Amy Bell Peter Cherouny Sue Gullo Session Code L22 These presenters have nothing to disclose L22 Full Circle: Amy Bell Peter Cherouny Sue Gullo December 7, 2014 1:00pm-4:30pm Aruba/Bahama

Preventing the First Cesarean Delivery The movement in national OB imperatives Decreasing the hospital and provider variation Minimizing misuse of our tools Increasing where underused Avoiding overuse Clarifying definitions where required Reliably delivering care Spong CY et al. Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol;120:1181

Preventing the First Cesarean Delivery Clarifying definitions Defining abnormal labor Defining normal labor that is understood and accepted

Preventing the First Cesarean Delivery Spong CY et al. Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol;120:1181

Preventing the First Cesarean Delivery Spong CY et al. Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol;120:1181

Preventing the First Cesarean Delivery Zhang J et al (for the Consortium on Safe Labor). Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes. Obstet Gynecol 2010; 116:1281.

Preventing the First Cesarean Delivery Active phase arrest 6 cm or greater dilation with membrane rupture and no cervical change for 4 hrs or more of adequate uterine contractions 6 hrs or more if contractions inadequate Second stage arrest No progress (descent or rotation) for 3 hrs or more in nulliparous w/o epidural 4 hrs or more in nulliparous with epidural Spong CY et al. Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol;120:1181

Preventing the First Cesarean Delivery Induction of Labor Labor induction should be performed only for medical indication; if done for nonmedical indications, the gestational age should be 39 weeks or more, and the cervix should be favorable (Bishop score more than 8), especially in the nulliparous patient Adequate time for normal latent and active phases of the first stage, and for the second stage, should be allowed unless expeditious delivery is medically indicated Spong CY et al. Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol;120:1181

Preventing the First Cesarean Delivery Failed Induction of Labor 40% of women not in active labor after 12 hours of oxytocin and membrane rupture delivered vaginally. Failure to generate regular contractions and cervical change after at least 24 hours of oxytocin administration with AROM (if feasible) or at least 12 hours after membrane rupture Rouse DJ, et al. Failed Labor Induction: Toward an Objective Diagnosis. Obstet Gynecol 2011;117:267 Spong CY et al. Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol;120:1181

Preventing the First Cesarean Delivery NICHD recommended Quality Measures Rate of nonmedically indicated cesarean delivery Rate of nonmedically indicated induction Rate of labor arrest or failed induction diagnosed without meeting accepted criteria Rate of cesarean deliveries for nonreassuring fetal heart rate (NICHD Guidelines) Rate of cesarean section for singleton gestation, vertex presentation, at 37 0/7 to 41 6/7 weeks of gestation Spong CY et al. Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol;120:1181