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When is an induced labor “prolonged”? (Your guess is as good as mine.)

I seriously have no time to blog right now. I’m flying to Orlando for the Lamaze Conference this afternoon, and there’s plenty on the to do list still! But I was putting the finishing touches on my powerpoint talk this morning and I had to get a little something off my chest. My talk is called Optimizing Labor Progress: What the Research Does and Does Not Tell Us. I of course include a section about how we define labor progress (debunking the Friedman Curve, etc.)  At the last moment, I added this slide:

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That’s right, we have essentially no data on how “normal” labor should progress when labor is induced. And in fact, the recent Practice Bulletin describing the clinical management of induction of labor put out by American College of Obstetricians and Gynecologists provides no guidance on how to assess or promote healthy progress in induced labors. The Practice Bulletin also provides no information to help providers or women themselves determine when the harms of cesarean surgery are outweighed by the benefits of getting a baby out sooner.  The only thing ACOG has to say on the matter is this:

Labor progression differs significantly for women with an elective induction of labor compared with women who have spontaneous onset of labor. Allowing at least 12–18 hours of latent labor before diagnosing a failed induction may reduce the risk of cesarean delivery. (p. 698)

ACOG cites only one study to support the fact that induced labors don’t progress the same way that spontaneous labors do. That study was undertaken in first time mothers undergoing elective induction, hardly a group whose outcomes can be generalized to all induced labors.

I’m just wondering, how are clinicians supposed to make rational decisions about when to recommend a cesarean in an induced labor? And how are women to know whether to go along with those recommendations? I have a feeling I’ll be blogging about this again soon.

Off to Orlando!

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  1. October 1st, 2009 at 09:43 | #1

    I hope you do blog about this again soon.

    Enjoy the conference.

  2. October 1st, 2009 at 10:07 | #2

    I so wish you were going to be there!

  3. avatar
    alexa gilbert
    October 1st, 2009 at 11:02 | #3

    This is one of the central aspects of my training as a CNM that I am struggling with–our preceptors vary widely in their practice. One CNM gives two hours after inserting an IUPC to reach adequate montevideo units and if she isn’t there, recommends section….others wait much longer to make that call. Still the question remains, at what point does she need the IUPC…after how long, how little/much progress, etc. Also, OBs recommend section several hours-sometimes full days-earlier than the CNMs at my institution. Very little standardization, lots of variability in practice…. I’d love for you to blog more on this. It is a major issue.

  4. October 1st, 2009 at 11:57 | #4

    So true! Can’t wait to meet you in person a the conference.

  5. October 1st, 2009 at 12:05 | #5

    Likewise, Rixa!

    Alexa, stay tuned. I have at least 3 follow-up posts already writing themselves in my little brain.

  6. avatar
    Susan Jaszemski
    October 1st, 2009 at 12:24 | #6

    Thanks for posting this, even as you were running out the door. I want to share this with every woman I know!!

  7. October 1st, 2009 at 13:18 | #7

    Thank you .. thank you.. thank you – for bringing up this topic.

    We see this all the time – no standardization of protocol following labor induction. Even more so with ARM .. some OBs feel 2 hours is enough – if they are progressing, great. If not section them. No mention of “is she allowed to walk”, “has she been given painkillers” or “epidosin” …and the list can go on. Even if no other interventions are done, and even if she is mobile – how long is long enough before one offers C-Section as an option?

    I would love to hear more of your thoughts on this.

    Vijaya

  8. October 1st, 2009 at 13:22 | #8

    Amy,

    I will be taking part in the some of the Conference sessions through the Virtual Conference facility from India. I just wish your session was available online too! I would have definitely joined in.

    Have a great time at the Conference.

    Vijaya

  9. October 1st, 2009 at 15:21 | #9

    There is some information in ACOG’s Practice Bulletin #106 on Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General management Principals. But, I don’t think it is exactly what you are looking for or anywhere near adequate.

    At some point in the bulletin, the authors state that the term “hyperstimulation” and “hypercontractility” should be abandoned (both would be used to describe one of the complications of an induced labor). They prefer the term “tachysystole”. This is first of two times there is even a sideways referral to induction / augmentation of labor. They write: “The term tachysystole applies to both spontaneous and stimulated labor. The clinical response to tachysystole may differ depending on whether contractions are spontaneous or stimulated.”

    Well, spontaneous onset of labor can still lead to stimulated contractions, since there is a difference between induction and augmentation. Induction usually involves continuous augmentation, and both can lead to hypercontractility and/ or tachysystole, but they should not be grouped together as if they were synonymous. The terms “induction” and “augmentation” do not appear in the document.

    In fact, it does not appear in the section on patients who are “high risk” and should be candidates for continuous external fetal monitoring as opposed to intermittent monitoring. As far as I know, almost every labor and delivery unit in hospitals, even ones that allow intermittent monitoring, say augmentation with Pitocin mandates continuous external fetal monitoring. Well, not in this practice bulletin.

    Neither do the words “Pitocin”, “Oxytocin” or “Cytotec” or “Misoprostol” show up anywhere in the document, for that matter. Interestingly, the section on drugs that may influence fetal heart tones has a noticeable lack of any of these induction or augmentation agents.

    But, even more interestingly, the very first recommendation under the section on what can be done with non-reassuring (Category II or Category III) tracings is “Discontinuation of any labor stimulating agent.”

    Really? Why would that be? Because according to the list of agents we should suspect, none of those agents have a high index of suspicion for affecting fetal heart tones. But, someone seems to think they have enough of an effect that the very first recommendation is that they should be immediately suspended.

    You are also supposed to check her labor progression (dilation, effacement, station, etc). What to do with this information? Not a word.

    And then what? Has the stimulation (which may be an induction) failed? Do you proceed to cesarean? Do you allow the drug to wash out and hope the fetus will recover with other techniques of intrauterine resuscitation? They discuss using tocolytic agents and beta agonists and amnioinfusion. I would think amnioinfusion would not be done if a cesarean was imminent.

    Anyway, they talked around failed induction a lot without ever actually discussing it.

  10. October 1st, 2009 at 15:32 | #10

    Oh, and back to the Friedman curve argument…how many induced moms are given 12 to 18 hours? And twelve to eighteen hours to do what? Deliver? Be progressing steadily and labor is imminent? Does it matter if their membranes are broken (and is this an argument to avoid AROM in these situations?) Does it matter what their Bishop’s score was initially and what the indication is for induction?

  1. October 1st, 2009 at 15:21 | #1
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