uterine contractions. An IUPC may be considered in situations in which accurate assessment of uterine contractions cannot be assessed with external tocodynamometry.11 When using an IUPC, contraction strength is considered to be adequate at 50 to 60 mmHg above baseline or > 200 Montevideo units (sum of uterine contraction pressure above baseline multiplied by the number of contractions in 10 minutes). of these more contemporaneous labour patterns.8,9 The upper limit of normal active phase dilatation appears to be Passage pelvic bony structure longer and the rate of cervical dilatation slower that those soft tissue factors (pelvic tumours, full bladder/ initially set by Friedman, ranging from 0.5 to 0.7 cm/hour rectum, vaginal septum, obesity) for nulliparous women and from 0.5 to 1.3 cm/hour for parous women. Only half of nulliparous women in the Clinical examination of the passage may reveal prominent active phase dilated at a rate greater than 1.2 cm/hour. spines or sacrum, a narrow pubic arch, or a space- Although authors from the Consortium of Safe Labor did occupying mass in the pelvis (e.g., fibroids). Neither ante- not identify labour duration for the diagnosis of dystocia in natal radiological nor clinical pelvimetry has been shown to the active phase, they suggested that the diagnosis should predict the outcome of labour.12 not be made before 6 cm of cervical dilatation. This, Psyche pain however, has yet to be evaluated.9 anxiety Multiple factors can affect the length of labour for any 10 given woman. Peisner and Rosen found that dilatation in “Hormones released in response to stress 90% of women who experienced a successful vaginal birth can . bring about dystocia. Sources of stress vary progressed at greater than or equal to 1 cm/hour after 5 for each woman, but pain and the absence of a cm. They concluded that when a woman’s cervix is not support person are the two accepted factors. rapidly dilating after reaching 5 cm, her labour is probably Confinement to bed and the restriction of maternal abnormal and should be closely evaluated. movement can also be a source of psychological stress. Maternal anxiety may inhibit normal cervical From all of the aforementioned labour studies, it is evident dilatation resulting in prolonged labour and increased that the duration of labour varies from woman to woman pain perception. Maternal anxiety also causes an and the rate of cervical change is faster in the active phase increase in the levels of stress-related hormones of the first stage of labour and in parous women. (b-endorphin, adrenocorticotropic hormone, cortisol, and epinephrine). These hormones, which fl Physiological Factors In uencing Labour act on the smooth muscle of the uterus, can lead to Successful labour and vaginal delivery depend on the dystocia by reducing uterine contractions.”13 dynamic relationship between the fetus, the maternal pelvis, and uterine and maternal power. Dystocia can be Fetal factors fi related to the dif culty with any of the 4 Ps: power, Passenger position passenger, passage, and psyche, which can influence the progress of labour and delivery. attitude

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size among 583 843 nulliparous women in Scotland between 1980 and 2005 on primary Caesarean delivery rates was abnormalities (e.g., hydrocephalus) studied by Smith et al.18 For every 5-year increase in age, The fetus should be assessed for size and position. Adequate they noted an increase of 0.49 hours in duration of labour uterine power in labour will often correct malposition, (95% CI 0.46 to 0.51). The authors also demonstrated a whereas inadequate power may result in persistent malpo- reduction in spontaneous myometrial contractile activity sition. A normal-sized infant may present an increased with increasing maternal age. diameter to the pelvis because the head is not flexed or is Obesity. A number of observational cohort studies have asynclitic. Adequate maternal/uterine power may overcome examined the relationship between maternal pre-pregnancy this problem. Use of the hands and knees position for 10 19e25 BMI and the duration of labour. Overall, the studies minutes twice daily was not found to correct an occiput have found that the duration of the first stage of labour posterior fetal position in late pregnancy.14 increases with a rising BMI. In a high-quality study of 5200 The diagnosis of true or absolute cephalopelvic dispro- deliveries in which the second stage of labour was reached, 24 portion should be limited to the uncommon instance of Norman et al. found that obese (BMI 30) nulliparous real disproportion (i.e., the inability of the well-flexed and parous women took approximately 1 hour longer to head [suboccipito bregmatic presentation] to pass dilate from 4 to 10 cm compared with women with a through the bony pelvis despite clinical evidence of normal pre-pregnancy BMI ( 25). In a smaller, second study of 612 term deliveries to nulliparous women, Vahra- adequate uterine power [caput and molding or IUPC]). 19 Malposition, on the other hand, may lead to relative tian et al. found that dilatation from 4 to 10 cm was 105 > disproportion. Accurate assessment and description minutes longer in obese (BMI 29) women, adjusted for guide management, and if a CS is performed for true labour induction and augmentation. It is likely that the true fi cephalopelvic disproportion, it will help determine suit- difference in rst stage labour duration between obese and ability for a future trial of labour after CS. non-obese women is larger than what was observed in these studies. Because obese women are more likely to undergo a fi Other factors influencing labour rst stage Caesarean delivery due to dystocia, women with the longest labour durations may have been excluded from 19e21,25 Prenatal education. Women and their partners seek prenatal the cohort. education to help them understand the process of birth The median and 95th percentile values for the duration of and the potential options related to labour, pain relief, and the first stage of labour according to maternal BMI at the infant care. The effects of various forms of prenatal edu- time of delivery admission from a large cohort of 119 000 cation on labour outcomes are largely non-conclusive and deliveries may be useful in establishing normal and abnormal have not been fully evaluated to date.15 progress.26 Table 2 shows that labour proceeds more slowly as BMI increases, suggesting that labor management should Maternal age. The average maternal age is rising. The pro- be tailored to allow for these differences. portion of women who are 35 years or over giving birth has increased steadily in the past decades.16 Older maternal Overall, there is good evidence that the duration of the age is associated with increased obstetrical and perinatal first stage of labour increases with a rise in maternal BMI. complications and increased obstetrical intervention, Biological/physiological studies27 that have examined including labour induction, oxytocin augmentation, pro- hypothesized relationships in vitro between secretions longed labour, instrumental delivery, and intrapartum from adipose tissue and characteristics of uterine Caesarean birth.16,17 The effect of delayed child-bearing contractility complement the epidemiological literature

Table 2. Adjusted duration of labour (hours) by BMI (kg/m2) categories BMI categories at admission with median (and 95th percentile) traverse times in hours Cervical dilatation 4 to 10 cm < 25 25 to 29.9 30 to 34.9 35 to 39.9 40 P value for trend Nulliparous 5.4 (18.2) 5.7 (18.8) 6.0 (19.9) 6.7 (22.2) 7.7 (25.6) < 0.0001 Parous 4.6 (17.5) 4.5 (17.4) 4.7 (17.9) 5.0 (19.0) 5.4 (20.6) < 0.0001

Adapted from Kominiarek MA, Zhang J, Vanveldhuisen P, Troendle J, Beaver J, Hibbard JU. Contemporary labor patterns: the impact of maternal body mass index. Am J Obstet Gynecol 2011;205:244.e1e8.26

848 l SEPTEMBER JOGC SEPTEMBRE 2016 Management of Spontaneous Labour at Term in Healthy Women and further elucidate the causal mechanism underlying Early labour assessment and support at home from an this relationship.20 obstetric nurse reduce the number of women presenting to the hospital in the latent phase and the number of women Summary Statement not coping with their contractions on admission compared with telephone support, but these measures did not reduce 1. The duration of the first stage of labour increases with the use of obstetrical interventions such as oxytocin, maternal age and body mass index. (II-2) epidural analgesia, or Caesarean delivery.34 Recommendation MANAGEMENT OF THE FIRST STAGE OF LABOUR 1. Health care providers should delay term labour Labour is a normal physiological process. Most women admission to the birthing unit until active labour (i.e., who enter labour spontaneously would be expected to equal to or greater than 4 cm dilation) is established. experience their labour and birth with minimal in- (II-2A) terventions.28 Any interventions to this process should be based on an identified real or potential problem. Use of unnecessary interventions (e.g., routine amniotomy) may Active Phase of the First Stage of Labour lead to further interventions, including Caesarean birth. Partogram Over the past few decades there has been a dramatic Partograms are graphical records used during active labour increase in the number of CS being performed.29 CS is to help visually assess labour progress by recording cervical associated with increased maternal morbidity and mor- dilatation and the descent of the presenting part, facilitating tality, increased neonatal morbidity, and increased health early detection of dystocia and timely intervention of care costs. Labour dystocia and elective repeat CS ac- amniotomy and oxytocin augmentation. For this purpose, count for the majority of CS being performed. Optimal some partograms include action lines to trigger the treat- management with support of the normal labour pro- ment of dystocia. cesses and the appropriate management of labour A 2013 Cochrane review that included 7706 women in 6 fi dystocia, if it occurs, could potentially lead to a signi cant randomized trials35 found no difference between the use or reduction in the primary CS rate and the number of non-use of a partogram related to outcomes of CS in women labouring in a subsequent pregnancy after a prior women presenting in spontaneous labour at term, instru- CS. mental vaginal delivery, or an Apgar score less than 7 at 5 minutes. In the single high-quality trial performed in a Latent Phase of the First Stage of Labour higher-resourced setting, there were no significant differ- Management during the latent phase of the first stage of ences between groups in these outcomes. When compared labour is controversial due to the limited number of pub- with a 4-hour action line, women in the 2-hour action line lished studies. Cohort studies have consistently shown that group were more likely to require oxytocin augmentation women presenting to the hospital in the latent phase of but showed no difference in Caesarean delivery or other labour experience increased obstetrical interventions (e.g., maternal or neonatal outcomes. When the 3- and 4-hour epidural analgesia, oxytocin use, Caesarean delivery) action lines were compared, the CS rate was 70% lower 30e32 compared with women presenting in active labour. in the 4-hour action-line group. Despite the routine use of However, because of the observational nature of these a partogram in both low- and high-resourced settings, there studies, it is unclear whether the increased level of inter- is insufficient evidence that its use results in measurable vention is due to prolonged exposure to the hospital clinical outcomes. However, given its widespread use as a environment or to underlying labour abnormalities among documentation tool in monitoring maternal/fetal status women who present earlier. One small randomized trial by and labour progress, the use of a partogram may 33 McNiven et al. found that women who received an early contribute to overall team functioning and communication. labour assessment in a triage area required less oxytocin Recommendation and epidural analgesia and reported a more positive labour and birth experience compared with women directly admitted to the labour and delivery unit. The small sample 2. Documentation and communication of labour size precluded the assessment of effects on Caesarean progress are important aspects of labour delivery and other important measures of maternal- management. Labour and delivery units should newborn outcomes. establish local policy regarding labour documentation,

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It is recognized that a healthy woman entering labour may including partogram use and its application in labour develop complications resulting in a change of her risk management. (III-A) status and labour management; clear communication and common understanding among care providers about her Ambulation and upright positioning revised risk status are critical. Policies regarding oral intake For women who do not receive epidural analgesia, in labouring women should be determined at each site by ambulation, position change, and upright positions may the health care team. fi reduce the length of the rst stage of labour and opera- Recommendation tive delivery. A 2013 Cochrane review found that women randomly assigned to upright positions (walking or up- 4. Women who are at low risk of requiring general right non-walking [e.g., sitting, standing, kneeling, squat- anesthesia should have the choice to eat or drink as ting, and all fours]) compared with recumbent positions desired or tolerated in labour. (I-A) (supine, semi-recumbent, and lateral) experienced first stages that were 82 minutes shorter and lower rates of CS, were less likely to receive epidural analgesia, and delivered Birthing companion/continuous emotional support babies that were less likely to be admitted to neonatal CLS is defined as non-medical care provided during labour intensive care. However, there was no difference in length that includes continuous presence, emotional support, of the second stage of labour or other outcomes related comfort measures, advocacy, information, and advice.38 to the well-being of mothers and babies. Interestingly, for CLS may be provided by a trained person such as a women who received epidural analgesia, there were no doula, nurse, or midwife or from a friend or family differences between those randomly assigned to upright member of the woman’s choice.39 positions versus recumbent positions for any of the outcomes examined in the review.36 A 2013 Cochrane review of over 15 000 women in low- and middle-resource settings showed that CLS increased Recommendation the likelihood of vaginal delivery, lowered the risk of Caesarean delivery, reduced the use of epidural analgesia, fi 39 3. Women should be informed of the bene ts of upright and improved Apgar scores and maternal satisfaction. positioning in labour and encouraged and assisted to Subgroup analyses showed that CLS was most effective fi assume whatever positions they nd most when the provider was not part of the hospital staff or comfortable. (I-B) from the women’s social network.40

Recommendation Eating and drinking during labour fl A 2013 Cochrane review on restricting oral uid and 5. Continuous labour support is recommended for all food intake during labour examined women in active la- women in active labour. Each labour unit should aim bour and at low risk of potentially requiring general to provide the opportunity for each woman to receive anesthesia. The investigators compared restricting continuous 1-to-1 labour support. (I-A) women to nothing except ice chips or sips of water or water alone with providing women with fluid and foods or the freedom to eat and drink at will and found no Amniotomy/artificial rupture of membranes significant differences in CS, assisted vaginal births or An RCT (n ¼ 752) comparing early amniotomy alone with Apgar scores. The pooled data were insufficient to assess expectant care found no difference in the overall Caesarean for the incidence of the rare outcome of Mendelson’s rate or neonatal outcome. Even though there was a modest syndrome (aspiration associated with general anesthesia). reduction in labour duration, investigators found more The authors concluded that there is no evidence of frequent abnormal fetal decelerations and CS performed in benefits or harms associated with restricting women’s cases in which abnormal fetal surveillance was either the access to fluids and foods during labour for women at only or contributing indication in the amniotomy group.41 low risk of potentially requiring a general anaesthetic.37 These findings suggest that in settings in which diagnosis No studies have assessed the restriction of oral fluid in of abnormal fetal surveillance is based primarily on elec- women with risk factors for induction of general anes- tronic fetal monitoring, routine early amniotomy may in- thesia; the conclusion should not be extrapolated to non- crease CS for abnormal fetal monitoring. An updated 2013 low-risk populations. Cochrane review examined routine first stage amniotomy

850 l SEPTEMBER JOGC SEPTEMBRE 2016 Management of Spontaneous Labour at Term in Healthy Women compared with no amniotomy in 5583 women whose la- labour’ should not be used unless all components of the bour started spontaneously and when labour became package of care were applied as originally described. prolonged.42 The findings showed no difference in the Further work is required to determine the acceptability of length of the first stage labour, CS, maternal satisfaction, or active management to women in labour.”47 Apgar score less than 7 at 5 minutes, concluding that Summary Statement routine amniotomy should not be standard practice. Early routine amniotomy and oxytocin augmentation were 2. In low-risk nulliparous women in the active phase of compared for the prevention or treatment of dystocia in a labour (i.e., equal to or greater than 4 cm dilatation), 2013 Cochrane review. The primary analysis that included progress of cervical dilation greater than or equal to all trials showed no difference in the risk of CS. However, 0.5 cm/hour is considered normal. (II-2) subgroup analyses found that the use of amniotomy and oxytocin for slow labour progress in unselected women undergoing normal spontaneous labour were associated Comfort Measures and Pain Relief with a modest reduction in the CS rate and labour Labour hurts. Using the McGill pain scale, the average pain duration.43 in labour equals that of amputation of a digit. Women experience a wide range of pain during labour. The severity In normally progressing labour, routine amniotomy is of and tolerance of pain are unique to each labouring woman questionable benefit and may result in more frequent and cannot be predicted reliably prior to the occurrence of variable decelerations in fetal heart rate. If amniotomy is pain. Because pain and a woman’s response to it are in- performed, it is necessary to ensure that the fetal head is dividual, women need to be aware of a variety of strategies well applied to the cervix (not ballottable) to minimize the to assist with their management of pain. Using a pain scale risk of cord prolapse. If these conditions have been met, to assess pain during labour helps to determine the need the woman is free to ambulate after amniotomy. for offering interventions and the effectiveness of those interventions. It has been suggested that in addition to a Recommendation pain scale, a coping scale be used. This differentiates those women able to cope with significant pain from those 6. Amniotomy and oxytocin, in addition to other requiring intervention.48 measures, should be considered once a diagnosis of dystocia has been made in either the first or second Some women in labour reach the limit of their pain stage of labour. (I-B) tolerance. Women experiencing excessive pain or anxiety have high endogenous catecholamines.49,50 This produces a direct inhibitory effect on uterine contractility and es- Active Management of Labour tablishes a vicious circle of poor uterine progress, leading The active management of labour was originally defined as to increased anxiety, leading to increased catecholamines, including clear criteria for the diagnosis of labour (regular and leading to further impairment of progress. The relief contractions with spontaneous rupture of membranes or of pain by effective support and analgesia may allow for complete cervical effacement), routine amniotomy in la- release of the uterus from the constraints of the endoge- bour, close attention to progress in labour, and liberal use nous catecholamines and allow for progress in labour. of high-dose oxytocin if cervical dilatation was less than 1 High endogenous catecholamine levels may adversely cm/hour. Observational studies by the initial advocates of affect uterine blood flow and therefore fetal oxygenation. active management demonstrated lower CS rates, a lower incidence of prolonged labour, better neonatal outcomes, The management of pain during labour involves more than and improved maternal satisfaction.44 Subsequent follow- the simple and timely administration of the best anesthetic up observational studies also supported these results.45,46 agent available. Successful control of pain during labour requires active management of the entire process. This pain Active management requires more interventions and cre- management should begin with prenatal education and ates a more medicalized birth process. A 2013 Cochrane counselling. Measures to enhance comfort and reduce review stated “Active management is associated with small apprehension are required for the care of all women in reductions in the CS rate, but is highly prescriptive and labour. If appropriate measures are used early in the pro- interventional. It is possible that some components of the cess of labour, analgesic needs decrease. Health care pro- active management package are more effective than others. viders who care for women in labour need to be aware We therefore suggest that the term ‘active management of of all the available options for the prevention and

SEPTEMBER JOGC SEPTEMBRE 2016 l 851 SOGC CLINICAL PRACTICE GUIDELINE management of pain. When the health care team un- 8. When appropriate, health care providers should derstands the indications, possible variations, and potential support women in their choice of analgesic options in side effects, the woman and her family are able to make labour. These may include pharmacological and non- choices in a less stressful environment. pharmacological measures. (III-A) 9. Each woman should be provided with evidence-based Non-pharmacologic pain relief information about labour analgesia options prior to A 2006 Cochrane review on complementary and alterna- fi the onset of labour and offered ample opportunity to tive therapies for labour pain management showed bene ts discuss the risks and benefits of each option available in pain reduction from self-hypnosis and acupuncture. at her planned site of delivery. (III-A) However, the study results were limited by small sample size. The efficacy of acupressure, aromatherapy, audio analgesia, and massage has not been established. The Pharmacological methodsdsystemic requirement for more 1-to-1 care in these situations may Providing satisfactory and effective pain relief in labour is a have influenced outcomes.51 primary responsibility of the health care team. Having thorough knowledge of the pharmacology of the drugs A 2009 Cochrane review on TENS reported that women used during labour is necessary to promote appropriate receiving TENS were less likely to report severe pain and and satisfactory care and to limit side effects. It is impor- most would use it again; however, there was no difference tant to understand the following: in pain scores, mode of delivery, duration of labour, use of other analgesia, or augmentation of labour.52 The analgesic Sedative and hypnotic drugs do not provide pain relief effect of TENS was found to be weak.53 and may increase respiratory depression when given in conjunction with opioids. However, in women with high A 2009 Cochrane review of 12 RCTs evaluated immersion levels of anxiety not alleviated by support and reassurance, in water during labour. Water immersion was found to sedative drugs can reduce episodes of nausea/vomiting significantly reduce the use of epidural/spinal/paracervical and enhance the analgesia obtained with opioids. fi analgesia and result in shorter duration of rst stage labour Anticholinergic side effects are common with anti- among women compared with control patients. There was fi emetics and sedatives, and care should be directed at a reduction in the duration of the rst stage of labour with recognizing and addressing discomforts. no difference in assisted vaginal deliveries, CS, oxytocin use, perineal trauma, or maternal infection. Similarly, no No drug is devoid of maternal or fetal side effects. With difference was found in Apgar score less than 7 at 5 mi- almost all pharmaceutical therapies, some amount of the nutes, neonatal unit admissions, or neonatal infection rates. drug reaches the fetus. This may interfere with the There was insufficient evidence about water immersion in success of breastfeeding. the second stage of labour. Further research was Although all opioids provide analgesic effects, some recommended.54 opioids have active metabolites that may have a very prolonged half-life in the newborn (e.g., meperidine). A 2009 systematic review of 828 women found that those Women can be medicated with opioids or an inhalational randomized to intracutaneous sterile water injections agent just before birth without causing significant res- experienced significantly reduced visual analogue scale pain piratory depression in the newborn. scores for up to 2 hours and a reduced CS rate (4.6%) compared with a saline comparison group (9.9%). How- ever, the heterogeneity and quality of trials were weak, and When the health care team understands the indications, the authors recommended a large RCT to validate their limitations, and side effects of these drugs, adverse findings.55 Additional Cochrane review of intracutaneous maternal and fetal outcomes can be minimized. Ideally, the injection of sterile water was found not to be effective for care provider should discuss options and provide written low back or any other labour pain.56 information and links to other sources of information, in appropriate languages, regarding medications, possible Recommendations variations, and potential side effects during the antenatal period. This allows the woman and her family the oppor- 7. Women and health care providers should have tunity to make decisions in a less stressful environment. information about coping strategies for early labour When labour occurs, appropriate and individually desired and mechanisms for accessing support from non-pharmacological or pharmacological agents may be caregivers. (III-A) used.

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Nitrous oxide. Entonox is a mixture of 50% nitrous oxide average and maximum doses, route of administration, and 50% oxygen that provides mild to moderate analgesia. possible maternal and fetal side effects, precautions, It must be self-administered for safety reasons via a and opioid antagonists and resuscitative measures for demand-valve and used with scavenging in a well-ventilated each drug. (III) room for workplace safety.57 Deep inhalation should begin as soon as the woman is aware of the onset of a contraction for maximal benefit. It is often useful for the Peripheral nerve blocks. The local anesthetic agents typically woman who has coped well until transition and then re- used for labour analgesia are lidocaine and bupivacaine. quires some form of analgesia for a short time. It may also Providers using these agents need to be knowledgeable be used as an adjunct during other procedures, such as about the maximum safe doses, how to calculate the dose, placement of a pudendal block or perineal repair. and the signs/symptoms of early local anesthetic toxicity. Action should be taken to prevent toxicity with all local Opioids. Opioids are widely used in many centres. A variety anesthetics. Protocols for managing local anesthetic toxicity of options are available, and opioids may be given intra- should be in place.62 muscularly, subcutaneously, or by repeated IV boluses, including patient-controlled administration. The IV route Pudendal nerve blocks. Pudendal nerve blocks are used for has the advantage of a rapid effect when needed. Opioids analgesia of the perineum in the second stage of labour. may be usefully combined with an antiemetic. A 2010 This form of analgesia can be very useful and should be Cochrane review found that parenteral opioids provide some considered when other regional analgesia is not available. pain relief in labour and were associated with maternal side Local anesthesia with epinephrine allows for the safe effects of nausea, vomiting, and drowsiness. Overall, the administration of larger volumes of anesthetic, leading to fi trials were of low quality evidence. There was insuf cient greater effectiveness as the epinephrine limits the peak evidence to recommend which opioid drug provides the best systemic levels in the mother and therefore the amount 58 pain relief with the least adverse outcomes. transferred to the fetus. An injection of 10 mL of 1% A number of studies have reported on the negative lidocaine or equivalent is made in 2 locations through or neonatal effects of opioids with a longer half-life (e.g., just inferior to the sacrospinal ligament, just medial to the 59e61 ischial spine on each side. The effect is usually felt within 3 meperidine). The negative effects are based on the active 63 metabolite half-life in the newborn that may last 2 to 3 days to 4 minutes. and may include respiratory depression and neurobehavioural fi outcomes affecting regulation of states of consciousness and Perineal infiltration. Perineal in ltration is used for repair fl 59,60 of lacerations and episiotomy. Generous and widespread re exes. The use of meperidine is discouraged, whereas fi other opioids with a shorter half-life, such as morphine or in ltration should be used. Use of an agent with fentanyl, are preferred. It is important to note that even epinephrine is helpful. Care should be taken to not inject though fentanyl is a short-acting opioid, it has a long half-life intravascularly or exceed the maximum dose. The once maximum doses have been used. maximum dose of plain lidocaine is 4 to 5 mg/kg or a single dose of 300 mg of a 1% solution. The maximum When pharmacological agents are used for pain control dose of lidocaine with epinephrine is 7 mg/kg or a 500 mg during labour, guidelines regarding their safe and effective single dose (Table 3).62 use should be available for all staff. These guidelines should include the method of action, average and Regional analgesia/anesthesia maximum doses, possible maternal and fetal side effects, precautions for use, and resuscitative measures for each Epidural block. Epidural block can provide effective pain drug. When any opioid is used, an opioid antagonist (e.g., relief throughout all stages of labour and delivery. The naloxone) and resuscitation capabilities should be available, hormonal response to pain includes a rise in endogenous with a clear protocol on how to administer the naloxone, catecholamines. The effective relief of pain lowers including appropriate dosing (because complete reversal of epinephrine concentrations and may result in improved analgesia is not a desired outcome). uterine contractions and possibly improved placental perfusion. A particular benefit of epidural analgesia Summary Statement exists for women with labour dystocia and who require augmentation. Effective pain relief may increase the 3. Each labour unit should have a guideline for opioid acceptance of augmentation and the likelihood of subse- use during labour that includes the method of action, quent vaginal delivery.

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A 2011 Cochrane review involving 9658 women showed that who were encouraged and able to ambulate to the toilet compared with an opiate or no analgesia, epidural analgesia during labour had a significantly improved ability to empty provided superior pain relief in labour, a small decrease in the bladder, avoiding urinary catheterization. neonatal acidosis, and less need for naloxone. However, fi epidural analgesia was associated with increased risk of Promoting mobility may be more bene cial than focusing assisted vaginal birth, maternal hypotension, motor on actual walking after receiving an epidural. Allowing for blockade, maternal fever, urinary retention, longer second mobility means tailoring the labour epidural to minimize “ ” stage of labour, oxytocin administration, and increased risk motor blockade. Even though no ideal epidural solution of CS for fetal distress.64 There was no significant difference mixture or PCEA program has been found, the basic in overall risk of CS, long-term backache, Apgar score less principles include the following: low-dose local anesthetic/ than 7 at 5 minutes, and maternal satisfaction with pain re- opioid mixture with a low background infusion and 64 generous patient-controlled bolus function to maintain lief. A separate 2012 meta-analysis of RCTs involving 4667 70 women showed increased neonatal septic workup and anti- analgesia without causing cumulative motor blockade. 65,66 biotic treatment in women receiving epidural analgesia. PCEA has been shown to produce greater maternal Even though it provides excellent pain relief, epidural satisfaction and excellent analgesia despite the use of low- analgesia often slows second stage labour and results in dose/very low-dose epidural solutions compared with motor blockade, which interfere with mobility and traditional continuous epidural infusion. A 2002 meta- maternal pushing efforts. analysis of 9 studies (n ¼ 640) demonstrated a lower anesthetic dose and less motor blockade with PCEA Modern epidural techniques use lower concentration of local compared with continuous epidural infusion.71 anesthetics (0.1% or less) than those used previously (up to 0.25%). In a meta-analysis of 2000 women, low-dose epi- A 2011 RCT demonstrated lower overall local anesthetic durals were as effective as high-dose epidurals at relieving dose, less motor blockade, and fewer operative vaginal de- pain but were less likely to cause motor blockade and urinary liveries with programmed intermittent bolus administration 72 retention or to interfere with ambulation.67 Compared with versus continuous epidural infusion of a local anesthetic. low-dose epidurals, high-dose epidurals are more likely to A 2009 randomized trial of 12 793 nulliparous women cause prolongation of the second stage of labour. This may reported that epidural initiation early in the first stage of be due to blockage of the natural increase in endogenous spontaneous labour (cervical dilatation of at least 1.0 cm) oxytocin that occurs in the second stage. Oxytocin does not seem to prolong labour or increase the CS rate augmentation may be necessary if contractions are infre- compared with later initiation at a cervical dilatation of 4.0 quent or ineffective. Relaxation of the pelvic floor muscu- cm or greater).73 A systematic review of over 15 000 lature may result in persistent fetal head malposition. Low- nulliparas compared early versus late initiation of labour dose epidurals are preferred because they lead to less mo- epidural; early epidural was administered prior to 4 to 5 tor blockade and therefore less malposition, a shorter second cm, whereas late epidural was administered after 4 to 5 cm stage of labour, and less hypotension. Women who received cervical dilatation. The investigators found no difference in low-dose epidurals were less likely to require assisted vaginal all measured outcomes, including CS, instrumental births, birth, although there was no difference in the CS rate.67 duration of second stage of labour, Apgar scores, and 74 Maintaining an upright position and mobility during labour umbilical arterial or umbilical venous pH. fi has been shown to be bene cial in promoting vaginal birth. Summary Statement Mobility is associated with greater maternal satisfaction when a labour epidural is providing analgesia, although that 4. Epidural analgesia provides the most effective pain may be due to the typical manner of managing a mobile relief for women in labour. The timing of initiation of d labour epidural with PCEA. Mobility does not neces- labour epidural is dependent on the woman’s choice sarily mean freely ambulating; it means labouring in a non- once the diagnosis of labour has been established. (I) recumbent position, attempting to void spontaneously, and using a non-lithotomy delivery position. Ambulation, per se, with a labour epidural has not been shown to alter birth Recommendations outcome; however, all of the studies were flawed by the fact that few women actually ambulated for a significant 10. The use of meperidine as labour analgesia should be period following epidural insertion.68 Weiniger et al.69 avoided due to its long-acting active metabolites and noted that women who received a low-dose epidural and negative effects on neonatal behaviours. (II-2B)

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Delayed Pushing 11. Low dose epidural, when available, is preferred over The 2000 PEOPLE trial randomized 1862 nulliparous high dose epidural for labour analgesia and in women who received an epidural at full dilatation to im- promoting mobility in labour. (I-A) 12. Women who receive an epidural should be mediate pushing or delayed pushing for a maximum of 2 fl hours. Women in the delayed pushing group experienced encouraged to maintain mobility and exibility in fi positions of comfort throughout labour. (I-B) more spontaneous and fewer dif cult births. This was most marked in women whose babies were above station þ2 (zero station at the level of the ischial spines) or SECOND STAGE LABOUR MANAGEMENT in a non-occiput anterior position during the early second stage.81,82 In women who do or do not receive epidural Position in Second Stage of Labour anesthesia, waiting up to 2 hours prior to the onset of ¼ A 2005 meta-analysis reported limited studies (n 281) pushing is appropriate in the presence of continued comparing the upright versus recumbent position in the sec- descent of the head and fetal and maternal status are ond stage of labour. With an upright position, there was a non- satisfactory.82,83 significant reduction in instrumental and Caesarean births and 75 a statistically significant reduction in labour duration. Two Duration of Pushing Cochrane reviews compared upright versus the recumbent There is a lack of quality evidence on defined time limits position in the second stage of labour in women who did or for the active second stage once it has commenced. Several did not receive epidural analgesia. No difference in outcomes cohort studies examining the duration of the second stage was found for women who received epidural analgesia, of labour found no evidence of adverse neonatal outcomes although the sample size was small. For women without an or increased maternal morbidity and operative deliveries e epidural, upright posture reduced the risk of operative vaginal with longer second stages.84 86 However, most studies did deliveries, episiotomy, and abnormal fetal heart rate pattern not distinguish between the passive and active phases of but increased the likelihood of second-degree perineal lacer- the second stage of labour. It appeared that the duration of 76,77 ation and blood loss over 500 mL. active pushing has more direct impact on maternal and neonatal outcomes than does the total duration of the Epidural Analgesia second stage of labour.87,88 In light of these findings, Continue the epidural. Discontinuing an epidural in the documentation of the time of the onset of active pushing is “ ” second stage of labour to allow effective pushing often important; it is reasonable that hourly reassessment of results in the sudden return of pain. This practice may be progress in fetal descent and rotation should be made to worse than if no relief had been provided at all. The woman determine whether intervention or assisted birth is may become so distressed by the pain that she cannot push required. Table 483,89 describes the recommended practices effectively. Maintaining the epidural does not significantly 78,79 for pushing by parity and use of epidural anesthesia. increase the incidence of assisted vaginal birth. A sec- Oxytocin administration may be indicated if there is evi- ondary analysis of early versus late pushing in an RCT dence of slow or lack of progress or when contractions are revealed an increased incidence of Caesarean birth, mid- assessed as being inadequate (e.g., < 200 Montevideo pelvic procedures, and third- and fourth-degree tears for units). women who reported suboptimal pain control during the 80 second stage of labour in the early pushing group. Total Duration of the Second Stage of Labour 90 Recommendation Menticoglou et al. studied the duration of the second stage of labour and perinatal outcomes. They found no 13. Once an epidural has been established, the infusion association between the duration of the second stage of should be continued until completion of the third labour and low Apgar scores at 5 minutes, neonatal sei- stage of labour. (I-A) zures, or admission to neonatal intensive care units. Limited evidence makes it difficult to a set time limit for

Table 3. Maximum dose of local anesthetic peripheral nerve blocks and infiltration Agent Lidocaine Lidocaine with epinephrine Bupivacaine Bupivacaine with epinephrine Dose 4 to 5 mg/kg 7 mg/kg 2.5 mg/kg 3 mg/kg Maximum single dose 300 mg 500 mg 175 mg 225 mg NOTE: Conversion formula % to mg/mL: multiply the % concentration by 10 (i.e., 1% ¼ 10 mg/mL).

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Table 4. Recommended practices in second stage of labour by parity and use of epidural analgesia (after full cervical dilatation and when power is adequate) Nulliparous Parous No epidural Epidural No epidural Epidural Total duration* 3 hours 4 hours 2 hours 3 hours Passive second stage† May wait up to 2 hours before May wait up to 1 May wait up to 2 hours before pushing, pushing, particularly when the hour provided continued passive descent presenting part is above þ2 station or in an non-OA position and the urge to push is absent. Encourage waiting to allow passive descent. Commence pushing When urge to push present When urge to push present or and not able to allow passive After 2 completed hours of passive second stage descent or After 2 completed hours of passive second stage Assessment Hourly for descent and position. Reassess the need for assisted birth after 2 hours of active pushing. OA: Occiput anterior. *Continuing beyond the following time limits should be carefully evaluated, and consideration should be given to expedite delivery. Extending these time limits may be appropriate in the presence of continued descent of the head, when maternal status and fetal surveillance are normal, and when spontaneous vaginal birth is imminent. †Waiting for up to the period indicated prior to the onset of pushing is appropriate in the presence of continued descent of the head and if fetal and maternal conditions are satisfactory. Sources: Sprague A, Oppenheimer L, McCabe L, Brownlee J, Graham I, Davies B. The Ottawa Hospital’s clinical practice guideline for the second stage of labour. J Obstet Gynaecol Can 2006;28:769e79.83 Perinatal Services BC. Core competencies for management of labour: evaulation of progress of labor/dystocia. Perinatal Services BC; 2011. Available at: http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Standards/Competencies/4CoreCompDSTEvalofLabourDystocia.pdf. Accessed January 23, 2013.89 the duration of the second stage of labour. It is suggested 15. Delayed pushing is preferred when the woman has that assessment of maternal status, fetal status, and rate of no urge to push, particularly if the presenting part is descent should be the basis of individualizing appropriate above station þ2 and/or in a non-occiput anterior management. It is reasonable to consider intervention position, assuming the fetus does not display when there is no further descent of the fetus despite op- abnormal monitoring and the pregnant woman’s timum uterine contractions and maternal expulsive efforts. status is satisfactory. (I-A) The effect of pre-pregnancy BMI on the duration of the 16. Delay of pushing according to parity and the second stage of labour is unclear. Some authors reported presence or absence of an epidural should follow the no significant difference in duration of the second stage of time limits described in the text unless there are e labour by BMI,25,91 94 whereas other studies have re- extenuating circumstances. (II-2B) ported a reduced length of the second stage in obese 17. The method of pushing, spontaneous or directed women.19,95 The interpretation of any estimates based on with Valsalva manoeuvre, should be chosen by the woman’s own preference. Directed pushing may second stage characteristics is challenging. This is because fi the group of women that progresses to the second stage of assist with the nal expulsion of the head. (II-2B) labour excludes women who had a Caesarean delivery during the first stage. Thus, any observed differences in characteristics between obese and non-obese women in the METHOD OF PUSHING second stage may be due to selection factors, limiting the generalizability of findings. A meta-analysis of 3 trials comparing Valsalva and spon- taneous pushing in 425 nulliparous women who did not Recommendations receive labour epidural found no difference in rates of operative deliveries, perineal repair, and PPH. For the 14. Pushing, as a component of second stage progress, Valsalva technique, a woman is instructed to take a deep may commence when the cervix is fully dilated, the fi breath at the start of the contraction and hold her breath presenting part is con rmed to be engaged, and the and push hard for the duration of the contraction. In the woman feels an urge to push. (III-A) spontaneous pushing method, the woman is self-directed

856 l SEPTEMBER JOGC SEPTEMBRE 2016 Management of Spontaneous Labour at Term in Healthy Women and may push with an open glottis, using an intermittent components have been controlled, slow delivery of the exhalation or vocalization technique. Although a significant crowning fetal head and selective use of mediolateral reduction in duration of second stage labour by 18.59 episiotomy. minutes was found in the Valsalva group, the mean dif- ¼ ference diminished to 9.75 minutes after sensitivity ana- A 2011 Cochrane review (n 1525) of warm perineal lyses. Women who used Valsalva pushing showed a compresses in labour versus no intervention showed a fi fi reduction in third- and fourth-degree perineal tears from signi cant decrease in urodynamic factors in rst urge to 104 void and bladder capacity measured at 3 months post- 5% to 2.5%. Investigators also found no difference in partum. There were no differences in other important the reduction of perineal trauma between a hands-on and maternal and newborn outcomes. The authors concluded hands-off technique on the perineum. Due to the high that the Valsalva pushing technique should not be routinely clinical heterogeneity and poorly described perineal tech- used until more evidence is available.96 niques in the studies, it was not possible to conduct planned analyses on outcomes. The only common theme was that a slow, controlled delivery of the fetal head was EPISIOTOMY AND PERINEAL MANAGEMENT used to facilitate delivery. A 2009 Cochrane review of 8 studies related to episiotomy Recommendation for vaginal birth concluded that restrictive episiotomy fi policies appear to have a number of bene ts compared 18. Avoid the use of routine episiotomy in spontaneous with routine episiotomy policies. There was less posterior vaginal births. (I-A) perineal trauma, less suturing, and fewer complications, with no difference for most pain measures or severe vaginal and/or perineal trauma. However, there was an Perineal Repair increased risk of anterior perineal trauma with a restrictive A 2010 Cochrane review involving 10 171 women episiotomy policy.97 When the perineum is preventing de- demonstrated decreased pain and need for re-suturing with livery, particularly if the fetal heart rate is abnormal, an synthetic versus catgut suture material for episiotomy and episiotomy may expedite a vaginal birth, although this has perineal tear repairs. Rapidly absorbable synthetic suture not been examined prospectively. needed to be removed less often than did regular synthetic suture. There were no differences in long-term pain or Although routine episiotomy has been shown to cause dyspareunia.105 more harm than good, selective mediolateral episiotomy should be considered in women who are considered at an A 2012 Cochrane review involving 8184 women demon- increased risk of OASIS, such as nulliparous women strated decreased analgesia use, less pain for up to 10 days, requiring assisted vaginal birth or those with a history of and reduced need for suture removal with continuous prior OASIS. Randomized evidence is limited98 but cor- versus interrupted perineal repair technique. There was no roborates observational evidence that more liberal (but not difference in long-term pain or need for re-suturing.106 routine) use of mediolateral episiotomy prevents OASIS at e assisted vaginal births, particularly with forceps.99 101 A randomized trial of 147 women with OASIS found that a single 1 g IV dose of cefotetan or cefoxitin given during The angle at which a mediolateral episiotomy is cut is repair reduced the incidence of perineal complications important. An observational study showed that the angle from 24% to 8% (P ¼ 0.037).107 The evidence in this 1 of an episiotomy from midline when performed at study may not be sufficient to recommend routine antibi- crowning decreased by 20 degrees on average after de- otic prophylaxis for third- and fourth-degree lacerations livery.102 An episiotomy performed at 45 degrees leaves an after delivery. incision after delivery at 25 degrees from midlinedvery close to the anal sphincter. To avoid causing OASIS, an THIRD STAGE LABOUR MANAGEMENT episiotomy should be performed more than 60 degrees from midline when the head is crowning (i.e., less than 30 AMTSL involves a package of interventions that includes degrees from horizontal). Midline episiotomy increases the administering prophylactic uterotonics, early cord clamp- risk of anal sphincter injury. ing, and CCT to assist in placental expulsion and to prevent or reduce blood loss. Personnel with the training and skills Quality improvement efforts in large regions of Norway to actively manage the third stage of labour should be in over the past decade have succeeded in reducing the attendance. Even though an SOGC guideline recom- incidence of OASIS from 4% to less than 2%.103 The key mended AMTSL as a package of care in 2009, the package

SEPTEMBER JOGC SEPTEMBRE 2016 l 857 SOGC CLINICAL PRACTICE GUIDELINE of 3 interventions is no longer recommended for all delivery of the placenta does not affect the risk of PPH women.108 A 2015 Cochrane review of AMTSL involving greater than 500 mL, rate of retained placenta, third stage 8247 women, in all but 1 high-income countries, found that labour duration, and use of additional uterotonics.111 compared with expectant management, active management demonstrated a reduction in PPH of more than 1000 mL Controlled Cord Traction and in the maternal hemoglobin level of less than 9 g/dL at After delivery of the baby, the uterus continues to contract. 24 to 72 hours after delivery, regardless of the woman’s Once there is evidence of placental separation, traction is bleeding risk profile. Although AMTSL reduced the risk of applied to the umbilical cord with counter pressure to the bleeding greater than 1000 mL and blood transfusions in a suprapubic area on the uterus until the placenta delivers. mixed risk population, it also demonstrated a statistically Until recently, CCT was not studied independently in significant increase in postpartum hypertension, pain, and relation to the prevention of PPH. A 2015 Cochrane re- return to the hospital due to bleeding. In addition, AMTSL view involving 27 665 women showed that CCT is asso- is associated with a lower average birth weight, likely as a ciated with reduced blood loss of 500 mL or more and less result of reduction in the neonate’s blood volume from manual removal of the placenta; the latter occurred mainly early cord clamping.109 No statistical difference was iden- in settings in which ergometrine was used routinely in the tified between the groups in the mean length of the third third stage of labour. Although CCT can be routinely stage of labour, manual or surgical removal of retained offered during the third stage of labour, the authors products, or maternal blood transfusion. Overall, high- cautioned that it should only be applied in settings in which quality evidence was lacking and more studies are the birth attendant has the necessary skills.112 needed. The authors concluded that AMTSL carried both benefits and harms and that the individual components of Timing of Cord Clamping AMTSL should be evaluated separately to determine It appears that the adverse effects of reduced placental whether all components are required to reduce PPH or transfusion can be decreased if late cord clamping is 109 which component confers the most benefit. practised and is equally beneficial in both term and preterm births. Delaying cord clamping by at least 60 to 180 sec- Routine Use of Prophylactic Uterotonics onds is associated with less need for transfusion for ane- Recent evidence in a 2013 Cochrane review of 20 trials mia, less intraventricular hemorrhage, and less risk of involving 10 806 women showed that prophylactic necrotizing enterocolitis in non-resuscitated premature in- oxytocin at any dose decreases both PPH greater than 500 fants under 37 weeks’ gestation compared with immediate mL and the need for therapeutic uterotonics compared clamping.113 with placebo and ergot alkaloids.110 Prophylactic oxytocin is preferred over ergot alkaloids for prevention of PPH In a 2013 Cochrane review that included a total of 3911 because it has minimal side effects. The benefit of pro- women and neonates at term, late cord clamping (> 60 phylactic oxytocin in reducing PPH greater than 500 mL seconds) was associated with enhanced hemoglobin levels was found regardless of the route of delivery, the man- and iron stores in infants for up to 6 months compared agement of the third stage labour, or the dose of oxytocin with the early cord clamping (< 60 seconds) group. There given. The benefits of prophylactic oxytocin associated were no significant differences in maternal outcomes in with decreased use of therapeutic uterotonics was seen terms of severe PPH or blood loss greater than 500 mL. only in trials in which oxytocin was given in the context of Although fewer neonates in the early cord clamping group AMTSL, delivered intravenously, and administered as a 10 required phototherapy for jaundice, in settings where there IU dose slow IV bolus. If an IV is not available, an is ready access of phototherapy for treatment of jaundice, intramuscular dose of 10 IU offers similar clinical benefit the authors concluded that late cord clamping is warranted 114 in reducing blood loss greater than 500 mL and a non- for healthy term infants. fi signi cant trend in reduced use of therapeutic utero- Recommendations tonics.110 Prophylactic oxytocin administered as an IV infusion is preferred over a rapid bolus IV due to potential 19. Prophylactic oxytocics should be given after the adverse maternal cardiovascular effects and potential delivery of the baby. (I-A) placental separation but retention due to entrapment. The 20. In term and preterm infants who do not require effect of the timing of oxytocin administration as a pro- neonatal resuscitation, delayed umbilical cord phylactic to prevent PPH was studied in a 2010 Cochrane clamping for 60 seconds is recommended review of 3 trials involving 1671 women. Investigators irrespective of the mode of delivery. (I-B) found that administration of oxytocin before and after the

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DYSTOCIA Complications of oxytocin. Table 5 describes possible com- plications of oxytocin administration, their mechanism of Dystocia is the most common problem associated with occurrence, and the preventive management associated labour and primarily affects nulliparous women. Even with the use of oxytocin. though the diagnosis of active labour requires assessment of uterine activity and cervical status, the diagnosis of Sensitivity to oxytocin. Each woman’suterusvariesinits fi fi dystocia rst requires the con rmation of active labour. A sensitivitytooxytocin.Eveninthesameuterus,the Dublin study demonstrated a decrease in dystocia when sensitivity may change during the course of labour. The active management of labour principles were followed, dose used must be sufficient to achieve adequate fi including the use of speci c criteria to diagnose labour to contractions. Protocols or guidelines for the adminis- avoid inappropriate intervention in the pre-active labour 44 tration of oxytocin vary, but many suggest starting with phase. Dystocia cannot be diagnosed prior to the onset a low dose followed by small increments at intervals of of labour or during the latent phase of labour (before 4 30 minutes.118,119 The starting incremental dosages for cm); CS carried out at this time for an indication of augmentation may be less than those used for induc- dystocia is inappropriate. tion. Every obstetrical unit must have an identified and accessible protocol that includes a starting dose, Definition and Diagnosis of Dystocia increment interval, and maximum dose. Consistent use Dystocia is defined as delayed or arrested progress in la- of one standard method to infuse oxytocin in any one bour, irrespective of causes. Dilatation of less than 0.5 cm/ obstetrical unit is recommended.120,121 The dose hour over 4 hours or no cervical change over 2 hours in should be ordered and recorded as milliunits/minute, the active first stage or greater than 1 hour of active notasvolumeofinfusion.Forexample,anobstetrical pushing and no descent of the presenting part in the sec- unit may administer an infusion solution of 30 U of ond stage is well below the 5th percentile for a popula- oxytocin in 500 mL saline; thus the dose of oxytocin in tion.2,115 It is associated with increased CS, maternal stress milliunits/minute equals the volume of infusion in and anxiety, maternal infection, and PPH. mL/hour. Therefore, conversion calculations of dose to Recommendation volume of the infusion pump need not be performed. Electronic fetal monitoring should be initiated or continued when oxytocin is started. 21. Dystocia should not be diagnosed prior to the onset fi of the active phase of the rst stage of labour or IV oxytocin can be administered using a low- or high-dose before the cervix is at least 4 cm dilated. (II-2D) protocol. The choice of protocol should be based on the relative risks of uterine rupture, sensitivity to oxytocin, and the likelihood of placental compromise. Any oxytocin Management of Dystocia in the First Stage of protocol used should be assessed against uterine response Labour and the fetus’s tolerance of associated contractions. If an Oxytocin early adverse uterine response (tachysystole) is noted with a In the event of dystocia due to inadequate power despite high-dose protocol, then a low-dose protocol should be appropriate analgesia, hydration, and rest with or without used. amniotomy, oxytocin is indicated to achieve adequate con- tractions before operative delivery is considered.116,117 Prin- cipal concerns about the use of oxytocin are fetal Table 5. Complications of Oxytocin compromise and uterine rupture. It must be remembered Adverse that it is not oxytocin that causes the problem but rather effects Mechanism Prevention excessive contractions. The correct use of oxytocin achieves Fetal Tachysystole Correct dose adequate contractions while avoiding excessive uterine ac- compromise tivity that could compromisethefetusorcauseuterine Uterine Tachysystole Correct dose rupture. rupture Water ADH effect Use crystalloid IV solution with Even with close titration of oxytocin, excess uterine activity intoxication concentrated oxytocin to limit the can occur. All labour and delivery units must be prepared volume of water infused to manage uterine tachysystole whether or not it is asso- Hypotension Vasodilatation Avoid IV bolus injection, including for ciated with oxytocin use. This is outlined in the Clinical AMTSL Practice Guideline on the induction of labour.4 ADH: Antidiuretic hormone.

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fi Table 6. Clinical considerations for oxytocin was shortened by 1.3 hours (95% con dence interval 1.0 to augmentation protocol 1.7 hours) compared with low-dose oxytocin (1 mU/min 122 Clinical considerations Suggested oxytocin protocol starting dose) after adjusting for potential confounders. However, evidence on the relationship between high-dose Prior CS Low dose oxytocin for labour augmentation and Caesarean delivery Fetal growth restriction Low dose is inconsistent. Although most studies reported a trend Parity > 4 Low dose towards lower Caesarean delivery rates in women who e Parous augmentation, no epidural Low dose received high-dose regimens,122 124,126 only 1 reached sta- Parous induction Low or high dose tistical significance.126 Parous augmentation with epidural Low or high dose Nullipara augmentation, no epidural Low dose Nulliparous women and women who receive an epidural Nullipara induction Low or high dose analgesia during labour are particularly likely to benefit 127 Nullipara with epidural Consider high dose from high- versus low-dose oxytocin augmentation. The clinical goal of oxytocin augmentation is to achieve an effective uterine contraction mechanism of 4 to 5 con- tractions in 10 minutes. If an IUPC is used, the goal is 200 A 2010 meta-analysis of RCTs including 5400 women or greater Montevideo units (e.g., 4 contractions of 50 to concluded that high-dose oxytocin protocols were associ- 60 mmHg in 10 minutes).Several studies have examined ated with a lower CS rate than were low-dose protocols. the optimal duration of oxytocin augmentation when la- e Tachysystole was more common with high-dose protocols, bour dystocia or arrest occurrs.128 130 A prospective but there was no difference in maternal or neonatal fi cohort study evaluated labour progress in 220 nulliparous morbidity. Low dose was de ned as 1 to 2 mU/min in- women and 99 parous women who entered labour spon- crements, and high-dose was defined as 4 mU/min 119 taneously and subsequently were assessed as having un- increments. This meta-analysis was dominated by satisfactory progress. Investigators found that in women studies that included only nulliparous women. Evidence fi who received oxytocin for a total of 8 hours, 38% delivered speci c to parous women or women with a prior CS scar is vaginally. In nulliparous women, the CS rate was 18% after lacking. Therefore it may be prudent to use a low-dose 8 hours of oxytocin augmentation with no resulting protocol in women labouring with a prior CS or other adverse neonatal outcomes. Another study of over 500 uterine surgery because of a potential increase in the risk of women evaluated a mandated protocol of 4 hours or more uterine rupture. It is also prudent to use a low-dose pro- of oxytocin augmentation before CS for active phase la- tocol in grand multiparous women because of their bour arrest. Investigators found that extending the mini- increased sensitivity to oxytocin and women with suspected fi mum period of oxytocin augmentation from 2 to 4 to 6 fetal growth restriction due to risks of placental insuf - hours increased the vaginal delivery rate without severe ciency (Table 6). adverse maternal or neonatal outcomes.129 This was further corroborated in a similar study by the same 130 Oxytocin and Epidural researchers. There is limited evidence to determine whether high-dose oxytocin regimens should be used for labour augmentation Recommendation among women who have received an epidural. One large, high-quality, contemporary observational study from the 22. Oxytocin augmentation should be titrated to avoid United States and several smaller RCTs compared high- tachysystole or excessive uterine activity and to and low-dose oxytocin augmentation protocols in women produce a uterine contraction pattern of 4 to 5 e with high (67% to 94% and higher) epidural use.122 126 contractions in 10 minutes (200 Montevideo units). One of these trials evaluated high-dose oxytocin as part A minimum of 4 to 6 hours of adequate uterine of an active management of labour intervention, decreasing activity may be required to have the desired response. the applicability of the results.124 (I-A) It is recommended that every obstetrical unit have an identified and accessible protocol that Based on available evidence, high-dose oxytocin for labour includea a starting dose, increment interval, and augmentation has consistently been shown to shorten labour maximum dose. Consistent use of 1 standard duration compared with low-dose oxytocin. In the large approach to oxytocin administration in any 1 fi observational study, the rst stage of labour in women who obstetrical unit should be considered. (III-A) received high-dose oxytocin ( 4 mU/min starting dose)

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Management of Dystocia in the Second Stage of Admit only women in the active phase of labour (see Labour definition in the previous text) to the hospital. Prolonged second stage Provide continuous support with non-hospital associated In the presence of strong contractions, prolonged second persons to labouring women. stage of labour may be defined by the following: Use appropriate analgesia. Nulliparous women: 3 hours with regional anesthesia or 2 hours without regional anesthesia Management of Dystocia Parous women: 2 hours with regional anesthesia or 1 hour without regional anesthesia Assess the adequacy of labour progress. Intervene when necessary. If no urge to push occurs after 1 hour of the second stage B Analgesia of labour, reassess the contractions and fetal presenting B Rest position and descent and consider the use of oxytocin if contractions are inadequate. B Amniotomy B Augmentation A population-based cohort analysis of 120 000 women identified an increase in the risk of maternal obstetrical For women who received an epidural analgesia, if inad- trauma, postpartum hemorrhage, puerperal febrile equate labour progress is suspected, augment with early fi morbidity, composite maternal morbidity, low 5-minute arti cial rupture of membranes and IV oxytocin. A high- fi Apgar score, birth depression, admission to the neonatal dose IV oxytocin protocol may be particularly bene cial. intensive care unit, and composite perinatal morbidity as Intervene operatively when necessary. the duration of the second stage surpassed 3 hours in nulliparous women and 2 hours in parous women.131 SUMMARY Labour is a normal physiological process. Recommendations Normal labour is enhanced with supportive care, delayed 23. Operative delivery less than 2 hours after admission until active labour, comfort measures, commencing pushing is not recommended appropriate pain management, and interventions only provided, maternal status and fetal surveillance when necessary. are normal. (III-D) There is an increasing trend towards induction of labour 24. When the second stage exceeds the recommended and an increase in CS primarily due to dystocia and time limits (see text), consideration should be given repeat CS. to expediting delivery. Extending these time limits Dystocia can only be diagnosed once active labour is may be appropriate in the presence of continued established. descent the head, satisfactory maternal and fetal status, and imminent vaginal birth. (II-2B) Interventions for dystocia may include analgesia, rest, 25. High dose regimens have been shown to decrease amniotomy, augmentation, and assisted vaginal birth. labour duration compared with low dose regimens. (I-A) The lowest dose needed to produce normal progress is recommended to reduce the risk REFERENCES of tachysystole or excessive uterine activity and create a uterine contraction pattern of 3 to 5 1. Induction and augmentation of labor. ACOG Technical Bulletin Number contractions or 200 or more Montevideo units 157dJuly 1991. Int J Gynaecol Obstet 1992;39:139e42. every 10 minutes. (IA) 2. Fraser WB, Krauss I, Boulvain M, Oppenheimer L, Milne KJ, Liston RM, Dystocia. SOGC Clinical Practice Guidelines, No. 40, October 1995. Available at: http://sogc.org/wp-content/uploads/2013/11/gui40EPS951 MANAGEMENT SUMMARY 0.pdf. Accessed May 5, 2016. 3. O’Driscoll K, Meagher D, Robson M. Active management of labour: the Prevention of Dystocia Dublin experience. ed 4. London: Mosby; 2003. Encourage the use of prenatal education. 4. Leduc D, Biringer A, Lee L, Dy J. Induction of labour. SOGC Clinical Practice Guidelines, No. 296, September 2013. J Obstet Gynaecol Can Avoid unnecessary/non-indicated induction of labour. 2013;35:840e60.

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