The development of a midwifery specific tool to enable midwives to identify barriers and enablers to change within the midwifery clinical setting

Abstract

Recommendations on preventing primary cesarean delivery removed the previously defined time limits for latent labor (defined as ending at 6 cm) and urged clinicians to avoid cesarean delivery for labor abnormalities in the latent phase. However, relatively little is known about the implications of labor curve abnormalities from 4 to 6 cm and subsequent outcomes.To examine the association between length of time for dilation from 4 to 6 cm, delivery outcomes, and maternal and neonatal morbidity.This is a secondary analysis of a prospective cohort study of patients at ≥37 weeks presenting in spontaneous or induced labor with a nonanomalous living singleton in vertex presentation. Patients with a history of cesarean delivery or who did not achieve 6-cm dilation were excluded. We used interval censored regression to determine the 90th percentile for dilation time from 4 to 6 cm and used logistic regression to estimate the odds ratios and 95% confidence intervals for adverse outcomes for patients above this cutoff percentile compared with those at or below. Analyses were adjusted for obesity, nulliparity, race, hypertension, diabetes, and type of labor (induced vs spontaneous/augmented). Outcomes included cesarean delivery, maternal morbidity (composite of postpartum fever, wound infection, hemorrhage), and neonatal morbidity (composite of neonatal death, hypothermic therapy, mechanical ventilation, respiratory distress, meconium aspiration syndrome, seizure, or treatment of sepsis). In addition, we created receiver operator characteristic curves to predict cesarean delivery, and maternal and neonatal morbidity based on time to dilate from 4 to 6 cm. The cutoff for time for each outcome was identified using the Youden index to maximize sensitivity and specificity, and test characteristics were computed.There were 7355 patients eligible for analysis, 728 (10%) had dilation times from 4 to 6 cm >10.3 hours, which was the 90th percentile, and 6627 (90%) had dilation times ≤10.3 hours. Having dilation time from 4 to 6 cm above the 90th percentile (10.3 hours) was associated with cesarean delivery (adjusted odds ratio, 2.05; 95% confidence interval, 1.67–2.52), composite maternal morbidity (adjusted odds ratio, 1.48; 95% confidence interval, 1.10–2.00), and composite neonatal morbidity (adjusted odds ratio 1.92; 95% confidence interval 1.52–2.4). The area under the receiver operator characteristic curve for predicting cesarean delivery was 0.73 (95% confidence interval, 0.71–0.75). The test characteristics for the cutoff of 9.75 hours were sensitivity 68.3% (95% confidence interval, 64.8%–71.7%), specificity 66.2% (95% confidence interval, 55.0%–67.3%), positive predictive value 18.5% (95% confidence interval, 17.1%–20.0%), and negative predictive value 94.9% (95% confidence interval, 94.2%–95.5%). For composite maternal morbidity, the cutoff was 6.98 hours and the area under the curve was 0.62 (95% confidence interval, 0.59–0.65), whereas for composite neonatal morbidity it was 5.5 hours (area under the curve 0.69; 95% confidence interval, 0.67–0.71).Patients whose dilation time from 4 to 6 cm exceeds the 90th percentile have increased odds of cesarean delivery and postpartum complications. Prolonged dilation time has moderate predictive ability for adverse outcomes. Future studies should investigate at what point, if any, intervention is warranted during this period to reduce these risks.