Prevention of primary caesarean delivery: comprehensive management of dystocia in nulliparous patients at term

Abstract

Purpose

Dystocia is the leading indication for primary caesarean sections. Our aim is to compare two approaches in the management of dystocia in labor in nulliparous women with a singleton fetus in cephalic presentation at term in spontaneous or induced labor.

Methods

Prospective cohort study. Four hundred and nineteen consecutive patients were divided into two groups: the standard management group (SM), in acceleration of labor was commenced at the “action line” in the case of arrested or protracted labor, and the comprehensive management group (CM) in which arrested or protracted labor was considered as a warning sign promoting further diagnostic assessment prior to considering intervention.

Results

Caesarean sections rate was 22.2 % in the SM group (216 patients) and 10.3 % in the CM group (203 patients) (p = 0.001). The rate of oxytocin use decreased from 33.3 % in SM group to 13.8 % in the CM group (p < 0.0005). The rate of amniotomy decreased from 41.7 % in the SM group to 7.4 % in the CM group (p < 0.0005). The percentage of newborns with 5-min Apgar score <7 and/or umbilical cord arterial pH ≤ 7.00 decreased from 2.3 % in SM cohort to 0.5 % in CM cohort (p = ns). The average length of labor did not differ between the two groups of patients (264 vs 277 min; p = ns).

Conclusion

Comprehensive management of dystocia enabled us to achieve a reduction in iatrogenic interventions in labor while maintaining good neonatal outcomes.

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References

  1. 1.

    American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine (2014) Obstetric care consensus no. 1: safe prevention of the primary cesarean delivery. Obstet Gynecol 123:693–711

    Article  Google Scholar 

  2. 2.

    Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY (2010) Abnormal labor. In: Williams obstetrics, 23rd edn. McGraw-Hill, New York

  3. 3.

    Gregory KD, Curtin SC, Taffel SM, Notzon FC (1998) Changes in indications for cesarean delivery: United States, 1985 and 1994. Am J Public Health 88:1384–1387

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Zhang J, Troendle J, Reddy UM, Laughon SK, Branch DW, Burkman R et al (2010) Contemporary cesarean delivery practice in the United States. Am J Obstet Gynecol 203(326):e1–e10

    Google Scholar 

  5. 5.

    World Health Organization (1994) World Health Organization partograph in management of labour. World Health Organization Maternal Health and Safe Motherhood Programme. Lancet 343:1399–1404

    Google Scholar 

  6. 6.

    Gifford DS, Morton SC, Fiske M, Keesey J, Keeler E, Kahn KL (2000) Lack of progress in labor as a reason for cesarean. Obstet Gynecol 95:589–595

    CAS  PubMed  Google Scholar 

  7. 7.

    Kominiarek MA, Zhang J, Vanveldhuisen P, Troendle J, Beaver J, Hibbard JU (2011) Contemporary labor patterns: the impact of maternal body mass index. Am J Obstet Gynecol 205(244):e1–e8

    PubMed  Google Scholar 

  8. 8.

    Gizzo S, Patrelli TS, Rossanese M, Noventa M, Berretta R, Di Gangi S, Bertin M, Gangemi M, Nardelli GB (2013) An update on diabetic women obstetrical outcomes linked to preconception and pregnancy glycemic profile: a systematic literature review. ScientificWorldJournal 6(2013):254901

    Google Scholar 

  9. 9.

    Ijaiya MA, Adesina KT, Raji HO, Aboyeji AP, Olatinwo AO, Adeniran AS et al (2011) Duration of labor with spontaneous onset at the University of Ilorin Teaching Hospital, Ilorin, Nigeria. Ann Afr Med 10:115–119

    Article  PubMed  Google Scholar 

  10. 10.

    Frigo MG, Larciprete G, Rossi F, Fusco P, Todde C, Jarvis S et al (2011) Rebuilding the labor curve during neuraxial analgesia. J Obstet Gynaecol Res 37:1532–1539

    Article  PubMed  Google Scholar 

  11. 11.

    Gizzo S, Noventa M, Fagherazzi S, Lamparelli L, Ancona E, Di Gangi S, Saccardi C, D’Antona D, Nardelli GB (2014) Update on best available options in obstetrics anaesthesia: perinatal outcomes, side effects and maternal satisfaction. Fifteen years systematic literature review. Arch Gynecol Obstet 290(1):21–34

    CAS  PubMed  Google Scholar 

  12. 12.

    Gizzo S, Di Gangi S, Saccardi C, Patrelli TS, Paccagnella G, Sansone L, Barbara F, D’Antona D, Nardelli GB (2012) Epidural analgesia during labor: impact on delivery outcome, neonatal well-being, and early breastfeeding. Breastfeed Med 7:262–268

    Article  PubMed  Google Scholar 

  13. 13.

    Patrelli TS, Gizzo S, Cosmi E, Carpano MG, Di Gangi S, Pedrazzi G, Piantelli G, Modena AB (2012) Maternal hydration therapy improves the quantity of amniotic fluid and the pregnancy outcome in third-trimester isolated oligohydramnios: a controlled randomized institutional trial. J Ultrasound Med 31(2):239–244

    PubMed  Google Scholar 

  14. 14.

    Gizzo S, Di Gangi S, Noventa M, Bacile V, Zambon A, Nardelli GB (2014) Women’s choice of positions during labour: return to the past or a modern way to give birth? A cohort study in Italy. Biomed Res Int 2014:638093

    PubMed  PubMed Central  Google Scholar 

  15. 15.

    Mittal P, Romero R, Tarca AL, Draghici S, Nhan-Chang CL, Chaiworapongsa T et al (2011) A molecular signature of an arrest of descent in human parturition. Am J Obstet Gynecol 204(177):e15–e33

    PubMed  Google Scholar 

  16. 16.

    Rouse DJ, Owen J, Savage KG, Hauth JC (2001) Active phase labor arrest: revisiting the 2 our minimum. Obstet Gynecol 98:550–554

    CAS  PubMed  Google Scholar 

  17. 17.

    National Institute for Health and Clinical Excellence (NICE) (2007) Intrapartum care. Care of healthy women and their babies during childbirth. NICE clinical guidelines 55

  18. 18.

    Gizzo S, Noventa M, Anis O, Saccardi C, Zambon A, Di Gangi S, Tormene D, Gangemi M, D’Antona D, Nardelli GB (2014) Pharmacological anti-thrombotic prophylaxis after elective caesarean delivery in thrombophilia unscreened women: should maternal age have a role in decision making? J Perinat Med 42(3):339–347

    CAS  Article  PubMed  Google Scholar 

  19. 19.

    Gizzo S, Nardelli GB, Noventa M (2014) Postpartum venous thromboembolism: incidence and risk factors. Obstet Gynecol 124(4):837–838

    Article  PubMed  Google Scholar 

  20. 20.

    Gizzo S, Andrisani A, Noventa M, Di Gangi S, Quaranta M, Cosmi E, D’Antona D, Nardelli GB, Ambrosini G (2015) Caesarean section: could different transverse abdominal incision techniques influence postpartum pain and subsequent quality of life? A systematic review. PLoS ONE 10(2):e0114190

    Article  PubMed  PubMed Central  Google Scholar 

  21. 21.

    Gizzo S, Patrelli TS, Gangi SD, Carrozzini M, Saccardi C, Zambon A, Bertocco A, Fagherazzi S, D’Antona D, Nardelli GB (2013) Which uterotonic is better to prevent the postpartum hemorrhage? Latest news in terms of clinical efficacy, side effects, and contraindications: a systematic review. Reprod Sci. 20(9):1011–1019

    Article  PubMed  Google Scholar 

  22. 22.

    Gizzo S, Saccardi C, Patrelli TS, Di Gangi S, Breda E, Fagherazzi S, Noventa M, D’Antona D, Nardelli GB (2013) Fertility rate and subsequent pregnancy outcomes after conservative surgical techniques in postpartum hemorrhage: 15 years of literature. Fertil Steril 99(7):2097–2107

    Article  PubMed  Google Scholar 

  23. 23.

    Gizzo S, Zambon A, Saccardi C, Patrelli TS, Di Gangi S, Carrozzini M, Bertocco A, Capobianco G, D’Antona D, Nardelli GB (2013) Effective anatomical and functional status of the lower uterine segment at term: estimating the risk of uterine dehiscence by ultrasound. Fertil Steril 99(2):496–501

    Article  PubMed  Google Scholar 

  24. 24.

    Kenyon S, Tokumasu H, Dowswell T, Pledge D, Mori R (2013) High-dose versus low-dose oxytocin for augmentation of delayed labour. Cochrane Database Syst Rev 7:CD007201

    PubMed  Google Scholar 

  25. 25.

    Dupuis O, Silveira R, Zentner A, Dittmar A, Gaucherand P, Cucherat M et al (2005) Birth simulator: reliability of transvaginal assessment of fetal head station as defined by the American College of Obstetricians and Gynecologists classification. Am J Obstet Gynecol 192:868–874

    Article  PubMed  Google Scholar 

  26. 26.

    Sherer DM, Miodovnik M, Bradley KS, Langer O (2002) Intrapartum fetal head position I: comparison between transvaginal digital examination and transabdominal ultrasound assessment during the active stage of labor. Ultrasound Obstet Gynecol 19:258–263

    CAS  Article  PubMed  Google Scholar 

  27. 27.

    Sherer DM, Miodovnik M, Bradley KS, Langer O (2002) Intrapartum fetal head position II: comparison between transvaginal digital examination and transabdominal ultrasound assessment during the second stage of labor. Ultrasound Obstet Gynecol 19:264–268

    CAS  Article  PubMed  Google Scholar 

  28. 28.

    Blasi I, D’Amico R, Fenu V, Volpe A, Fuchs I, Henrich W (2010) Sonographic assessment of fetal spine and head position during the first and second stages of labor for the diagnosis of persistent occiput posterior position: a pilot study. Ultrasound Obstet Gynecol 35:210–215

    CAS  Article  PubMed  Google Scholar 

  29. 29.

    Gizzo S, Saccardi C, Di Gangi S, Dalla Toffola A, D’Antona D, Nardelli GB et al (2013) Ultrasound investigation during labour of consensual or nonconsensual fetal spine in an occiput posterior cephalic presentation can improve the management of delivery? Ultrasound Med Biol 39:550–551

    Article  PubMed  Google Scholar 

  30. 30.

    Gizzo S, Andrisani A, Noventa M, Burul G, Di Gangi S, Anis O, Ancona E, D’Antona D, Nardelli GB, Ambrosini G (2014) Intrapartum ultrasound assessment of fetal spine position. Biomed Res Int 2014:783598

    PubMed  PubMed Central  Google Scholar 

  31. 31.

    Desbriere R, Blanc J, Le Du R, Renner JP, Carcopino X, Loundou A et al (2013) Is maternal posturing during labor efficient in preventing persistent occiput posterior position? A randomized controlled trial. Am J Obstet Gynecol 208(60):e1–e8

    PubMed  Google Scholar 

  32. 32.

    Simkin P (2010) The fetal occiput posterior position: state of the science and a new perspective. Birth 37:61–71

    Article  PubMed  Google Scholar 

  33. 33.

    Stremler R, Hodnett E, Petryshen P, Stevens B, Weston J, Willan AR (2005) Randomized controlled trial of hands-and-knees positioning for occipitoposterior position in labor. Birth 32:243–251

    Article  PubMed  Google Scholar 

  34. 34.

    Hollins Martin CJ, Martin CR (2013) A narrative review of maternal physical activity during labour and its effects upon length of first stage. Complement Ther Clin Pract 19:44–49

    Article  PubMed  Google Scholar 

  35. 35.

    Racinet C (2005) Positions maternelles pour l’accouchement. [Maternal posture during parturition.] (in French). Gynecol Obstet Fertil 33:533–538

    CAS  Article  PubMed  Google Scholar 

  36. 36.

    Le Ray C, Serres P, Schmitz T, Cabrol D, Goffinet F (2007) Manual rotation in occiput posterior or transverse positions: risk factors and consequences on the cesarean delivery rate. Obstet Gynecol 110:873–879

    Article  PubMed  Google Scholar 

  37. 37.

    Reichman O, Gdansky E, Latinsky B, Labi S, Samueloff A (2008) Digital rotation from occipito-posterior to occipito-anterior decreases the need for cesarean section. Eur J Obstet Gynecol Reprod Biol 136:25–28

    Article  PubMed  Google Scholar 

  38. 38.

    American College of Obstetricians and Gynecologists (2009) ACOG Practice Bulletin No. 106: intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. Obstet Gynecol 114:192–202

    Article  Google Scholar 

  39. 39.

    Piquard F, Hsiung R, Mettauer M, Schaefer A, Haberey P, Dellenbach P (1988) The validity of fetal heart rate monitoring during the second stage of labor. Obstet Gynecol 72:746–751

    CAS  PubMed  Google Scholar 

  40. 40.

    Lowe NK, Corwin EJ (2011) Proposed biological linkages between obesity, stress, and inefficient uterine contractility during labor in humans. Med Hypotheses 76:755–760

    Article  PubMed  Google Scholar 

  41. 41.

    Pascali-Bonaro D, Kroeger M (2004) Continuous female companionship during childbirth: a crucial resource in times of stress or calm. J Midwifery Womens Health 49:19–27

    Article  PubMed  Google Scholar 

  42. 42.

    Leap N, Sandall J, Buckland S, Huber U (2010) Journey to confidence: women’s experiences of pain in labour and relational continuity of care. J Midwifery Womens Health 55:234–242

    Article  PubMed  Google Scholar 

  43. 43.

    Stjernholm YV, Nyberg A, Cardell M, Höybye C (2015) Circulating maternal cortisol levels during vaginal delivery and elective cesarean section. Arch Gynecol Obstet (in press)

  44. 44.

    Rosand GM, Slinning K, Eberhard-Gran M, Roysamb E, Tambs K (2011) Partner relationship satisfaction and maternal emotional distress in early pregnancy. BMC Public Health 11:161

    Article  PubMed  PubMed Central  Google Scholar 

  45. 45.

    Onyeije CI, Divon MY (2001) The impact of maternal ketonuria on fetal test results in the setting of postterm pregnancy. Am J Obstet Gynecol 184:713–718

    CAS  Article  PubMed  Google Scholar 

  46. 46.

    Hayes BC, McGarvey C, Mulvany S, Kennedy J, Geary MP, Matthews TG et al (2013) A case/control study of hypoxic ischaemic encephalopathy in newborns > 36 weeks gestation. Am J Obstet Gynecol 209:29.e1–29.e19

    Article  Google Scholar 

  47. 47.

    Jonsson M, Nordén-Lindeberg S, Ostlund I, Hanson U (2008) Acidemia at birth, related to obstetric characteristics and to oxytocin use, during the last two hours of labor. Acta Obstet Gynecol Scand 87:745–750

    Article  PubMed  Google Scholar 

  48. 48.

    Institute for Safe Medication Practices (2014) List of high-alert medications. https://www.ismp.org/tools/institutionalhighAlert.asp. Accessed 11 Dec 2014

  49. 49.

    Lee SM, Lee KA, Lee J, Park CW, Yoon BH (2010) “Early rupture of membranes” after the spontaneous onset of labor as a risk factor for cesarean delivery. Eur J Obstet Gynecol Reprod Biol 148:152–157

    Article  PubMed  Google Scholar 

  50. 50.

    Cohain JS (2013) The less studied effects of amniotomy. J Matern Fetal Neonatal Med 26:1687–1690

    Article  PubMed  Google Scholar 

  51. 51.

    Gross MM, Frömke C, Hecker H (2014) The timing of amniotomy, oxytocin and neuraxial analgesia and its association with labour duration and mode of birth. Arch Gynecol Obstet 289:41–48

    CAS  Article  PubMed  Google Scholar 

  52. 52.

    Zhang J, Troendle JF, Yancey MK (2002) Reassessing the labor curve in nulliparous women. Am J Obstet Gynecol 187:824–828

    Article  PubMed  Google Scholar 

  53. 53.

    Berghella V, Baxter JK, Chauhan SP (2008) Evidence-based labor and delivery management. Am J Obstet Gynecol 199:445–454

    Article  PubMed  Google Scholar 

  54. 54.

    Kjaergaard H, Olsen J, Ottesen B, Nyberg P, Dykes AK (2008) Obstetric risk indicators for labour dystocia in nulliparous women: a multicentre cohort study. BMC Pregnancy Childbirth 8:45

    Article  PubMed  PubMed Central  Google Scholar 

  55. 55.

    Marpeau L, Sergent F, Manson F, Verspyck E, Eurin D (2002) Mécanismes des stagnations de la dilatation en phase active du travail. [Mechanisms of the stagnation of dilatation in the active phase of labor.] (in French). Gynecol Obstet Fertil 30:282–285

    CAS  Article  PubMed  Google Scholar 

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Correspondence to Antonio Ragusa.

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Ragusa, A., Gizzo, S., Noventa, M. et al. Prevention of primary caesarean delivery: comprehensive management of dystocia in nulliparous patients at term. Arch Gynecol Obstet 294, 753–761 (2016). https://doi.org/10.1007/s00404-016-4046-5

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Keywords

  • Labor dystocia
  • Cesarean section
  • Partogram
  • Labor augmentation
  • Intrapartum strategy
  • Nulliparity