NICE guidelines for management of labour: First stage of labour Bronselaer Bart 21-02-2008 Pretoria, South Africa

Aim of guideline Clinical guidelines have been defined as ‘systematically developed statements which assist clinicians and patients in making decisions about appropriate treatment for specific conditions’. The guideline has been developed with the aim of providing guidance on care of healthy women and their babies during childbirth.

Normal labour: Friedman’s curve (1967)

Normal labour: First stage Definition Latent first stage of labour – a period of time, not necessarily continuous, when: there are painful contractions, and there is some cervical change, including cervical effacement and dilatation up to 4 cm. Active first stage of labour – when: there are regular painful contractions, and there is progressive cervical dilatation from 4 cm.

Duration of the first stage Length of established first stage of labour varies between women.  First labours last on average 8 hours and are unlikely to last over 18 hours.  Second and subsequent labours last on average 5 hours and are unlikely to last over 12 hours Cervical dilatation of 2 cm in 4 hours for first labours (0,5 cm/h)

Duration of the first stage: South-Africa Philpott and Castle 1972: - Introduction of Alert line in primigravidae - Cervical dilatation of 1 cm in 1 hour - slowest progressing 20% of primigravidae

Monitoring of progress of labour The partogram should be used once labour is established. Where the partogram includes an action line, the WHO recommendation of a 4-hour action line should be used. 4-hourly temperature and blood pressure hourly pulse half-hourly documentation of frequency of contractions frequency of emptying the bladder vaginal examination offered 4-hourly, or where there is concern about progress or in response to the woman’s wishes (after abdominal palpation and assessment of vaginal loss).

WHO partogram

4 hour action line: 3 RCT’s World Health Organization partograph in management of labour. World Health Organization Maternal Health and Safe Motherhood Programme. Lancet 1994;343(8910):1399–404. Lavender T, Alfirevic Z, Walkinshaw S. Partogram action line study: a randomised trial. BJOG: 1998;105(9):976–80. Pattinson RC, Howarth GR, Mdluli W, et al. Aggressive or expectant management of labour: a randomised clinical trial. BJOG: 2003;110(5):457–61  Reduces the likelihood of CS.

 increase mother’s satisfaction Lavender T et al: Partogram action line study: a randomised trial. BJOG: 1998 2h vs 3h Action Line:  increase mother’s satisfaction  no evidence of a difference in interventions  amniotomy (OR 0.9)  epidural (OR 1,3)  CS for failure (OR 0,7)  instrumental birth (OR 0,9)  no evidence of a difference in neonatal outcome

 increases the rate of CS (OR 1.8) 3h vs 4h Action Line  increases the rate of CS (OR 1.8)  no increase of CS for fetal distress or failure to progress  no evidence of a difference in other interventions, women’s satisfaction or neonatal outcome 2h vs 4h Action Line  increase women’s satisfaction  no evidence of a difference in rate of interventions or neonatal outcome.

Pattinson RC, et al. Aggressive or expectant management of labour: a randomised clinical trial. BJOG: 2003 Aggressive Mx: Single line partogram, vaginal examination every two hours and use of an oxytocin infusion if the line was crossed Expectant Mx 2 line partogram: alert line and 4h action line vaginal examination every four hours. If the action line was reached, oxytocin was started. The women were reassessed every two hours thereafter

Aggressive MX: Reduction:  rate of CS (RR 0.68)  instrumental births (RR 0.73) Increasing use of oxytocin (RR 1.51) There was no evidence of differences in use of analgesia (RR 1.01), neonatal outcomes (RR 1.24) or perinatal death RR 7.12

Evidence from low income settings show that the use of partograms, that have an action line, increases vaginal birth and reduces maternal morbidity. A 4 hour action line is associated with fewer intrapartum interventions than a 2 hour action line with the same outcomes. There is no current evidence on the efficacy or otherwise of partograms without action or alert lines.  Placing an action line earlier than that recommended by the WHO (at 4 hours) increases interventions without any benefit in outcomes to either woman or baby.

4 hourly vaginal examination Abukhalil et al. 1996;  109 nulliparous in spt labour at term  2 hourly VS 4 hourly VE  no significant difference in duration of labour  no difference in the number of VEs  increase maternal and neonatal sepsis when PPROM

In normally progressing labour, amniotomy should not be performed routinely. Combined early amniotomy with use of oxytocin should not be used routinely.

Delay in active first stage of labour Cervical dilatation of less than 2 cm in 4 hours for first labours (< 0,5 cm/h) Cervical dilatation of less than 2 cm in 4 hours or a slowing in the progress of labour for second or subsequent labours Descent and rotation of the fetal head Changes in the strength, duration and frequency of uterine contractions.

Managing active phase South Africa 2 hourly VE, Transfer line Progress to left of alert line:  Continu monitoring mother and fetus Progress crosses alert line:  Make diagnose and act: 4 P’s (Patient, Power, Passenger, Passage)

Patient, Passenger Malposition, maternal distress, pain, dehydration  improve maternal status, reassess in 2h  if left of TL: reassess in 2h  if crosses TL: consider C/S

Power Passage Poor contractions:  start Oxytocinon safely Disproportion: consider C/S

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