Health Care Guideline Management of Labor How to cite this document: Creedon D, Akkerman D, Atwood L, Bates L, Harper C, Levin A, McCall C, Peterson D, Rose C, Setterlund L, Walkes B, Wingeier R. Institute for Clinical Systems Improvement. Management of Labor. Updated March 2013. Copies of this ICSI Health Care Guideline may be distributed by any organization to the organization’s employees but, except as provided below, may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc. If the organization is a legally constituted medical group, the ICSI Health Care Guideline may be used by the medical group in any of the following ways: • copies may be provided to anyone involved in the medical group’s process for developing and implementing clinical guidelines; • the ICSI Health Care Guideline may be adopted or adapted for use within the medical group only, provided that ICSI receives appropriate attribution on all written or electronic documents and • copies may be provided to patients and the clinicians who manage their care, if the ICSI Health Care Guideline is incorporated into the medical group’s clinical guideline program. All other copyright rights in this ICSI Health Care Guideline are reserved by the Institute for Clinical Systems Improvement. The Institute for Clinical Systems Improvement assumes no liability for any adap- tations or revisions or modifications made to this ICSI Health Care Guideline. www.icsi.org Copyright © 2013 by Institute for Clinical Systems Improvement Health Care Guideline and Order Set: Management of Labor 1 Pregnant patient > 20 Text in blue in this algorithm weeks with symptoms indicates a linked corresponding of labor Fifth Edition annotation. March 2013 2 Triage for symptoms of labor 3 4 See Management of yes Signs/Symptoms of < 37 weeks? Preterm Labor algorithm and annotations no 1 0 5 7 • Patient education for Previous reassurance yes yes Admit for no • Observe and reevaluate uterine labor? incision? • Consider labor induction if appropriate no 6 Have 11 yes no membranes See VBAC algorithm ruptured? 8 and annotations yes Subsequent 1 2 labor? Intrapartum care • Cervical exam no • Supportive care • Adequate pain relief 9 • Consider amniotomy unless Out of contraindicated guideline • Monitoring of fetal heart rate • Nurse ausculatory monitoring or continuous EFM-ext 1 3 14 15 Any concerns or no Normal vaginal Management of third complications? delivery stage of labor yes 1 6 1 7 18 Is progression of no Is fetal heart rate a no Other labor a concern? concern? • Out of guideline yes yes 19 20 See Management of Labor See Intrapartum Fetal Dystocia algorithm and Heart Rate Management annotations algorithm and annotations Return to Table of Contents www.icsi.org Copyright © 2013 by Institute for Clinical Systems Improvement 1 Management of Labor Fifth Edition/March 2013 Management of Signs/Symptoms of Preterm Labor (PTL) Algorithm This algorithm applies to singleton pregnancies only. 21 21 Text in blue in this algorithm Assessment includes: indicates a linked corresponding • Sterile speculum exam Assessment of patient with annotation. - Fetal fibronectin testing signs/symptoms of possible PTL - Consider GBS, wet prep for bacterial vaginosis - GC, chlamydia • Digital cervical exam 23 • Transvaginal ultrasound 2 2 Obstetric/medical for cervical length (if consultation as indicated; available) no Patient and fetus treat per standard emergency • Ultrasound for growth, both medically medical and obstetric fluid, placenta stable? procedures • Assess contraction patterns • Assess fetal well-being yes • Urinalysis and urine culture 2 4 25 yes See Management of Critical 24 Is there a critical Event algorithm Critical events: event? • Cervix 5+ cm dilated • pPROM no • Vaginal bleeding • Chorioamnionitis 2 6 suspected Cervix > 2 cm dilated, > 80% yes effaced, contractions 4/20 or 6/60? no 27 28 yes Monitor for minimum Ultrasound cervical 2 hours for cervical length < 3.0 cm or fFn changes positive? no 30 31 2 9 yes See Management of See ICSI Routine Cervical change? Prenatal Care Critical Event algorithm guideline no 32 • Consider antenatal cortiosteroids • Dismiss and schedule follow-up Return to Table of Contents www.icsi.org Institute for Clinical Systems Improvement 2 Management of Labor Fifth Edition/March 2013 Management of Critical Event Algorithm 33 Text in blue in this algorithm Patient has critical event indicates a linked corresponding annotation. 34 35 3 7 36 3 9 Initial dose antenatal Consider magnesium • Prepare for preterm Cervix 5+ cm yes corticosteroids STAT, IV Is delivery yes sulfate for delivery/transport dilated? antibiotics for group imminent? neuroprotection • Neonatal consult B streptococcus (GBS) no 40 no 41 • Broad spectrum 38 Chorioamnionitis yes antibiotics suspected? • Plan for delivery • Stabilize on tocolytics • Transfer mother to appropriate level of care no if possible 42 • Stabilize on tocolytics • Transfer mother to appropriate level of care if possible 44 45 46 43 Sonogram for: 47 Sonogram Antenatal corticosteroids • Amniotic fluid index (AFI) yes Fetal anomaly no Await spontaneous 23-34 weeks • Presentation/placentation detects gross compatible with labor • Follow-up level II as indicated anomaly? life? no yes 48 49 50 Initiate tocolytics, antenatal Vaginal pool + corticosteroids and antibiotics for yes amniocentesis at 32+ group B streptococcus (GBS) ROM? weeks for fetal lung prophylaxis maturity (FLM) no 5 3 Deliver for: 51 • Disseminated intravascular 5 2 coagulation (DIC) Management of preterm yes • FLM Vaginal labor with bleeding • Fetal distress bleeding? • Non-reassuring FHT • Significant bleeding no 55 Deliver for: 54 • Fetal distress • Chorioamnionitis no Fetal lung maturity • Active labor (FLM) study • 34 weeks PROM positive? • Other obstetrical indicators yes 56 Preterm delivery Return to Table of Contents www.icsi.org Institute for Clinical Systems Improvement 3 Management of Labor Fifth Edition/March 2013 Vaginal Birth After Caesarean (VBAC) Algorithm 5 7 Patient in active labor 58 with previous uterine • Patient has made an informed incision choice to have planned VBAC • Availability of Caesarean delivery team • Determine previous 5 8 uterine incision and review prior op report if available Special considerations of • EFM and intermittent labor management auscultation • Use of foley bulb catheter for cervical ripening 59 Vaginal birth yes appropriate for planned VBAC? 6 0 no 63 no Normal labor? Repeat Caesarean delivery 61 Complicated labor yes management 6 1 Signs and symptoms of uterine rupture: 62 • Fetal distress Vaginal birth • Uterine pain • Hemorrhage • Palpation of fetal parts • Loss of contraction Text in blue in this algorithm • Recession of presenting part indicates a linked corresponding • Fetal death annotation. Return to Table of Contents www.icsi.org Institute for Clinical Systems Improvement 4 Management of Labor Fifth Edition/March 2013 Management of Labor Dystocia Algorithm 64 Text in blue in this algorithm Labor dystocia indicates a linked corresponding diagnosis annotation. 73 65 72 74 Fetal head yes Stage I labor Stage II labor descent Normal vaginal > 1 cm/hour? delivery 66 no 75 < 1 cm dilation for no Management of protracted labor – 2 consecutive stage II hours and 6 cm • Oxytocin augmentation dilation? • Consider decreasing epidural anesthesia yes • Consider assisted delivery 67 • Evaluate passenger and passageway Management of protracted labor • Consider OB/surgery consult Stage I • Evaluate potential causes Possible interventions: - IV fluids 7 6 - Amniotomy/IUPC yes - Decrease anesthesia Is the head - Oxytocin augmentation descending? - Evaluate passenger and passageway no - OB/surgery consult 77 68 no 78 Assisted Adequate 69 yes Assisted vaginal vaginal delivery delivery contractions labor yes Is cervix yes indicated? for 2 hours with completely cervical change? dilated? no no 7 0 Arrest of labor 7 1 Caesarean delivery Return to Table of Contents www.icsi.org Institute for Clinical Systems Improvement 5 Management of Labor Fifth Edition/March 2013 Intrapartum Fetal Heart Rate (FHR) Management Algorithm 7 9 Text in blue in this algorithm Concern about fetal heart rate indicates a linked corresponding annotation. 80 Continuous EFM-ext or EFM-int (if needed) 81 Consider amnioinfusion for oligohydramnios and severe variable or prolonged decelerations 82 FHR pattern is yes predictive of normal acid-base status? no 84 Assessment and intrauterine resuscitation 8 5 8 3 FHR pattern yes See algorithm #13, predictive of "Any concerns or normal acid-base complications?" status now? no 8 6 87 Expedited vaginal yes Vaginal delivery delivery imminent? no 8 8 Further FHR assessment predictive yes of normal acid-base status? no 89 Emergent delivery Return to Table of Contents www.icsi.org Institute for Clinical Systems Improvement 6 Management of Labor Fifth Edition/March 2013 Table of Contents Work Group Leader Algorithms and Annotations ........................................................................................ 1-33 Douglas Creedon, MD Algorithm (Main) .................................................................................................................1 OB/Gyn, Mayo Clinic Algorithm (Management of Signs/Symptoms of Preterm Labor [PTL]) .............................2 Work Group Members Algorithm (Management of Critical Event) .........................................................................3 Affiliated Community Algorithm (Vaginal