taglio cesareo di emergenza nel primo stadio: indicazioni ......cate- gory i fhr patterns may be...

G I U L I A N A S I M O N A Z Z I

Taglio cesareo di emergenza nel primo stadio: indicazioni cliniche e quadri

CTG, tempi e tecniche

TC nel primo stadio: indicazioni cliniche

�  First stage arrest (dystocia) �  Non reassuring fetal heart rate

Major Indications for Primary Cesarean Delivery

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Spong et al. Page 18

Table 1

Major Indications for Primary Cesarean Delivery

Indication %

Prelabor Malpresentation 10–15*

Multiple gestation 3

Hypertensive disorders 3

Macrosomia 3

Maternal request 2–8

In labor First-stage arrest 15–30*

Second-stage arrest 10–25

Failed induction 10

Nonreassuring fetal heart rate 10

Data from Zhang J, Troendle J, Reddy UM, Laughon SK, Branch DW, Burkman R, Landy HJ, Hibbard JU, Haberman S, Ramirez MM, Bailit JL,Hoffman MK, Gregory KD, Gonzalez-Quintero VH, Kominiarek M, Learman LA, Hatjis CG, van Veldhuisen P; Consortium on Safe Labor.Contemporary cesarean delivery practice in the United States. Am J Obstet Gynecol 2010;203:326.e1-326.e10. Epub 2010 Aug 12 and Barber EL,Lundsberg LS, Belanger K, Pettker CM, Funai EF, Illuzzi JL. Indications contributing to the increasing cesarean delivery rate. Obstet Gynecol2011 Jul;118:29–38.

*Percentage of all cesareans that have this as a primary indication.

Some indications may occur both prelabor and in labor.

Obstet Gynecol. Author manuscript; available in PMC 2013 November 01.

Preventing the First Cesarean DeliverySummary of a Joint Eunice Kennedy Shriver National Institute ofChild Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians andGynecologists Workshop

Catherine Y. Spong, MD, Vincenzo Berghella, MD, Katharine D. Wenstrom, MD, Brian M. Mercer, MD,and George R. Saade, MD

With more than one third of pregnancies in the UnitedStates being delivered by cesarean and the growingknowledge of morbidities associated with repeat cesar-ean deliveries, the Eunice Kennedy Shriver National Insti-tute of Child Health and Human Development, theSociety for Maternal-Fetal Medicine, and the AmericanCollege of Obstetricians and Gynecologists conveneda workshop to address the concept of preventing the firstcesarean delivery. The available information on maternaland fetal factors, labor management and induction, andnonmedical factors leading to the first cesarean deliverywas reviewed as well as the implications of the firstcesarean delivery on future reproductive health. Key

points were identified to assist with reduction in cesar-ean delivery rates including that labor induction shouldbe performed primarily for medical indication; if donefor nonmedical indications, the gestational age should beat least 39 weeks or more and the cervix should be favor-able, especially in the nulliparous patient. Review of thecurrent literature demonstrates the importance of adher-ing to appropriate definitions for failed induction andarrest of labor progress. The diagnosis of “failed induc-tion” should only be made after an adequate attempt.Adequate time for normal latent and active phases ofthe first stage, and for the second stage, should beallowed as long as the maternal and fetal conditions per-mit. The adequate time for each of these stages appearsto be longer than traditionally estimated. Operative vag-inal delivery is an acceptable birth method when indi-cated and can safely prevent cesarean delivery. Given theprogressively declining use, it is critical that training andexperience in operative vaginal delivery are facilitatedand encouraged. When discussing the first cesareandelivery with a patient, counseling should include itseffect on future reproductive health.(Obstet Gynecol 2012;120:1181–93)

DOI: http://10.1097/AOG.0b013e3182704880

Cesarean delivery is the most commonly performedmajor surgery in the United States. Approxi-

mately one in three pregnancies is delivered by cesar-ean, accounting for more than 1 million surgeries eachyear.1 In 2007, 26.5% of low-risk women giving birthfor the first time had a cesarean delivery.2 The HealthyPeople target for 2020 is a cesarean delivery rate of23.9% in low-risk full-term women with a singleton,vertex presentation. This is much higher than thenever achieved target cesarean delivery rate of 15%for Healthy People 2010.3 The appropriate rate of

From the Pregnancy and Perinatology Branch, Eunice Kennedy ShriverNational Institute of Child Health and Human Development, National Insti-tutes of Health, Bethesda, Maryland; the Division of Maternal-Fetal Medicine,Department of Obstetrics and Gynecology, Jefferson Medical College of ThomasJefferson University, Philadelphia, Pennsylvania; the Division of Maternal-FetalMedicine, Department of Obstetrics and Gynecology, Brown Alpert School ofMedicine, Women and Infants Hospital, Providence, Rhode Island; the Depart-ment of Obstetrics & Gynecology, MetroHealth Medical Center Case WesternReserve University, Cleveland, Ohio; the Division of Maternal-Fetal Medicine,Department of Obstetrics & Gynecology, University of Texas Medical Branch,Galveston, Texas; and the Publications and Executive Committees of the Societyfor Maternal-Fetal Medicine, Washington, DC.

This article is an executive summary of a Society for Maternal-Fetal Medicine,Eunice Kennedy Shriver National Institute of Child Health and HumanDevelopment, and American College of Obstetricians and Gynecologists workshopthat was held February 7–8, 2012, in Dallas, Texas.

Dr. Spong, Associate Editor of Obstetrics & Gynecology, was not involved inthe review or decision to publish this article.

Corresponding author: Catherine Y. Spong, MD, Chief, Pregnancy andPerinatology Branch, NICHD, NIH, 6100 Executive Boulevard, Room 4B03MSC 7510, Bethesda, MD 20892; e-mail: [email protected].

Financial DisclosureThe authors did not report any potential conflicts of interest.

© 2012 by The American College of Obstetricians and Gynecologists. Publishedby Lippincott Williams & Wilkins.ISSN: 0029-7844/12

VOL. 120, NO. 5, NOVEMBER 2012 OBSTETRICS & GYNECOLOGY 1181

Current Commentary

In addition to monitoring and providing feed-back to clinicians regarding their indications for andrates of primary cesarean deliveries, institutionsshould identify those occurring without an acceptedmedical indication. Of those with specific indications,attention should be paid to cesarean deliveriesoccurring after labor inductions, those labeled as for“nonreassuring fetal status,” and those occurring forlabor arrest or “failed induction” without meetingaccepted criteria (Table 5). A classification system isneeded to track cesarean deliveries, compare ratesbetween practices and over time, perform audits, pro-vide feedback, and identify areas for potential inter-vention.6 Although not uniquely designed forprimary cesarean deliveries, the Robson classificationis an example of a simple method that allows com-parison of cesarean delivery rates between practicesas well as over time.7–9

LABOR MANAGEMENT PRACTICES ANDPRIMARY CESAREAN DELIVERYAntepartum and intrapartum management decisionscan have a profound effect on the individual patient’slikelihood of cesarean delivery. The decision to

induce labor for medical or nonmedical indications,labor management style, the diagnosis and manage-ment of arrest disorders in the first and second stagesof labor, the use of labor neuroaxial anesthesia, theuse of operative vaginal delivery, and evaluation offetal factors as well as nonmedical indications mayaffect the potential for successful vaginal delivery.

Induction of LaborThe overall likelihood of vaginal delivery is lowerafter labor induction than after spontaneous labor,especially when labor induction is attempted ina nulliparous woman with an unfavorable cervix.Institutions should have a clear policy regarding laborinduction, including a list of acceptable indications,and should specify the definitions of a favorablecervix, options for cervical ripening in the presenceof an unripe cervix, oxytocin infusion protocols, andcriteria for the diagnosis of failed induction. Laborinduction with an unfavorable cervix should not beundertaken unless delivery is indicated for clearmaternal or fetal benefit. Any time induction isundertaken, it should be clear that the goal is vaginaldelivery.

Table 2. Selected Potentially Modifiable Obstetric Indications for First Cesarean Delivery

IndicationDiagnosticAccuracy*

Effect on Preventionof First Cesarean

Delivery† Preventive Strategies

Failed induction Limited Large See Table 5 and Figure 1Arrest of labor Limited Large See Table 5 and Figure 3Multiple gestation High Small Prevent multiple gestations: encourage single embryo

transferSafe trial of labor: training for vaginal twin delivery,simulation for cephalic version, or breechextraction of second twin

Preeclampsia High Small Education: preeclampsia is not an indication forcesarean delivery

Prior shoulder dystocia Limited Small Improved documentation as to prior shoulder dystociaEducation regarding risk of recurrence based onestimated fetal weight

Prior shoulder dystocia is not an absolute indicationfor cesarean delivery

Prior myomectomy Limited Small Improved documentation of prior myomectomyEducation regarding impact of myomectomy ondelivery

Prior third-degree or fourth-degreelaceration, prior breakdown ofrepair, fistula

High Small Education: not an absolute indication for cesareandelivery

Education: limited ability to predict recurrenceMarginal and low-lyingplacentation

High Small Education: attempt at vaginal delivery acceptable aslong as placenta is 1 cm or more from internal os38

* Diagnostic criteria accuracy: how readily and accurately cases can be diagnosed. For example, the ability to diagnose multiple gestationsis high, whereas the ability to identify all cases of shoulder dystocia is limited as a result of subjectivity of the definition.

† Effect on prevention of first cesarean delivery: large means that modification of indication (eg, arrest of labor) could lead to a largedecrease in cesarean deliveries. Small means that modification of indication (eg, prior shoulder dystocia) could lead to a small decreasein cesarean deliveries.

VOL. 120, NO. 5, NOVEMBER 2012 Spong et al Preventing the First Cesarean Delivery 1183

TC nel primo stadio: indicazioni cliniche

�  First stage arrest (dystocia)

Contemporary patterns of spontaneous labor with normal

neonatal outcomes. Zhang, Obstet Gynecol 2010; 116:1281–7.

� Da 4-6 cm, nullipare e pluripare progrediscono allo stesso stesso modo, più lentamente di quanto descritto storicamente (0.5-0.7 cm/h e 0.5-1.3 cm/h rispettivamente)

� Dopo 6 cm, il decorso del travaglio è più rapido nelle multipare

�  La fase attiva del travaglio non parte prima di aver raggiunto 6 cm di dilatazione

� Non si può parlare di distocia (arresto o prolungamento del primo stadio) finchè non si sono raggiunti 6 cm di dilatazione

Institutional factors, such as time constraints forscheduling on the labor and delivery unit, varyingoperating room staff availability, and the inability tosupport prolonged inductions with resources andspace that may be scarce all play a role in thedecision to proceed to cesarean delivery. Physicianfactors such as fatigue, workload, and anticipatedsleep deprivation likely also affect decision-making.Several studies have suggested that cesarean deliveryrates are influenced by the “leisure incentive”; whenthe health care provider can go to sleep or go homeafter the delivery, the cesarean delivery rate, espe-cially cesarean deliveries performed for “dystocia”(prolonged or dysfunctional labor) and “fetal intoler-ance of labor,” increases.33,34 Financial incentivesand disincentives related to work efficiency and staff-ing workload may also tilt the scale toward moreliberal performance of scheduled cesarean deliveries.Given the time required to monitor a complicatedlabor, there is a financial disincentive to perseverewhen labor does not proceed efficiently or if border-line fetal heart patterns are present. Evidence sug-gests that doctors who are salaried and participatein profit-sharing, thus reducing the financial incen-tive to limit the time spent managing labor, havelower cesarean delivery rates.14

The current medical–legal climate has also madewaiting for a vaginal delivery less attractive to manyphysicians when labor is not proceeding smoothly. Inmany centers, the number of cesarean deliveries per-formed for “nonreassuring fetal status” has increasedmore than any other indication despite the fact thatthe number of women classified as high risk has notincreased concomitantly.35,36 All of these factors arecompounded by the belief among many patients thatcesarean delivery is safer for the fetus.37

Patient expectations, the medical–legal climate,and practice patterns regarding intrapartum manage-ment need to be addressed if the rate of primarycesarean delivery is to be reduced. Importantly, themisperception among reproductive-age women thatlabor and vaginal delivery can harm the neonate,whereas cesarean delivery ensures a normal out-come, must be recognized and corrected. Given theimplications of primary cesarean delivery on bothpregnancy complications and subsequent deliveries,it is important to institute practice management thatlimits performance of the first cesarean delivery(Table 5).

CONCLUSIONSAlthough numerous factors contribute to the primarycesarean delivery rate, the clinician’s ability to modifysome of these and mitigate others is the first steptoward lowering the primary cesarean delivery rate(Tables 2–5; Box 2). The available information onmaternal and fetal factors, labor management andinduction, and nonmedical factors leading to the firstcesarean delivery as well as the implications of thefirst cesarean delivery on future reproductive healthare reviewed and critical key points were identified(Box 2). The implications of a cesarean delivery rateof 30% or more have tremendous effects on the med-ical system as well as on the health of women andchildren. It is essential to embrace this concern andprovide guidance on strategies to lower the primarycesarean delivery rate. Education regarding the nor-mal labor course and the implications of first cesareandelivery may allow women and their health care pro-viders to avoid practices that increase the potential forunneeded first cesarean deliveries.

Rupture of membranes

No cervical change despite adequate contractions for at

least 4 hours

Consider cesareandelivery

Cervical change

Continue labor

No cervical change Cervical change

Continue labor

At least 6 cm

Supportive care†

No cervical change Cervical change

Continue labor

3–5.9 cm

Spontaneous labor*

Inadequate contractions; no cervical change

for at least 6 hours

Fig. 3. Algorithm for spontaneouslabor. *Consider outpatient manage-ment of uncomplicated labor until atleast 3 cm dilated or fetal membranerupture occurs. †Continued observa-tion in latent phase, with augmenta-tion as indicated. Discharge may beappropriate if labor subsides, mem-branes remain intact, and maternaland fetal status remain stable.Spong. Preventing the First CesareanDelivery. Obstet Gynecol 2012.

VOL. 120, NO. 5, NOVEMBER 2012 Spong et al Preventing the First Cesarean Delivery 1191

of oxytocin

TC nel primo stadio: quadri CTG

�  Non reassuring fetal heart rate

2.8.3 Classificazione delle caratteristiche del tracciato cardiotocografico(CTG)

un CTG in cui tutti e quattro i parametri rientrano nella categoria rassicurante

un CTG in cui un parametro rientra in una dellecategorie non-rassicuranti e gli altri sono normali

un CTG in cui due o più parametri rientrano nella categorianon-rassicurante o uno o più nella categoria anormale

• Nei casi in cui il CTG rientra nella categoria sospetto adottare misure con-servative come descritte in 2.4.1

• Nei casi in cui il CTG rientra nella categoria patologico adoperarsi perl’espletamento del parto

26

La sorveglianza del benessere fetale in travaglio di parto. Linea guida basata su prove di efficacia

2.8.2 Classificazione delle caratteristiche della frequenza cardiaca fetale

110 - 160 ≥5 Nessuna Presenti

100 - 109 <5 per 161 - 180 ≥40 min.

e <90 min.

<100 <5 per>180 ≥90 min. Patternsinusoidale≥ 10 minuti

Linea base(bpm)

Variabilità(bpm) Decelerazioni Accelerazioni

Rassicurante

Nonrassicurante

Anormale

L’assenza diaccelerazionicon untracciatocomunquenormale ha unsignificatoincerto

•Decelerazionivariabili atipiche

•Decelerazioni tardive

•Decelerazioni prolungate ripetute

•Decelerazioni precoci

•Decelerazioni variabili

•Decelerazione singola prolungata

NORMALE

SOSPETTO

PATOLOGICO

2.8.3 Classificazione delle caratteristiche del tracciato cardiotocografico(CTG)

un CTG in cui tutti e quattro i parametri rientrano nella categoria rassicurante

un CTG in cui un parametro rientra in una dellecategorie non-rassicuranti e gli altri sono normali

un CTG in cui due o più parametri rientrano nella categorianon-rassicurante o uno o più nella categoria anormale

• Nei casi in cui il CTG rientra nella categoria sospetto adottare misure con-servative come descritte in 2.4.1

• Nei casi in cui il CTG rientra nella categoria patologico adoperarsi perl’espletamento del parto

26

La sorveglianza del benessere fetale in travaglio di parto. Linea guida basata su prove di efficacia

2.8.2 Classificazione delle caratteristiche della frequenza cardiaca fetale

110 - 160 ≥5 Nessuna Presenti

100 - 109 <5 per 161 - 180 ≥40 min.

e <90 min.

<100 <5 per>180 ≥90 min. Patternsinusoidale≥ 10 minuti

Linea base(bpm)

Variabilità(bpm) Decelerazioni Accelerazioni

Rassicurante

Nonrassicurante

Anormale

L’assenza diaccelerazionicon untracciatocomunquenormale ha unsignificatoincerto

•Decelerazionivariabili atipiche

•Decelerazioni tardive

•Decelerazioni prolungate ripetute

•Decelerazioni precoci

•Decelerazioni variabili

•Decelerazione singola prolungata

NORMALE

SOSPETTO

PATOLOGICO1

frontespizio

Aziende USL di Bologna, Cesena, Forlì, Modena, RiminiAzienda Ospedaliera di Bologna

Direzione Generale Sanità e Politiche Sociali

CeVEASCentro per la Va lutaz ione

de ll’Efficac ia de ll’Assistenza Sanitaria

LA SORVEGLIANZADEL BENESSERE FETALE

IN TRAVAGLIO DI PARTOLinea guida basata su prove di efficacia

Agenzia Sanitaria Regionale

PROGRAMMA DELLA REGIONE EMILIA ROMAGNA

FINALIZZATO ALLA ATTIVAZIONE, ALLA GESTIONE

E ALLA RIORGANIZZAZIONE DEI CONSULTORI

(legge n. 34/96 Settore Materno Infantile)Finanziamento riferito alle annualità ‘97-’98

Management of intrapartum fetal heart rate tracings: ACOG practice bulletin no. 116.

Obstet Gynecol 2010;116: 1232-40.

�  Category I fetal heart rate tracings are strongly predictive of normal fetal acid-base status and are considered “normal”.

�  Category III fetal heart rate patterns are predictive of abnormal fetal acid-base status at the time of observation and are considered “abnormal.”

�  The intermediate Category II fetal heart rate patterns include those that cannot be classified as Category I or III.

1232 VOL. 116, NO. 5, NOVEMBER 2010 OBSTETRICS & GYNECOLOGY

P RAC T I C EBUL L E T I N

THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTSWOMEN’S HEALTH CARE PHYSICIANS

BackgroundIn 2008, a workshop sponsored by the American College of Obstetricians and Gynecologists, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the Society for Maternal–Fetal Med-icine focused on updating EFM nomenclature, recom-mending an interpretative system, and setting research priorities (1). Nomenclature for baseline FHR and FHR variability, accelerations, and decelerations were reaf-firmed (Table 1). New terminology was recommended for the description and quantification of uterine contrac-tions. Normal uterine activity was defined as five or fewer contractions in 10 minutes, averaged over a 30-minute window. Tachysystole was defined as more than five contractions in 10 minutes, averaged over 30 minutes and should be categorized by the presence or absence of FHR decelerations. Tachysystole can be applied to spontaneous or induced labor. The terms hyperstimulation and hyper-contractility were abandoned.

A three-tiered system for intrapartum EFM interpre-tation also was recommended (Box 1), with the nomenclature and interpretation described elsewhere (1). This second Practice Bulletin on intrapartum FHR tracings reviews the management of heart rate patterns based on the three-tiered classification system (Figure 1).

Clinical Considerations and Recommendations

How is a Category I EFM tracing managed?

Category I FHR tracings are normal (Box 1). These tracings are not associated with fetal acidemia (2–6). Cate- gory I FHR patterns may be managed in a routine manner with either continuous or intermittent monitoring. Trac-ings should be periodically evaluated and documented during active labor by a health care provider (eg, this may include physician, nurse, or midwife) based on clinical

Management of Intrapartum Fetal Heart Rate Tracings Intrapartum electronic fetal monitoring (EFM) is used for most women who give birth in the United States. As such, clinicians are faced daily with the management of fetal heart rate (FHR) tracings. The purpose of this document is to provide obstetric care providers with a framework for evaluation and management of intrapartum EFM patterns based on the new three-tiered categorization.

NUMBER 116, NOVEMBER 2010

CLINICAL MANAGEMENT GUIDELINES FOR OBSTETRICIAN–GYNECOLOGISTS

Committee on Practice Bulletins—Obstetrics. This Practice Bulletin was developed by the Committee on Practice Bulletins—Obstetrics with the assis-tance of George Macones, MD, and Sean Blackwell, MD, in collaboration with Thomas Moore, MD, Catherine Spong, MD, John Hauth, MD, Gary Hankins, MD, and representatives from the Association of Women’s Health, Obstetric and Neonatal Nurses–Audrey Lyndon RN, PhD, Kathleen R. Simpson, PhD RN, and Anne Santa-Donato, RNC, MSN, and the American College of Nurse–Midwives––Tekoa King, CNM, MPH. The information is designed to aid practitioners in making decisions about appropriate obstetric and gynecologic care. These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

this technology into obstetric prac-tice, well-designed studies areneeded to fill gaps in knowledge.Areas of highest priority for re-search include observational stud-ies focused on indeterminate FHRpatterns, including descriptive epi-demiology, frequency of specificpatterns, change over time, the re-

lationship to clinically relevant out-comes, and the effect of duration ofpatterns (eg, recurrent late deceler-ations with minimal variability) onclinical outcomes. Other neededstudies include work that evaluatescontraction frequency, strength,and duration on FHR and clinicaloutcomes. Research also needs to

be focused on the effectiveness ofeducational programs on EFM thatinclude all relevant stakeholders.Although computerized interpreta-tion systems have not developed asrapidly as anticipated, studies areneeded on the effectiveness of com-puterized compared with providerinterpretation, including the analy-

Three-Tier Fetal Heart Rate Interpretation System

Category I

Category I fetal heart rate (FHR) tracings include all of the following:

• Baseline rate: 110–160 beats per minute (bpm)• Baseline FHR variability: moderate• Late or variable decelerations: absent• Early decelerations: present or absent• Accelerations: present or absent

Category II

Category II FHR tracings include all FHR tracings not categorized as Category I or Category III. Category IItracings may represent an appreciable fraction of those encountered in clinical care. Examples of Category IIFHR tracings include any of the following:

Baseline rate

• Bradycardia not accompanied by absent baseline variability• Tachycardia

Baseline FHR variability• Minimal baseline variability• Absent baseline variability not accompanied by recurrent decelerations• Marked baseline variability

Accelerations• Absence of induced accelerations after fetal stimulation

Periodic or episodic decelerations• Recurrent variable decelerations accompanied by minimal or moderate baseline variability• Prolonged deceleration !2 minutes but !10 minutes• Recurrent late decelerations with moderate baseline variability• Variable decelerations with other characteristics, such as slow return to baseline, “overshoots,”

or “shoulders”

Category III

Category III FHR tracings include either:

• Absent baseline FHR variability and any of the following:- Recurrent late decelerations- Recurrent variable decelerations- Bradycardia

• Sinusoidal pattern

VOL. 112, NO. 3, SEPTEMBER 2008 Macones et al Electronic Fetal Heart Rate Monitoring 665

1232 VOL. 116, NO. 5, NOVEMBER 2010 OBSTETRICS & GYNECOLOGY

P RAC T I C EBUL L E T I N

THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTSWOMEN’S HEALTH CARE PHYSICIANS

BackgroundIn 2008, a workshop sponsored by the American College of Obstetricians and Gynecologists, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the Society for Maternal–Fetal Med-icine focused on updating EFM nomenclature, recom-mending an interpretative system, and setting research priorities (1). Nomenclature for baseline FHR and FHR variability, accelerations, and decelerations were reaf-firmed (Table 1). New terminology was recommended for the description and quantification of uterine contrac-tions. Normal uterine activity was defined as five or fewer contractions in 10 minutes, averaged over a 30-minute window. Tachysystole was defined as more than five contractions in 10 minutes, averaged over 30 minutes and should be categorized by the presence or absence of FHR decelerations. Tachysystole can be applied to spontaneous or induced labor. The terms hyperstimulation and hyper-contractility were abandoned.

A three-tiered system for intrapartum EFM interpre-tation also was recommended (Box 1), with the nomenclature and interpretation described elsewhere (1). This second Practice Bulletin on intrapartum FHR tracings reviews the management of heart rate patterns based on the three-tiered classification system (Figure 1).

Clinical Considerations and Recommendations

How is a Category I EFM tracing managed?

Category I FHR tracings are normal (Box 1). These tracings are not associated with fetal acidemia (2–6). Cate- gory I FHR patterns may be managed in a routine manner with either continuous or intermittent monitoring. Trac-ings should be periodically evaluated and documented during active labor by a health care provider (eg, this may include physician, nurse, or midwife) based on clinical

Management of Intrapartum Fetal Heart Rate Tracings Intrapartum electronic fetal monitoring (EFM) is used for most women who give birth in the United States. As such, clinicians are faced daily with the management of fetal heart rate (FHR) tracings. The purpose of this document is to provide obstetric care providers with a framework for evaluation and management of intrapartum EFM patterns based on the new three-tiered categorization.

NUMBER 116, NOVEMBER 2010

CLINICAL MANAGEMENT GUIDELINES FOR OBSTETRICIAN–GYNECOLOGISTS

Committee on Practice Bulletins—Obstetrics. This Practice Bulletin was developed by the Committee on Practice Bulletins—Obstetrics with the assis-tance of George Macones, MD, and Sean Blackwell, MD, in collaboration with Thomas Moore, MD, Catherine Spong, MD, John Hauth, MD, Gary Hankins, MD, and representatives from the Association of Women’s Health, Obstetric and Neonatal Nurses–Audrey Lyndon RN, PhD, Kathleen R. Simpson, PhD RN, and Anne Santa-Donato, RNC, MSN, and the American College of Nurse–Midwives––Tekoa King, CNM, MPH. The information is designed to aid practitioners in making decisions about appropriate obstetric and gynecologic care. These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

this technology into obstetric prac-tice, well-designed studies areneeded to fill gaps in knowledge.Areas of highest priority for re-search include observational stud-ies focused on indeterminate FHRpatterns, including descriptive epi-demiology, frequency of specificpatterns, change over time, the re-

lationship to clinically relevant out-comes, and the effect of duration ofpatterns (eg, recurrent late deceler-ations with minimal variability) onclinical outcomes. Other neededstudies include work that evaluatescontraction frequency, strength,and duration on FHR and clinicaloutcomes. Research also needs to

be focused on the effectiveness ofeducational programs on EFM thatinclude all relevant stakeholders.Although computerized interpreta-tion systems have not developed asrapidly as anticipated, studies areneeded on the effectiveness of com-puterized compared with providerinterpretation, including the analy-

Three-Tier Fetal Heart Rate Interpretation System

Category I

Category I fetal heart rate (FHR) tracings include all of the following:

• Baseline rate: 110–160 beats per minute (bpm)• Baseline FHR variability: moderate• Late or variable decelerations: absent• Early decelerations: present or absent• Accelerations: present or absent

Category II

Category II FHR tracings include all FHR tracings not categorized as Category I or Category III. Category IItracings may represent an appreciable fraction of those encountered in clinical care. Examples of Category IIFHR tracings include any of the following:

Baseline rate

• Bradycardia not accompanied by absent baseline variability• Tachycardia

Baseline FHR variability• Minimal baseline variability• Absent baseline variability not accompanied by recurrent decelerations• Marked baseline variability

Accelerations• Absence of induced accelerations after fetal stimulation

Periodic or episodic decelerations• Recurrent variable decelerations accompanied by minimal or moderate baseline variability• Prolonged deceleration !2 minutes but !10 minutes• Recurrent late decelerations with moderate baseline variability• Variable decelerations with other characteristics, such as slow return to baseline, “overshoots,”

or “shoulders”

Category III

Category III FHR tracings include either:

• Absent baseline FHR variability and any of the following:- Recurrent late decelerations- Recurrent variable decelerations- Bradycardia

• Sinusoidal pattern

VOL. 112, NO. 3, SEPTEMBER 2008 Macones et al Electronic Fetal Heart Rate Monitoring 665

•  >80% of fetuses in labor demonstrate these patterns

•  No specific ACOG managment recommendations

definitions should serve as an importantfirst step in both the investigation of thesignificance of various FHR patterns,and the development of a uniformstandard of care in the interpretationand management of such patterns. Withthis in mind, subsequent recommenda-tions have been developed by theAmerican Congress of Obstetricians andGynecologists (ACOG) for the manage-ment of category I (normal) and cate-gory III (pathologically abnormal) FHRpatterns.20,21 Although useful, theserecommendations remain insufficientsince !80% of fetuses in labor demon-strate FHR patterns that fall into cate-gory II, patterns for which no specificACOG management recommendationsexist.21,22

The management of category II FHRpatterns remains the most importantand challenging issue in the field ofFHRmonitoring, and is arguably second

only to preterm birth as the mostpressing issue in clinical obstetrics. Inaddition, the overall cesarean deliveryrate exceeded 32% in the United States in2011, and exceeds 50% of all births insome US hospitals.23 While dystocia andprior cesarean delivery remain the lead-ing indicators for such surgical inter-vention, the presence of a category II orIII FHR in labor is a frequent indicationas well.11,24 For cesarean deliveries, thereis a wide variance in the reportedindications and their frequency, bothbetween hospitals and among membersof the medical staff practicing obstet-rics.24 Concern regarding FHR patternsis perhaps the indication that has thegreatest such variance; we believe thisobservation is directly related to theabsence of defined management pro-tocols for category II patterns.Accordingly, we present a suggested

algorithm for the management of

category II FHR patterns (Figure 1)along with several important specificclarifications (Table). As outlined inFigure 1, it is reasonable to initiatemanagement of a category II FHRpattern with an assessment of variabilityand accelerations, thus allowing theclinician to immediately rule out thepresence of clinically significant meta-bolic acidemia. For nonacidemic fetuses,the focus then shifts to assessing thelikelihood of developing significantacidemia prior to delivery. While no al-gorithm can predict all cases of suddendeterioration due to sentinel events, evenwith category I FHR patterns, analysis ofthe frequency and nature of de-celerations and the progress in laborprovides the clinician with a reasonableapproach to such decision making(Figure 1).

With category II FHR tracings thatdo not exhibit moderate variability or

FIGURE 1Algorithm for management of category II fetal heart rate tracings

Yes

No

NoNo Yes No Yes

Yes Yes

No

No

Yes

Significant decelerations with ≥50% of contractions for 1 hour

Moderate variability or accelerations

Significant decelerations with ≥50% of contractions for 30 minutes

Latent Phase Active Phase Second Stage Observe for 1 hour

Normal labor progress Normal progress Persistent pattern

Manage per algorithmCesarean or OVDObserve ObserveCesarean Cesarean or OVD

OVD, operative vaginal delivery.aThat have not resolved with appropriate conservative corrective measures, which may include supplemental oxygen, maternal position changes, intravenous fluid administration, correction of hypotension,reduction or discontinuation of uterine stimulation, administration of uterine relaxant, amnioinfusion, and/or changes in second stage breathing and pushing techniques.

Clark. Category II FHRT. Am J Obstet Gynecol 2013.

Clinical Opinion Obstetrics www.AJOG.org

90 American Journal of Obstetrics & Gynecology AUGUST 2013

Intrapartum management of category II fetal heart rate tracings: towards

standardization of care. (Clark, Am J Obstet Gynecol 2013).

Definizione di “significant decelerations”

�  Decelerazioni variabili: durata >60 secondi; nadir >60 pbm sotto la linea di base

�  Decelerazioni variabili: durata >60 secondi; nadir <60 pbm (indipendentemente dalla linea di base)

�  Ogni decelerazione tardiva (qualunque sia la profondità) �  Ogni decelerazione prolungata (duarata >2 minuti, ma

inferiore a 10 minuti). In questo caso l’algoritmo non deve essere applicato

Punti fondamentali dell’algoritmo

�  Importanza della variabilità della linea di base e delle accelerazioni

�  Importanza della regolare progressione del travaglio

Tracing exhibits moderate variability and acceleration, thus excluding clinically significant acidemia

the likelihood of, and responseto, deterioration of category IIpatterns. A category II patternmay have a different indicatedmanagement when presenting inearly first-stage labor than anidentical pattern presenting in thelate second stage. We acknowledgerecent data suggesting that cesareandelivery based on classic definitionsof protracted active phase, arrest ofdilatation, or arrest of second-stagedescent alone may not be necessary,and that longer periods of obser-vation may yield lower interventionrates.10,37 However, data demon-strating the safety of these more

conservative approaches in thepresence of persistent category IIFHR patterns are lacking. Forexample, we hesitate to recommendnonintervention for an arrest ofactive phase dilatation of 4 hours inthe presence of recurrent late de-celerations, even in the presence ofmoderate variability. The superbreliability of accelerations andmoderate variability in excludingany degree of hypoxia-related cen-tral nervous system depression orrisk of ongoing hypoxic injurywould allow observation of patternswith these features and adequatelabor progress regardless of the

deceleration pattern (Figure 1).However, intervention in patientswith certain category II patternsand slow, but technically adequatelabor progression may also be anappropriate option.

7. Some well-defined features ofcategory II patterns (eg, fetal tachy-cardia or marked variability) arenot included in the algorithm-based decision tree for interven-tion. This does not signify that suchpatterns are innocuouseindeed, itmay be exactly these features of atracing that mandate considerationas a category II pattern, and the useof this algorithm. However, in such

FIGURE 4Tracing exhibits moderate variability and accelerations, thus excluding clinically significant acidemia

Late decelerations represent protective cardiovascular response to contraction-induced reductions in fetal oxygenation. Per algorithm, if labor isprogressing normally in active phase or second stage, careful observation would be appropriate. If the fetus is remote from delivery, delivery would beappropriate.Clark. Category II FHRT. Am J Obstet Gynecol 2013.

FIGURE 5Tracing exhibits moderate variability and acceleration, thus excluding clinically significant acidemia

Significant variable decelerations seen here suggest umbilical cord compression during contraction, which could, over time, lead to significant acidemia.Per algorithm, if labor is progressing normally in active phase or second stage, careful observation would be appropriate. If the fetus is remote fromdelivery, delivery would be appropriate.Clark. Category II FHRT. Am J Obstet Gynecol 2013.

www.AJOG.org Obstetrics Clinical Opinion

AUGUST 2013 American Journal of Obstetrics & Gynecology 93

Significant variable decelerations seen here suggest umbilical cord compression during contraction, which could, over time, lead to significant acidemia. Per algorithm, if labor is

progressing normally in active phase or second stage, careful observation would be appropriate. If the fetus is remote from delivery, delivery would be appropriate.

Tracing exhibits moderate variability and accelerations, thus excluding clinically significant acidemia

the likelihood of, and responseto, deterioration of category IIpatterns. A category II patternmay have a different indicatedmanagement when presenting inearly first-stage labor than anidentical pattern presenting in thelate second stage. We acknowledgerecent data suggesting that cesareandelivery based on classic definitionsof protracted active phase, arrest ofdilatation, or arrest of second-stagedescent alone may not be necessary,and that longer periods of obser-vation may yield lower interventionrates.10,37 However, data demon-strating the safety of these more

conservative approaches in thepresence of persistent category IIFHR patterns are lacking. Forexample, we hesitate to recommendnonintervention for an arrest ofactive phase dilatation of 4 hours inthe presence of recurrent late de-celerations, even in the presence ofmoderate variability. The superbreliability of accelerations andmoderate variability in excludingany degree of hypoxia-related cen-tral nervous system depression orrisk of ongoing hypoxic injurywould allow observation of patternswith these features and adequatelabor progress regardless of the

deceleration pattern (Figure 1).However, intervention in patientswith certain category II patternsand slow, but technically adequatelabor progression may also be anappropriate option.

7. Some well-defined features ofcategory II patterns (eg, fetal tachy-cardia or marked variability) arenot included in the algorithm-based decision tree for interven-tion. This does not signify that suchpatterns are innocuouseindeed, itmay be exactly these features of atracing that mandate considerationas a category II pattern, and the useof this algorithm. However, in such

FIGURE 4Tracing exhibits moderate variability and accelerations, thus excluding clinically significant acidemia

Late decelerations represent protective cardiovascular response to contraction-induced reductions in fetal oxygenation. Per algorithm, if labor isprogressing normally in active phase or second stage, careful observation would be appropriate. If the fetus is remote from delivery, delivery would beappropriate.Clark. Category II FHRT. Am J Obstet Gynecol 2013.

FIGURE 5Tracing exhibits moderate variability and acceleration, thus excluding clinically significant acidemia

Significant variable decelerations seen here suggest umbilical cord compression during contraction, which could, over time, lead to significant acidemia.Per algorithm, if labor is progressing normally in active phase or second stage, careful observation would be appropriate. If the fetus is remote fromdelivery, delivery would be appropriate.Clark. Category II FHRT. Am J Obstet Gynecol 2013.

www.AJOG.org Obstetrics Clinical Opinion

AUGUST 2013 American Journal of Obstetrics & Gynecology 93

Late decelerations represent protective cardiovascular response to contraction-induced reductions in fetal oxygenation. Per algorithm, if labor is progressing normally in active phase or second stage, careful observation would be appropriate. If the fetus is remote from delivery,

delivery would be appropriate.

Tracing exhibits minimal to absent variability and late decelerations occurring with >50% of contractions

attempted in specific situations.Their effect should be apparentwithin 30 minutes of application(Figure 1). If theFHRtracing remainscategory II following these efforts, thealgorithm is applied to the patternobserved following these attempts attherapeutic intervention.

Attention should be given to theprompt elimination of excessiveuterine activity including tachysystoleor prolonged contractions, especiallywhen uterine stimulants (oxytocin orprostaglandin-containing agents) arebeing applied.30,31 Oxytocin infusionshould be reduced or discontinuedin the presence of excessive uterineactivity and a persistent category

II FHR pattern.21 Acceptable ap-proaches to monitoring of uterineactivity are well described in availableliterature.30,31

5. Recent data suggest that no singlequantitative value of fetal arterialpH serves to define a point ofhypoxia-induced damage applicableto all fetuses.32 However, the litera-ture is consistent in its demonstra-tion that for any individual fetus,baseline variability and accelera-tions will reliably be depressedbefore the pH has reached a level ofacidemia associated with neurologicinjury for that fetus, regardless ofits quantitative value.33,34 Hencethis algorithm relies strongly on the

presence of moderate baseline vari-ability or accelerations. In contrast,conflicting data exist regardingthe significance of variability withindeceleration nadirs.35,36 Variabilitywithin decelerations alone cannotbe reliably used to exclude fetalacidemia and accordingly is notaddressed in this algorithm.

6. FHR patterns cannot be inter-preted in isolation. Accordingly,we have incorporated labor prog-ress as described in traditionalterms (stage I latent phase, stage Iactive phase and second stage) intothis algorithm. This is of signifi-cance since the expected remaininglength of labor may influence

FIGURE 2Tracing exhibits minimal to absent variability without decelerations, despite regular contractions

Medication effect has been excluded clinically as part of the initial period of intrauterine resuscitation attempts. While the fetus may have experiencedprelabor central nervous system injury, absence of late decelerations excludes ongoing hypoxia in a neurologically intact fetus. However, since suchfetuses may not tolerate labor without sudden deterioration and demise, cesarean delivery would be appropriate, per algorithm, if pattern persists for1 hour.Clark. Category II FHRT. Am J Obstet Gynecol 2013.

FIGURE 3Tracing exhibits minimal to absent variability and late decelerations occurring with >50% of contractions

Per algorithm, expedited delivery is indicated regardless of labor progress.Clark. Category II FHRT. Am J Obstet Gynecol 2013.



Per algorithm, expedited delivery is indicated regardless of labor progress.

Tracing exhibits minimal to absent variability without decelerations, despite regular contractions

attempted in specific situations.Their effect should be apparentwithin 30 minutes of application(Figure 1). If theFHRtracing remainscategory II following these efforts, thealgorithm is applied to the patternobserved following these attempts attherapeutic intervention.

Attention should be given to theprompt elimination of excessiveuterine activity including tachysystoleor prolonged contractions, especiallywhen uterine stimulants (oxytocin orprostaglandin-containing agents) arebeing applied.30,31 Oxytocin infusionshould be reduced or discontinuedin the presence of excessive uterineactivity and a persistent category

II FHR pattern.21 Acceptable ap-proaches to monitoring of uterineactivity are well described in availableliterature.30,31

5. Recent data suggest that no singlequantitative value of fetal arterialpH serves to define a point ofhypoxia-induced damage applicableto all fetuses.32 However, the litera-ture is consistent in its demonstra-tion that for any individual fetus,baseline variability and accelera-tions will reliably be depressedbefore the pH has reached a level ofacidemia associated with neurologicinjury for that fetus, regardless ofits quantitative value.33,34 Hencethis algorithm relies strongly on the

presence of moderate baseline vari-ability or accelerations. In contrast,conflicting data exist regardingthe significance of variability withindeceleration nadirs.35,36 Variabilitywithin decelerations alone cannotbe reliably used to exclude fetalacidemia and accordingly is notaddressed in this algorithm.

6. FHR patterns cannot be inter-preted in isolation. Accordingly,we have incorporated labor prog-ress as described in traditionalterms (stage I latent phase, stage Iactive phase and second stage) intothis algorithm. This is of signifi-cance since the expected remaininglength of labor may influence

FIGURE 2Tracing exhibits minimal to absent variability without decelerations, despite regular contractions

Medication effect has been excluded clinically as part of the initial period of intrauterine resuscitation attempts. While the fetus may have experiencedprelabor central nervous system injury, absence of late decelerations excludes ongoing hypoxia in a neurologically intact fetus. However, since suchfetuses may not tolerate labor without sudden deterioration and demise, cesarean delivery would be appropriate, per algorithm, if pattern persists for1 hour.Clark. Category II FHRT. Am J Obstet Gynecol 2013.

FIGURE 3Tracing exhibits minimal to absent variability and late decelerations occurring with >50% of contractions

Per algorithm, expedited delivery is indicated regardless of labor progress.Clark. Category II FHRT. Am J Obstet Gynecol 2013.



While the fetus may have experienced prelabor central nervous system injury, absence of late decelerations excludes ongoing hypoxia in a neurologically intact fetus. However,

since such fetuses may not tolerate labor without sudden deterioration and demise, cesarean delivery would be appropriate, per algorithm, if pattern persists for 1 hour.

Decelerazione prolungata

to ensure the safety of the mother and child. In the latest RCOG’s National Institute of Health andClinical Excellence guideline, The College recommends DDI of 30 mins to be used for category 1caesarean section, and both 30 and 75 mins for category 2 caesarean section (Table 3), to measure theoverall performance of an obstetric unit. The College also emphasises that these are only for auditstandards and not for judging multidisciplinary team performance for any individual caesareansection.37

Is the 30-minute rule achievable in real practice?

When the 30-min rule was first set by many professional bodies in the 1990s, a number of centrespublished their own audit data to show that a significant proportion of emergency caesarean sectioncould not be carried out before the ‘deadline’, and criticised such standard as being impractical.

Tuffnell et al.5 conducted four audit cycles on DDI in urgent caesarean section over several years(1993–2009) in a large district general hospital delivering babies to 5500 women each year in the UK.They found that the proportion of cases delivered within 30mins of the decision being made improvedfrom 41% in the first cycle in 1993, to 69% in the second cycle, but remained at around 60% in the thirdand in the final cycle between 1997 and 1999. The proportion of cases that could be delivered within40 mins was about 86%. The major reason for the delay of more than 50 mins was anaesthetic (51.7%),including multiple attempts at spinal anaesthesia and waiting for epidural top-up.

In another centre in the UK, Helmy et al.6 reported a similar improvement from 64–71% afterintroduction of a structured time sheet. The investigators, however, commented that it was nota realistic target to keep DDI to less than 30 mins for all emergency cases. Bruce et al.7 also conductedan audit cycle on emergency caesarean deliveries in a hospital in UK with the introduction of a pro-forma, which had to be completed within 72 h of delivery. They found the implementation had noeffect on DDI.7 Livermore and Cochrane8 reported an even lower rate of success, which was only 22.4%for all ‘crash’ caesarean section and ‘urgent’ caesarean section cases (according to Mackenzie’s clas-sification) (Table 2).

In developing countries, the situation was even worse. In a university hospital in Abuja in Nigeria,Onah et al.39 reported that the mean DDI was 551 mins. The shortest mean DDI was 341 mins for fetaldistress.

Fig. 3. Cardiotocography of a case of fetal bradycardia of unknown cause. The fetal heart rate recovered to normal after 5–6 mins.The subsequent progress of labour and fetal well being were normal. Crash caesarean section was avoided. OT, operation theatre.

T.Y. Leung, T.T. Lao / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 251–267262

Tachisistolia

the time the baby is delivered abdominally, the fetal hypoxic episode caused by hypertonic uterinecontractions would have already passed. That is, caesarean operation is unnecessary and not helpful.Therefore, a correct clinical judgement, discontinuation of oxytocin, and having the patience to awaitrecovery of the fetal heart rate, are the essence in the management of oxytocin-induced uterinehyperstimulation. Of course, it is always stressful for the clinician to withhold any actionwhile waitingfor the fetal bradycardia to recover.

To hasten the resolution of a hypertonic uterus, acute tocolytic therapy may be considered. Lipshitzet al.49 was probably the first group to report the successful reversion of uterine hyperstimulation ina patient. The hypertonic uterus was resolved 2 mins after the administration of ritodrine (6 mgintravenous bolus over 15 s).49 Interestingly, although many randomised-controlled trials evaluated

Fig. 1. Cardiotocography of a case of oxytocin-induced uterine hyperstimulation. Hypertonic uterine contractions resulted in fetalbradycardia. After stopping the oxytocin infusion for 9 mins, the fetal bradycardia recovered.

Fig. 2. Cardiotocography of a case of placental abruption. The sudden onset of fetal bradycardia is coupled with the frequent uterineactivity of low amplitude, indicating irritable uterus (between arrows).

T.Y. Leung, T.T. Lao / Best Practice & Research Clinical Obstetrics and Gynaecology 27 (2013) 251–267260

TC nel primo stadio: tempi e tecnica

Decision to incision rule

�  1982: “…to be able to begin cesarean delivery within 15 minutes”

�  1987: survey of 538 hospitals: “almost all hosptal had the ability to perform an emergency cesarean section within 30 minutes” (JAMA 1987; 257:494)

�  1988: ACOG Standard for Obstetrics Services: the 15 minutes rule was changed to a 30 minutes rule

�  No evidence-based medical studies supporting this rule �  2013: “Availability of anesthesia and surgical personnel to

permit the start of cesarean delivery in a timely manner in accordance with clinical needs and local resources”

2 of 4Good Practice No. 11

should be carried out with an urgency appropriate to the risk to the baby and the safety of themother. Units should strive to design guidelines that result in the shortest safely achievable DDI. Evidencesuggests that any delay is usually associated with the delay in transfer to theatre.7

A target DDI for caesarean section for ‘fetal compromise’ of 30 minutes is an audit tool that allowstesting of the efficiency of the whole delivery team and has become accepted practice; however:

● certain clinical situations will require a much quicker DDI than 30 minutes and units should work towardsimproving their efficiency

● undue haste to achieve a short DDI can introduce its own risk, both surgical and anaesthetic, with thepotential for maternal and neonatal harm.8

Communication

Good communication is central to timely delivery of the fetus, while avoiding unnecessary risk to the mother.The time taken for a patient to reach the operating theatre is a critical predictor of the DDI.7

● Communication is frequently highlighted as an area for improvement in obstetric practice.● All members of the multidisciplinary team must be informed of the need (or likely need) for caesarean

delivery as early as possible, as well as specific instructions on the degree of urgency.● Communication must ensure that all tasks and preparations for caesarean section that can be performed

concurrently should be done so and that, where appropriate, roles are interchangeable.7

● Communication could be more effective using a classification that confers a more precise and individualapproach to degree of urgency.

● Categorisation of risk should be reviewed by the multidisciplinary team when the mother arrives in theoperating theatre.

Proposed classificationA classification relating the degree of urgency to the presence or absence of maternal or fetal compromise isillustrated in Figure 1. It incorporates a modified version of the classification proposed by Lucas et al.1 Thecolour scale reinforces the need to recognise that a ‘continuum of urgency’ applies to caesarean section,rather than discrete categories. However, it is recognised that, for audit purposes, the use of the four definedcategories remains useful. Once a category is applied to an individual caesarean section, all members of theteam can have a common understanding of the degree of urgency of the procedure for that specific case.

Benefits

Universal use of an evidence-based classification for categorising urgency of caesarean section whichacknowledges a ‘continuum of risk’ has the following benefits:

• it uses a pre-existing classification which is familiar to many units and has been endorsed by the RCOG,Royal College of Anaesthetists, the Obstetric Anaesthetists’ Association, the Centre for Maternal and ChildEnquiries and the Clinical Negligence Scheme for Trusts

Figure 1. A classification relating the degree of urgency to the presence or absence of maternalor fetal compromise

Urgency Definition Category

Immediate threat to life of woman or fetus 1

Maternal or fetal compromise

No immediate threat to life of woman or fetus 2

Requires early delivery 3

No maternal or fetal compromise

At a time to suit the woman and maternity services 4

© Royal College of Obstetricians and Gynaecologists

Good Practice No. 11April 2010

Good Practice No. 11 1 of 4

CLASSIFICATION OF URGENCY OF CAESAREAN SECTION –A CONTINUUM OF RISK

Purpose

A. To encourage universal use of a nationally accepted classification of urgency of caesarean section withthe aim of:● facilitating local and national data collection● minimising communication difficulties relating to urgency of delivery, between and within teams● facilitating retrospective audit of outcomes.

B. To formalise the concept that urgency of caesarean section represents a continuum of risk:● four broad categories of risk are defined● all staff should be aware that, within each category, the degree of risk in individual cases can vary● a coloured spectrum is used to emphasise that continuum of risk● this variance in degree of risk requires an individual, case-by-case approach in deciding the specific

decision-to-delivery interval (DDI).

Issues

Classification

It is acknowledged that the traditional classification of caesarean section into ‘elective’ and ‘emergency’ is oflimited value for data collection and audit of obstetric and anaesthetic outcomes. This is because thespectrum of urgency that occurs in obstetrics is lost within a single ‘emergency’ category. The NationalConfidential Enquiry into Patient Outcome and Death (NCEPOD) classification, used for other surgicalprocedures, is not immediately applicable to caesarean section. In 2000, Lucas et al.1 proposed a newclassification based on clinical definitions. They demonstrated that this performed better than classificationswhich relied upon visual analogue scales, assessment of maximum time to delivery, a five-point verbal ratingscale or consideration of suitable anaesthetic technique. Importantly, the clinical definitions-based classifica-tion proved useful and reliable in clinical practice. The classification has not been adopted universally, makinginter-unit comparisons of outcome difficult. In a recent paper, Kinsella and Scrutton2 confirmed thatmodification of the wording of the definitions did not improve the consistency of assignment of urgency.Dupuis et al.3 used a three-colour code for categorising risk and suggested that this could shorten the DDIfor emergency caesarean section.

Urgency

The ‘Sentinel’ caesarean section audit suggested that in cases such as cord prolapse, a DDI of 15 minutes wasfeasible.4 However, in many category-1 cases, delivery within 30 minutes was not achieved.4 Delivery within75 minutes does not appear to increase the risk of compromise, while delivery within 30 minutes may notalways result in a good neonatal outcome.5,6 Once a decision to deliver has been made, therefore, delivery

© Royal College of Obstetricians and Gynaecologists

decision-to-delivery interval

�  Perform category 1 and 2 CS as quickly as possible after making the decision, particularly for category 1

�  Perform category 2 CS in most situations within 75 minutes of making the decision

�  Take into account the condition of the woman and the unborn baby when making decisions about rapid delivery. Remember that rapid delivery may be harmful in certain circumstances

�  Use the following decision-to-delivery intervals to measure the overall performance of an obstetric unit: ¡  30 minutes for category 1 CS ¡  both 30 and 75 minutes for category 2 CS

Intrapartum care

Care of healthy women and their babies duringchildbirth

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NICE clinical guideline 557E941>35�>935�?B7�E;37��

& *��F945>35�81C�133B549D54�D85�@B?35CC�EC54�2I�D85��5>DB5�6?B��<9>931<�(B13D935�1D�&!��D?@B?4E35�7E945<9>5C��33B549D1D9?>�9C�F1<94�6?B��I51BC�6B?=�*5@D5=25B��1>4�1@@<95C�D?�7E945<9>5C@B?4E354�C9>35��@B9<��EC9>7�D85�@B?35CC5C�45C3B9254�9>�&!��C��+85�7E945<9>5C�=1>E1<��E@41D54��%?B5�9>6?B=1D9?>�?>�133B549D1D9?>�31>�25�F95G54�1D�GGG�5F945>35�>8C�E;

L�&!��

Prophylactic antibiotics Hopkins L, Smaill FM. Cochrane 2009

�  > 81 RCTs �  ↓ fever by 70% �  ↓ endometritis by >60% (primary=repeat) �  ↓ wound infection by 25-65% �  ↓ UTI

Prophylactic antibiotics

�  When? ¡  30 min before incision

�  Which one? ¡  Amp = 1st generation cephalosporins ¡  No benefit from broader spectrum or from multiple antibiotics

�  What dose? ¡  No added benefit from multiple doses (1 enough)

Profilassi antibiotica nel cesareo NON elettivo

79Allegati

SNLG - Antibioticoprofilassi perioperatoria nell’adulto

Per un reparto di Ostetricia e Ginecologia (II)

Nei pazienti allergici ai betalattamici

Somministrare un antibiotico non betalattamico con spettroadeguato, ad esempio:• clindamicina^(600 mg)

± gentamicina^ 3 mg/Kg NB: la dose di gentamicina non varipetutaoppure• un fluorochinolone

(ad esempio ciprofloxacina^ 400 mg)

Vedi: Presenza di eventuali allergie ai betalattamici pag. 51

Tipo di intervento

CHIRURGIA OSTETRICA• Aborto indotto entro 90 gg• Aborto indotto dopo 90 gg

CHIRURGIA OSTETRICA• Parto cesareo non elettivo

(con travaglio in atto e/o rottura di membrane più di 6 ore primadell’intervento)

>>

° Le aminopeneicilline associate ad un inibitore delle betalattamasi sono tra gli antibiotici più frequentemente utilizzati in terapia;il loro uso in profilassi deve quindi essere limitato e considerato caso per caso.

^ Farmaco che non presenta in scheda tecnica l‘indicazione profilassi antibiotica in chirurgia.Le aree in grigio esprimono decisioni non supportate da forti evidenze in cui la linea guida nazionale non esprime una raccoman-dazione precisa, ma solo un suggerimento; in tale caso i gruppi di implementazione locale dovranno decidere la raccomandazionemutuandola da situazioni simili e tenendo conto dell’esperienza clinica dei singoli o di particolari situazioni. Le scelte effettuate dovran-no essere motivate.* Il gruppo di lavoro deve stabilire se, alla 3° ora di intervento, fare una somministrazione aggiuntiva dell’antibiotico scelto.** Il gruppo di lavoro dovrà decidere se ed in quali interventi prolungare la profilassi per 24 ore considerando la presenza di un pun-

teggio ASA ≥3 e la durata dell’intervento. In caso positivo la dose unitaria e l’intervallo fra le somministrazioni saranno quelle uti-lizzate in terapia.

Antibiotico e modalità di somministrazione

Somministrare per os 2 ore prima dell’intervento:• una tetraciclina (Doxiciclina 200 mg)

oppure• un macrolide (Eritromicina 900 mg)

Somministrare dopo il clampaggio del cordone ombelicale:• una cefalosporina di 2° generazione

(cefoxitina^ 2 g) come 2° scelta • una ureidopenicillina

(ad esempio piperacillina 4 g)oppure• una aminopenicillina associata

ad un inibitore delle betalattamasi[amoxicillina/ac. clavulanico 2,2 g(1,2 g se peso < 50 Kg) da infonderein 30 minuti]°

Valutazioni locali:• somministrazione di ulteriori dosi

di antibiotico entro le 24 ore**

Vedi: Durata della profilassi pag. 59

79Allegati

SNLG - Antibioticoprofilassi perioperatoria nell’adulto

Per un reparto di Ostetricia e Ginecologia (II)

Nei pazienti allergici ai betalattamici

Somministrare un antibiotico non betalattamico con spettroadeguato, ad esempio:• clindamicina^(600 mg)

± gentamicina^ 3 mg/Kg NB: la dose di gentamicina non varipetutaoppure• un fluorochinolone

(ad esempio ciprofloxacina^ 400 mg)

Vedi: Presenza di eventuali allergie ai betalattamici pag. 51

Tipo di intervento

CHIRURGIA OSTETRICA• Aborto indotto entro 90 gg• Aborto indotto dopo 90 gg

CHIRURGIA OSTETRICA• Parto cesareo non elettivo

(con travaglio in atto e/o rottura di membrane più di 6 ore primadell’intervento)

>>

° Le aminopeneicilline associate ad un inibitore delle betalattamasi sono tra gli antibiotici più frequentemente utilizzati in terapia;il loro uso in profilassi deve quindi essere limitato e considerato caso per caso.

^ Farmaco che non presenta in scheda tecnica l‘indicazione profilassi antibiotica in chirurgia.Le aree in grigio esprimono decisioni non supportate da forti evidenze in cui la linea guida nazionale non esprime una raccoman-dazione precisa, ma solo un suggerimento; in tale caso i gruppi di implementazione locale dovranno decidere la raccomandazionemutuandola da situazioni simili e tenendo conto dell’esperienza clinica dei singoli o di particolari situazioni. Le scelte effettuate dovran-no essere motivate.* Il gruppo di lavoro deve stabilire se, alla 3° ora di intervento, fare una somministrazione aggiuntiva dell’antibiotico scelto.** Il gruppo di lavoro dovrà decidere se ed in quali interventi prolungare la profilassi per 24 ore considerando la presenza di un pun-

teggio ASA ≥3 e la durata dell’intervento. In caso positivo la dose unitaria e l’intervallo fra le somministrazioni saranno quelle uti-lizzate in terapia.

Antibiotico e modalità di somministrazione

Somministrare per os 2 ore prima dell’intervento:• una tetraciclina (Doxiciclina 200 mg)

oppure• un macrolide (Eritromicina 900 mg)

Somministrare dopo il clampaggio del cordone ombelicale:• una cefalosporina di 2° generazione

(cefoxitina^ 2 g) come 2° scelta • una ureidopenicillina

(ad esempio piperacillina 4 g)oppure• una aminopenicillina associata

ad un inibitore delle betalattamasi[amoxicillina/ac. clavulanico 2,2 g(1,2 g se peso < 50 Kg) da infonderein 30 minuti]°

Valutazioni locali:• somministrazione di ulteriori dosi

di antibiotico entro le 24 ore**

Vedi: Durata della profilassi pag. 59

Vaginal irrigation

� Povidone-iodine (5 RCTs, n=1766) ¡  Lower Endometritis

÷ 3.6% vs 7.2%; RR 0.39, 95% CI 0.16 to 0.97 ¡  Antibiotics an issue

� Chlorexidine

¡  No effect

Haas DM et al Cochrane 2010 (5 RCTs) Cutland CL, et al. Lancet 2009;374:1909-16 (South Africa)

Incisione della cute trasversale Wylie BJ, et al. Obstet Gynecol 2010;115:1134-40 (NICHD)

Compared to vertical + 1 min for primary + 2 min for repeat

Neonatal outcomes not improved

Joel-Cohen techniques Dodd, Cochrane 2008

�  Reduction in: ¡  Operating time ¡  Time from skin incision to birth infant ¡  Blood loss ¡  Fever

Urinary catheter

�  More UTIs �  No difference in

¡  Urinary retention ¡  Intraoperative difficulties

�  Incidence injury in 1,000 CDs in literature: ¡  Bladder: 1.4 ¡  Ureter: 0.3

Ghoreishi et al IJGO 2003 (RCT, n=270, Iran, antib?) Nasr et al J Perinat 2009 (RCT, n=420, Egypt, antib?) Wen et al. BJOG 2010 (meta-analysis, 2 RCT and 1 NRCT)

Bladder Flap

•  1 RCT, 258 women (primary and repeat) •  10 min vs 9 min incision-delivery interval •  Similar

•  Total operating time, change in hgb, hematuria •  No bladder injuries •  ? Long-term effects

More adhesions at repeat cesarean

Tuuli M et al OG 2012;119:815 (April, Wash U)

Malvasi et al EJOGRB 2011

Uterine incision to delivery interval (UDI)

Autore N. Cases U-D interval associated with poor outcomes Maayan-Metzger, 2010 855 ≥120 sec Zhou, 1993 130 >150 sec Andersen, 1987 204 Not found association Haruta, 1986 60 >150 sec Datta, 1981 105 >180 sec

taglio cesareo di emergenza nel primo stadio: indicazioni ......cate- gory i fhr patterns may be...

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