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Grand Rounds

What is the Length of Latent Phase that Defines a ‘Failed Induction of Labor’?

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BACKGROUND AND PURPOSE:

  • There is lack of agreement regarding the amount of time required before labelling an induction of labor as ‘failed’
  • Grobman et al. (AJOG, 2018) assessed adverse maternal and neonatal outcomes in nulliparous women associated with the duration of the latent phase

METHODS:

  • Observational Cohort Study
    • NICHD MFMU (APEX study; 2008-2011)
    • Obstetric cohort of nulliparous women who had a term (≥37 weeks) singleton gestation in the cephalic presentation and underwent a labor induction
  • Latent phase
    • Start time: Once cervical ripening has ended (no longer used), oxytocin has been initiated, and rupture of membranes had occurred (spontaneous or artificial)
    • End time: Once 5-cm dilation occurred
  • Primary perinatal outcomes (as a function of the duration of the latent phase)
    • Frequency of cesarean delivery
    • Adverse maternal outcomes
  • Primary neonatal outcome defined as a composite of the following, including any
    • Seizures
    • Culture-proven sepsis
    • Bone or nerve injury
    • Encephalopathy
    • Death

RESULTS:

  • 10,677 women were included in the analyses
    • 1725 (16.2%) underwent induction for PROM
    • 5582 (52.3%) underwent cervical ripening
  • Approximately 2/3 of women had progressed to active labor by 6 hours
  • 96.4% of women progressed to active phase by 15 hours
  • The longer the latent phase, the greater the chance of cesarean delivery (P <.001)
    • >40% of women whose latent phase lasted ≥18 hours still had a vaginal delivery
  • With longer latent phase, frequency was increased for
    • Postpartum hemorrhage (P <.001)
    • Chorioamnionitis (P <.001)
    • PPH (P <.001)
  • Frequency of adverse neonatal outcomes were stable and did not differ over time including
    • Primary composite neonatal outcome
    • Low Apgar score
    • Acidemia
    • Shoulder dystocia
  • NICU admission did increase with duration of latent phase

CONCLUSION:

  • The frequency of adverse maternal outcomes increased as the latent phase lengthened
  • The absolute risk of adverse maternal outcomes was relatively small
  • This study suggests that cesarean delivery should not be opted for until 15 hours after administered oxytocin and rupture of membranes
  • Following 15 hours, management should be individualized

Learn More – Primary Sources:

Defining failed induction of labor

 

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Practical info on evidence based medicine for your women's healthcare practice
Labor Induction and an Unripe Cervix: Does it Result in More C-sections?
Cochrane Review 2017: Outpatient Cervical Ripening and Labor Induction
Induction to Prevent Stillbirths for Age 35 and Older: Impact on Cesarean Rates?
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