Labor Induction in Nulliparous Patients

PQCNC Spring Meeting April 9, 2013

Arthur Ollendorff, MD
Medical Director MAHEC OB/GYN Specialists Asheville, NC Clinical Professor of OB/GYN University of North Carolina SOM Arthur.Ollendorff@mahec.net

Objectives
Summarize

the statistics and evidence behind induction of labor (IOL) Review the Community Care of North Carolina (CCNC) Pregnancy Medical Home pathway for induction of nulliparous patients

Induction of Labor
Rates

have been increasing over the past 20 years Reasons are unclear but may include
l Patient/Provider

preference l Increasing medical complications among pregnant women l Access to care in certain areas

US Births: Rates of Cesarean Delivery and Induction of Labor

35 30

25

Percent

20 IOL 15 C/S

10

0 1990 2000 2005 2008

U.S. National Center for Health Statistics

U.S. Induction Rate Change by Gestational Age (1990-2005)

National Vital Statistics Reports; Vol 56, no 6.

NC Births: Rates of Cesarean Delivery and Induction of Labor (2007-2011)

35 30

25

20 IOL 15 C/S

10

0 2007 2008 2009 2011

The Baby Book. NC State Center for Health Statistics

IOL Is Not a Bad Thing

Critical

to distinguish elective from medically indicated induction

l Patient

counseling l Patient safety l Data collection

Elective

IOL is necessary at times but should be used judiciously

Obstetrics is a Balance

In order to review any IOL pathway

1.

2. 3. 4.

What are the medical indications for IOL? What are the risks of IOL? What is a failed induction? How can we choose the patients most likely to have a successful IOL?

Medical Indications for IOL

There

is some consensus and far less data to support the best practice for induction of labor in certain clinical situations There are some guidelines that exist based primarily on expert opinion

Medical Indications for IOL

Abruptio placentae Chorioamnionitis Fetal demise Gestational hypertension Preeclampsia, eclampsia Premature rupture of membranes Post-term pregnancy Maternal medical conditions (eg, diabetes mellitus, renal disease, chronic pulmonary disease, chronic hypertension, antiphospholipid syndrome) Fetal compromise (severe fetal growth restriction, isoimmunization, oligohydramnios)

Induction of Labor. ACOG Practice Bulletin No. 107. August 2009.

Non-medical Indications for IOL

Labor l risk

also may be induced logistic reasons

of rapid labor l distance from hospital l psychosocial indications.

Induction of Labor. ACOG Practice Bulletin No. 107. August 2009.

Indications and Timing for Late Preterm Delivery

Condition Chronic Hypertension Mild Pre-eclampsia Diabetes, well-controlled Diabetes, poorly controlled Fetal congenital malformations GA 36-39 weeks 37 weeks EIOL not advised 34-39 weeks 34-39 weeks

Oligohydramnios, isolated and persistent 36-37 weeks

Spong et al Obstetrics & Gynecology (2011) 118(2)

Latest ACOG Opinion (April 2013)

Non-medically Indicated Early-Term Deliveries. ACOG Committee Opinion 561. April 2013

What are the risks of IOL?

Cesarean

delivery Prolonged labor Increased risk of chorioamnionitis Postpartum hemorrhage Tachysystole Neonatal morbidity

Nullipara Rate of Cesarean Section: Spontaneous vs. Induced Labor

20 18 16

Frequency of Cesarean Delivery (%)

14 12 10 8 6 4 2 0 Seyb Maslow Cammu Dublin EIOL Spontanous Labor

Adapted from WA Grobman. Semin Perinatol 36:344-347

What is a Failed Induction?

A.

B. C.

Not able to get patient into active labor Not achieving a vaginal delivery Both

Failed Induction
Defined

as not able to achieve active labor during the course of induction A latent phase of as long as 18 hours during induction of labor in nulliparous women allows the majority of these women to achieve a vaginal delivery

Simon et al. Obstet Gynecol 2005; 105:7059

Defining Arrest of Labor

Conventional Wisdom 4 cm defines active labor Arrest of dilation after 2 hours of adequate contractions in active phase Second stage should last no more than 3 hours Newer Data Suggests 6 cm defines active labor Arrest of dilation after 4 hours of adequate contractions in active phase Second stage may last up to 4 hours

El-Sayed YY. Diagnosis and Management of Arrest Disorders: Duration to Wait. Semin Perinatol 2012; 36:374-378.

Practical Considerations
Indication l Provider

for Induction

may rightfully be less patient in a patient with severe pre-eclampsia than for another indication

Method l Foley

of Induction

bulb will get a patient to 4-5 cm fairly quickly but are they actually in labor?

Can We Predict Successful IOL Candidates?

Patients

with an unfavorable cervix have a higher chance of Cesarean delivery than those with a favorable cervix Cervical ripening does not lower the risk of Cesarean delivery
l Decreases

failed induction l Shortens time from induction to delivery

Bishop Score
Score of < 6 is unfavorable Score of 8 confers same likelihood of vaginal delivery as spontaneous labor

Why Did CCNC PMH Develop an Induction Guideline?

Judicious

use of induction can help meet two of PMH goals

l Reduction

in Cesarean Section l Eliminate elective IOL prior to 39 weeks

It

dovetails well with several other national initiatives

Ashe Watauga

Alleghany

Wilkes

Madison

Polk

Caldwell Alexander

Graham Cherokee

Clay

Swain

Haywood Jackson

Buncombe

McDowell

Burke

Surry

Yadkin

Stokes

Davie

Henderson

Rutherford

Macon

Catawba Lincoln

Cleveland

Gaston

Iredell

Rowan

Cabarrus

Mecklenburg

Union

Guilford

Forsyth

Rockingham Caswell Person

Granville

Warren

Northhampton Halifax

Orange

Durham

Franklin

Davidson

Wake

Johnston

Nash

Hertford Bertie

Randolph

Chatham Lee

Stanly

Harnett

Montgomery

Moore

Wilson

Edgecombe Martin

Gates
Chowan

r Dare

Vance

Alamance

Washington

Tyrrell Hyde

Wayne

Greene Lenoir

Richmond

Anson

Hoke

Cumberland

Sampson

Pitt

Beaufort

Scotland

AccessCare Network Sites AccessCare Network Coun?es Community Care of Western North Carolina Community Care of the Lower Cape Fear Carolina Collabora?ve Community Care Community Care of Wake and Johnston Coun?es Community Care Partners of Greater Mecklenburg Carolina Community Health Partnership Source: CCNC March 2013

Legend Community Care Plan of Eastern Carolina Community Health Partners Northern Piedmont Community Care Northwest Community Care Partnership for Community Care Community Care of the Sandhills Community Care of Southern Piedmont

Craven Jones

Pamlico

Duplin

Robeson

Bladen

Onslow Pender
New Hanover

Carte

ret

Columbus

Brunswick

CCNC Pregnancy Medical Home Program

An

outcome-driven initiative monitored for specific performance standards

l Participating

practices receive financial incentives and support from the local CCNC network l Practices agree to work toward quality improvement goals

Pregnancy Medical Home Program Quality Goals

Reducing elective deliveries prior to 39 weeks Performing standardized initial risk screening
l

Collaborating with pregnancy care management programs to serve high-risk patients

Using 17P to prevent recurrent preterm birth Reducing primary Cesarean Section rate

NC Pregnancy Medical Pathways

Collaborative l to

effort of the Pregnancy Medical Home Physician Champions

promote evidence-based, best practice care statewide

Three

pathways currently exist

l Hypertensive

Diseases in Pregnancy l Screening for Preterm Delivery l Induction of Labor-Nullipara

Choosing Wisely
An

initiative by ABIM Foundation to help physicians and patients engage in conversations to reduce overuse of tests and procedures ACOG is a partner in this initiative
l Identified

Five Things Physicians and Patients Should Question

Disclaimer
Pregnancy Medical Home Care Pathways are intended to assist providers of obstetrical care in the clinical management of problems that can occur during pregnancy. They are intended to support the safest maternal and fetal outcomes for patients receiving care at North Carolina Pregnancy Medical Home practices. This pathway was developed after reviewing the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists resources such as practice bulletins, committee opinions, and Guidelines for Perinatal Care as well as current obstetrical literature. PMH Care Pathways offer a framework for the provision of obstetrical care, rather than an inflexible set of mandates. Clinicians should use their professional knowledge and judgment when applying pathway recommendations to their management of individual patients.

Highlights of the CCNC Induction Pathway

Intended

for nulliparous patients only Do not induce labor before 39 weeks unless there is a medical indication Do not electively induce labor with an unfavorable cervix before 41 weeks

First Decision Point

Second Decision Point

Medical Indication Side

Elective Indication Side

End of Pathway

ACOG Patient Safety Checklist No. 5

References used for CCNC IOL Pathway

1. 2. 3.

4.

5.

6.

7.

8.

Induction of Labor. ACOG Practice Bulletin No. 107, August 2009 Fetal Lung Maturity. ACOG Practice Bulletin No. 97, September 2008. Spong CY, Mercer BM, DAlton M, et al. Timing of indicated latepreterm and early-term birth. Obstet Gynecol 2011;118:323-33. ACOG/ACP Guidelines for Perinatal Care, Sixth edition. Washington DC, November 2007. Scheduling induction of labor. Patient Safety Checklist No. 5. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:14734. Grobman WA. Predictors of Induction Success, Semin Perinatol 2012; 36:344-347 Swamy GK. Current Methods of Labor Induction. Semin Perinatol 2012; 36:348-352. El-Sayed YY. Diagnosis and Management of Arrest Disorders: Duration to Wait. Semin Perinatol 2012; 36:374-378.