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Labor Induction in
Nulliparous Patients
PQCNC Spring Meeting
April 9, 2013
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Arthur Ollendorff, MDMedical Director
MAHEC OB/GYN Specialists
Asheville, NC
Clinical Professor of OB/GYN
University of North Carolina SOM
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Objectives
Summarize the statistics andevidence behind induction of labor
(IOL) Review the Community Care of North
Carolina (CCNC) Pregnancy Medical
Home pathway for induction of
nulliparous patients
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Induction of Labor
Rates have been increasing over thepast 20 years
Reasons are unclear but may includelPatient/Provider preferencel Increasing medical complications
among pregnant womenlAccess to care in certain areas
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0
5
10
15
20
25
30
35
1990 2000 2005 2008
IOL
C/S
US Births: Rates of Cesarean
Delivery and Induction of Labor
U.S. National Center for Health Statistics
Percent
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U.S. Induction Rate Change by
Gestational Age (1990-2005)
National Vital Statistics Reports; Vol 56, no 6.
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NC Births: Rates of Cesarean Delivery and
Induction of Labor (2007-2011)
0
5
10
15
20
25
30
35
2007 2008 2009 2011
IOL
C/S
The Baby Book. NC State Center for Health Statistics
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IOL Is Not a Bad Thing
Critical to distinguish elective frommedically indicated induction
lPatient counselinglPatient safetylData collection
Elective IOL is necessary at times butshould be used judiciously
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Obstetrics is a Balance
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In order to review any IOL
pathway
1. What are the medical indications forIOL?
2. What are the risks of IOL?3. What is a failed induction?4. How can we choose the patients
most likely to have a successful IOL?
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Medical Indications for IOL
There is some consensus and far lessdata to support the best practice for
induction of labor in certain clinicalsituations
There are some guidelines that existbased primarily on expert opinion
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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, chronichypertension, antiphospholipid syndrome)
Fetal compromise (severe fetal growth restriction,isoimmunization, oligohydramnios)
Induction of Labor. ACOG Practice Bulletin No. 107. August 2009.
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Non-medical Indications for
IOL
Labor also may be induced logisticreasons
lrisk of rapid laborldistance from hospitallpsychosocial indications.
Induction of Labor. ACOG Practice Bulletin No. 107. August 2009.
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Indications and Timing for
Late Preterm Delivery
Spong et alObstetrics & Gynecology (2011) 118(2)
Condition GA
Chronic Hypertension 36-39 weeks
Mild Pre-eclampsia 37 weeks
Diabetes, well-controlled EIOL not advised
Diabetes, poorly controlled 34-39 weeks
Fetal congenital malformations 34-39 weeks
Oligohydramnios, isolated and persistent 36-37 weeks
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Latest ACOG Opinion (April 2013)
Non-medically Indicated Early-Term Deliveries. ACOGCommittee Opinion 561. April 2013
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What are the risks of IOL?
Cesarean delivery Prolonged labor Increased risk of chorioamnionitis Postpartum hemorrhage Tachysystole Neonatal morbidity
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Nullipara Rate of Cesarean Section:
Spontaneous vs. Induced Labor
0
2
4
6
8
10
12
14
16
18
20
Seyb Maslow Cammu Dublin
EIOL
Spontanous Labor
Frequen
cyofCesarean
Delivery(%)
Adapted from WA Grobman. Semin Perinatol 36:344-347
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What is a Failed Induction?
A. Not able to get patient into activelabor
B. Not achieving a vaginal deliveryC. Both
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Failed Induction
Defined as not able to achieve activelabor during the course of induction
A latent phase of as long as 18 hoursduring 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
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Defining Arrest of Labor
Conventional Wisdom
4 cm defines active laborArrest of dilation after 2
hours of adequatecontractions in activephase
Second stage should lastno more than 3 hours
Newer Data Suggests
6 cm defines active labor Arrest of dilation after 4
hours of adequatecontractions in activephase
Second stage may last upto 4 hours
El-Sayed YY. Diagnosis and Management of Arrest Disorders:Duration to Wait. Semin Perinatol 2012; 36:374-378.
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Practical Considerations
Indication for InductionlProvider may rightfully be less patient
in a patient with severe pre-eclampsiathan for another indication
Method of InductionlFoley bulb will get a patient to 4-5 cm
fairly quickly but are they actually in
labor?
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Can We Predict Successful
IOL Candidates?
Patients with an unfavorable cervixhave a higher chance of Cesarean
delivery than those with a favorablecervix
Cervical ripening does not lower therisk of Cesarean delivery
lDecreases failed inductionlShortens time from induction to
delivery
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Bishop Score
Score of < 6 isunfavorable
Score of
8confers same
likelihood of
vaginal delivery
as spontaneouslabor
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Why Did CCNC PMH Develop
an Induction Guideline?
Judicious use of induction can helpmeet two of PMH goals
lReduction in Cesarean SectionlEliminate elective IOL prior to 39
weeks
It dovetails well with several othernational initiatives
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CherokeeGraham
Swain
Clay MaconJackson
Haywood
Madison
Buncombe
Henderson
McDowellRutherford
Polk
Burke
Cleveland
Watauga
CaldwellAlexander
CatawbaLincolnGaston
Ashe
Wilkes
AlleghanySurry
Yadkin
Iredell
Mecklenburg
Union
StanlyCabarrus
Rowan
Davie
Stokes
Forsyth
Davidson
Anson
Rockingham
Guilford
Randolph
Montgomery
Richmond
Caswell
Chatham
Orange
Person
LeeMoore
HokeScotland
Robeson
Cumberland
Harnett
Wake
Va
nce
Franklin
Warren
Johnston
Sampson
Bladen
ColumbusBrunswick
Pender
Duplin
Wayne
Wilson
Nash
HalifaxNorthhampton
Edgecombe
PittGreeneLenoir
Jones
Onslow Carteret
CravenPamlico
BeaufortHyde
Martin
Bertie
HertfordGates
WashingtonTyrrellDare
Alamance DurhamGranville
Ne
wHanover
Chowan
ar
Source:CCNCMarch2013
Legend
AccessCareNetworkSites CommunityCarePlanofEasternCarolina
AccessCareNetworkCoun?es CommunityHealthPartners
CommunityCareofWesternNorthCarolina NorthernPiedmontCommunityCare
CommunityCareoftheLowerCapeFear NorthwestCommunityCare
CarolinaCollabora?veCommunityCare PartnershipforCommunityCare
CommunityCareofWakeandJohnstonCoun?es CommunityCareoftheSandhills
CommunityCarePartnersofGreaterMecklenburg CommunityCareofSouthernPiedmont
CarolinaCommunityHealthPartnership
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CCNC Pregnancy Medical
Home Program
An outcome-driven initiative monitoredfor specific performance standards
lParticipating practices receivefinancial incentives and support fromthe local CCNC network
lPractices agree to work toward qualityimprovement goals
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Pregnancy Medical Home
Program Quality Goals
Reducing elective deliveries prior to 39weeks
Performing standardized initial riskscreening
l Collaborating with pregnancy caremanagement programs to serve high-risk
patients
Using 17P to prevent recurrent preterm birth Reducing primary Cesarean Section rate
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NC Pregnancy Medical
Pathways
Collaborative effort of the PregnancyMedical Home Physician Champions
l to promote evidence-based, bestpractice care statewide
Three pathways currently existlHypertensive Diseases in PregnancylScreening for Preterm Deliveryl Induction of Labor-Nullipara
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Choosing Wisely
An initiative by ABIM Foundation tohelp physicians and patients engage
in conversations to reduce overuse oftests and procedures
ACOG is a partner in this initiativel Identified Five Things Physicians and
Patients Should Question
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Disclaimer
Pregnancy Medical Home Care Pathways are intended to assistproviders of obstetrical care in the clinical management of
problems that can occur during pregnancy. They are intended tosupport the safest maternal and fetal outcomes for patients
receiving care at North Carolina Pregnancy Medical Homepractices. This pathway was developed after reviewing the Society
for Maternal-Fetal Medicine and the American College of
Obstetricians and Gynecologists resources such as practicebulletins, 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 aninflexible set of mandates. Clinicians should use their professional
knowledge and judgment when applying pathwayrecommendations to their management of individual patients.
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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
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First Decision Point
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Second Decision Point
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Medical Indication Side
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Elective Indication Side
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ACOG Patient Safety
Checklist No. 5
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References used for CCNC IOL
Pathway
1. Induction of Labor. ACOG Practice Bulletin No. 107, August 20092. Fetal Lung Maturity. ACOG Practice Bulletin No. 97, September 2008.3. Spong CY, Mercer BM, DAlton M, et al. Timing of indicated late-
preterm and early-term birth. Obstet Gynecol 2011;118:323-33.
4.ACOG/ACP Guidelines for Perinatal Care, Sixth edition. WashingtonDC, November 2007.
5. Scheduling induction of labor. Patient Safety Checklist No. 5. AmericanCollege of Obstetricians and Gynecologists. Obstet Gynecol
2011;118:14734.
6. Grobman WA. Predictors of Induction Success, Semin Perinatol 2012;36:344-347
7. Swamy GK. Current Methods of Labor Induction. Semin Perinatol 2012;36:348-352.
8. El-Sayed YY. Diagnosis and Management of Arrest Disorders: Durationto Wait. Semin Perinatol 2012; 36:374-378.