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JOGC

Management of Spontaneous Labour at Term in Healthy Women

      Abstract

      Objective

      The purpose of this guideline is to provide guidance for the intrapartum management of spontaneous labour, whether normal or abnormal, in term, healthy women, and to provide guidance in the management of first and second stage dystocia to increase the likelihood of a vaginal birth and optimize birth outcomes.

      Evidence

      Published literature was retrieved through searches of PubMed and the Cochrane Library in October 2011 using appropriate, controlled vocabulary (e.g., labour pain; labour, obstetric; dystocia) and key words (e.g., obstetric labor, perineal care, dysfunctional labor). When appropriate, results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Results were limited to the last 10 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 Preventive Health Care (Table 1).

      Summary Statements

      • 1.
        The duration of the first stage of labour increases with maternal age and body mass index. (II-2)
      • 2.
        In low-risk nulliparous women in the active phase of labour (i.e., equal to or greater than 4 cm dilatation), progress of cervical dilatation greater than or equal to 0.5 cm/hour is considered normal. (II-2)
      • 3.
        Each labour unit should have a guideline for opioid use during labour that includes the method of action, average and maximum doses, route of administration, possible maternal and fetal side effects, precautions, and opioid antagonists and resuscitative measures for each drug. (III)
      • 4.
        Epidural analgesia provides the most effective pain relief for women in labour. The timing of initiation of labour epidural is dependent on the woman’s choice once the diagnosis of labour has been established. (I)

      Recommendations

      • 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 dilatation) is established. (II-2A)
      • 2.
        Documentation and communication of labour progress are important aspects of labour management. Labour and delivery units should establish local policy regarding labour documentation, including partogram use and its application in labour management. (III-A)
      • 3.
        Women should be informed of the benefits of upright positioning in labour and encouraged and assisted to assume whatever positions they find most comfortable. (I-B)
      • 4.
        Women who are at low risk of requiring general anesthesia should have the choice to eat or drink as desired or tolerated in labour. (I-A)
      • 5.
        Continuous labour support is recommended for all women in active labour. Each labour unit should aim to provide the opportunity for each woman to receive continuous 1-to-1 labour support. (I-A)
      • 6.
        Amniotomy and oxytocin, in addition to other measures, should be considered once a diagnosis of dystocia has been made in either the first or second stage of labour. (I-B)
      • 7.
        Women and health care providers should have information about coping strategies for early labour and mechanisms for accessing support from caregivers. (III-A)
      • 8.
        When appropriate, health care providers should support women in their choice of analgesic options in labour. These may include pharmacological and non-pharmacological measures. (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)
      • 10.
        The use of meperidine as labour analgesia should be avoided due to its long-acting active metabolites and negative effects on neonatal behaviours. (II-2B)
      • 11.
        Low-dose epidural, when available, is preferred over high-dose epidural for labour analgesia and in promoting mobility in labour. (I-A)
      • 12.
        Women who receive an epidural should be encouraged to maintain mobility and flexibility in positions of comfort throughout labour. (I-B)
      • 13.
        Once an epidural has been established, the infusion should be continued until completion of the third stage of labour. (I-A)
      • 14.
        Pushing, as a component of second stage progress, may commence when the cervix is fully dilated, the presenting part is confirmed to be engaged, and the woman feels an urge to push. (III-A)
      • 15.
        Delayed pushing is preferred when the woman has no urge to push, particularly if the presenting part is above station +2 and/or in a non-occiput anterior position, assuming the fetus does not display abnormal monitoring and the pregnant woman’s status is satisfactory. (I-A)
      • 16.
        Delay of pushing according to parity and the presence or absence of an epidural should follow the time limits described in the text unless there are extenuating circumstances. (II-2B)
      • 17.
        The method of pushing, spontaneous or directed with Valsalva manoeuvre, should be chosen using the woman’s own preference. Directed pushing may assist with the final expulsion of the head. (II-2B)
      • 18.
        Avoid the use of routine episiotomy in spontaneous vaginal births. (I-A)
      • 19.
        Prophylactic oxytocics should be given after the delivery of the baby. (I-A)
      • 20.
        In term and preterm infants who do not require neonatal resuscitation, delayed umbilical cord clamping for 60 seconds is recommended irrespective of the mode of delivery. (I-B)
      • 21.
        Dystocia should not be diagnosed prior to the onset of the active phase of the first stage of labour or before the cervix is at least 4 cm dilated. (II-2D)
      • 22.
        Oxytocin augmentation should be titrated to avoid tachysystole or excessive uterine activity and to produce a uterine contraction pattern of 4 to 5 contractions in 10 minutes (200 Montevideo units). A minimum of 4 to 6 hours of adequate uterine activity may be required to achieve the desired response. (I-A) It is recommended that every obstetrical unit have an identified and accessible protocol that includes a starting dose, increment interval, and maximum dose. Consistent use of 1 standard approach to oxytocin administration in any 1 obstetrical unit should be considered. (III-A)
      • 23.
        Operative delivery less than 2 hours after commencing pushing is not recommended, provided maternal status and fetal surveillance are normal. (III-D)
      • 24.
        When the second stage exceeds the recommended time limits (see text), consideration should be given to expediting delivery. Extending these time limits may be appropriate in the presence of continued descent of the head, satisfactory maternal and fetal status, and imminent vaginal birth. (II-2B)
      • 25.
        High-dose oxytocin regimens have been shown to decrease labour duration compared with low-dose regimens. The lowest dose needed to produce normal progress is recommended to reduce the risk of tachysystole or excessive uterine activity and to create a uterine contraction pattern of 3 to 5 contractions or 200 or more Montevideo units every 10 minutes. (I-A)

      Key Words

      Abbreviations:

      AMTSL (active management of the third stage of labour), BMI (body mass index), CCT (controlled cord traction), CLS (continuous labour support), CS (Caesarean section), IUPC (intrauterine pressure catheter), IV (intravenous), OASIS (obstetrical anal sphincter injuries), PCEA (patient-controlled epidural analgesia), PPH (postpartum hemorrhage), RCT (randomized controlled trial), SOGC (Society of Obstetricians and Gynaecologists of Canada), TENS (transcutaneous electrical nerve stimulation)
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      Linked Article

      • Prise en charge du travail spontané chez les femmes en santé, à terme
        Journal of Obstetrics and Gynaecology Canada Vol. 38Issue 9
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          La présente directive vise à fournir des conseils concernant la prise en charge du travail spontané intrapartum, normal ou anormal, à terme, chez les femmes en santé, ainsi que des conseils relatifs à la prise en charge de la dystocie lors du premier et du deuxième stade du travail, pour favoriser l’accouchement vaginal et optimiser les issues de la grossesse.
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