Download PDF
Am J Perinatol 2023; 40(01): 099-105
DOI: 10.1055/s-0041-1728836
Original Article

Considering Criteria for Active Phase Labor Management of Nulliparous Women: A Cost-Effectiveness Analysis

Eleanor M. Schmidt
1   Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
,
Alyssa R. Hersh
1   Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
,
Methodius Tuuli
2   Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana
,
Alison G. Cahill
3   Department of Women's Health, University of Texas at Austin, Dell Medical School, Austin, Texas
,
Aaron B. Caughey
1   Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
› Author Affiliations Funding None.
› Further Information
Also available at
    Permissions and Reprints

Abstract

Objective The aim of the study is to evaluate differences in maternal and neonatal outcomes based on updated criteria for defining active labor at 6 cm of cervical dilation and to determine if these recommendations are cost-effective.

Study Design A decision-analytic model was built using TreeAge Pro 2020 software. We included maternal outcomes of mode of delivery, endometritis, postpartum hemorrhage requiring transfusion, and death. Neonatal outcomes included rates of shoulder dystocia and permanent brachial plexus injury. Costs and quality-adjusted life years (QALYs) were included from the maternal and infant perspectives. We used a willingness-to-pay threshold of $100,000 per QALY and all model inputs were subjected to sensitivity analysis.

Results In a theoretical cohort of 1.4 million women, a threshold of 6 cm to define active labor resulted in 373,668 fewer cesarean deliveries, 33,181 fewer cases of endometritis, 143 fewer postpartum hemorrhages requiring transfusions, and seven fewer maternal deaths when compared with a threshold of 4 cm. However, there were higher rates of adverse neonatal outcomes, including 484 more cases of shoulder dystocia and 17 more instances of permanent brachial plexus injury. Using 6 cm as the threshold resulted in lower costs and greater effectiveness, making it a dominant strategy. Multivariate sensitivity analysis demonstrated the model was robust over a wide range of assumptions.

Conclusion In this model, considering 6 cm of cervical dilation as the threshold for the active phase of labor compared with 4 cm was a cost-effective strategy to prevent primary cesarean deliveries, lower costs, and improve maternal outcomes, despite associated increased adverse neonatal outcomes.

Key Pointsg

  • Cervical dilation of 6 cm should be considered the threshold for the active phase of labor. This is a change from the prior definition of 4 cm.

  • We built a theoretical model to compare outcomes and costs associated with the new active phase definition of 6 cm.

  • Using a 6-cm threshold is a cost-effective strategy for decreasing primary cesarean deliveries.

Keywords

active phase - cesarean delivery - cost-effectiveness analysis - labor - labor arrest - obstetric management

Authors' Contributions

All authors were involved in the design, analysis, and interpretation of the data reported in this study. Each author has indicated that he or she has met the journal's requirements for authorship.


Note

Institutional Review Board approval was not obtained, as this was a theoretical model with published model inputs.


Supplementary Material



Publication History

Received: 04 July 2020

Accepted: 02 March 2021

Article published online:
03 May 2021

© 2021. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Friedman E. The graphic analysis of labor. Am J Obstet Gynecol 1954; 68 (06) 1568-1575
    CrossrefPubMedGoogle Scholar
  • 2 Zhang J, Troendle JF, Yancey MK. Reassessing the labor curve in nulliparous women. Am J Obstet Gynecol 2002; 187 (04) 824-828
    CrossrefPubMedGoogle Scholar
  • 3 Osterman MJ, Martin JA. Primary cesarean delivery rates, by state: results from the revised birth certificate, 2006-2012. Natl Vital Stat Rep 2014; 63 (01) 1-11
    PubMedGoogle Scholar
  • 4 Spong CY, Berghella V, Wenstrom KD, Mercer BM, Saade GR. Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol 2012; 120 (05) 1181-1193
    CrossrefPubMedGoogle Scholar
  • 5 Zhang J, Landy HJ, Ware Branch D. et al; Consortium on Safe Labor. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol 2010; 116 (06) 1281-1287
    CrossrefPubMedGoogle Scholar
  • 6 Caughey AB, Cahill AG, Guise J-M, Rouse DJ. American College of Obstetricians and Gynecologists (College), Society for Maternal-Fetal Medicine. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014; 210 (03) 179-193
    CrossrefPubMedGoogle Scholar
  • 7 Martin JA, Hamilton BE, Osterman MJK. Births in the United States, 2018. NCHS Data Brief 2019; (346) 1-8
    PubMedGoogle Scholar
  • 8 Kawakita T, Reddy UM, Huang CC, Auguste TC, Bauer D, Overcash RT. Predicting vaginal delivery in nulliparous women undergoing induction of labor at term. Am J Perinatol 2018; 35 (07) 660-668
    Article in Thieme ConnectPubMedGoogle Scholar
  • 9 Burrows LJ, Meyn LA, Weber AM. Maternal morbidity associated with vaginal versus cesarean delivery. Obstet Gynecol 2004; 103 (5 Pt 1): 907-912
    CrossrefPubMedGoogle Scholar
  • 10 Shamsa A, Bai J, Raviraj P, Gyaneshwar R. Mode of delivery and its associated maternal and neonatal outcomes. Open J Obstet Gynecol 2013; 3: 307-312
    CrossrefPubMedGoogle Scholar
  • 11 Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins GD. Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery. Am J Obstet Gynecol 2008; 199 (01) 36.e1-36.e5
    CrossrefPubMedGoogle Scholar
  • 12 Christoffersson M, Rydhstroem H. Shoulder dystocia and brachial plexus injury: a population-based study. Gynecol Obstet Invest 2002; 53 (01) 42-47
    CrossrefPubMedGoogle Scholar
  • 13 Rouse DJ, Owen J. Prophylactic cesarean delivery for fetal macrosomia diagnosed by means of ultrasonography—a Faustian bargain?. Am J Obstet Gynecol 1999; 181 (02) 332-338
    CrossrefPubMedGoogle Scholar
  • 14 Economic Research Federal Reserve Bank of St. Louis. Consumer Price Index for All Urban Consumers: Medical Care in U.S. City Average. U.S. Bureau of Labor Statistics;
    Google Scholar
  • 15 Kaimal AJ, Little SE, Odibo AO. et al. Cost-effectiveness of elective induction of labor at 41 weeks in nulliparous women. Am J Obstet Gynecol 2011; 204 (02) 137.e1-137.e9
    CrossrefPubMedGoogle Scholar
  • 16 Chung A, Macario A, El-Sayed YY, Riley ET, Duncan B, Druzin ML. Cost-effectiveness of a trial of labor after previous cesarean. Obstet Gynecol 2001; 97 (06) 932-941
    PubMedGoogle Scholar
  • 17 Mackeen AD, Packard RE, Ota E, Speer L. Antibiotic regimens for postpartum endometritis. Cochrane Database Syst Rev 2015; (02) CD001067
    PubMedGoogle Scholar
  • 18 Gentamicin: Drug information. UpToDate. Published 2019. Accessed January 26, 2020 at: https://www.uptodate.com/contents/gentamicin-systemic-drug-information?search=chorioamnionitistreatment&topicRef=8489&source=see_link
    PubMedGoogle Scholar
  • 19 Clindamycin: Drug Information. UpToDate. Published 2019. Accessed February 20, 2020 at: https://www-uptodate-com.liboff.ohsu.edu/contents/clindamycin-systemic-drug-information?search=clindamycin&source=panel_search_result&selectedTitle=1~146&usage_type=panel&display_rank=1#F8008170
    PubMedGoogle Scholar
  • 20 Bureau of Labor Statistics. Labor Force Statistics from the Current Population Survey. US Department of Labor, Bureau of Labor Statistics website. Published 2019. Accessed January 26, 2020 at: https://www.bls.gov/opub/reports/womens-earnings/2018/home.htm
    PubMedGoogle Scholar
  • 21 Munnell AH. The Average Retirement Age—An Update. Chestnut Hill, MA: Center for Retirement Research at Boston College; 2015
    Google Scholar
  • 22 Mission JF, Ohno MS, Cheng YW, Caughey AB. Gestational diabetes screening with the new IADPSG guidelines: a cost-effectiveness analysis. Am J Obstet Gynecol 2012; 207 (04) 326.e1-326.e9
    CrossrefPubMedGoogle Scholar
  • 23 Angeja ACE, Washington AE, Vargas JE, Gomez R, Rojas I, Caughey AB. Chilean women's preferences regarding mode of delivery: which do they prefer and why?. BJOG 2006; 113 (11) 1253-1258
    CrossrefPubMedGoogle Scholar
  • 24 Carroll AE, Downs SM. Improving decision analyses: parent preferences (utility values) for pediatric health outcomes. J Pediatr 2009; 155 (01) 21-25 , 25.e1–25.e5
    CrossrefPubMedGoogle Scholar
  • 25 Saigal S, Stoskopf BL, Feeny D. et al. Differences in preferences for neonatal outcomes among health care professionals, parents, and adolescents. JAMA 1999; 281 (21) 1991-1997
    CrossrefPubMedGoogle Scholar
  • 26 Kuppermann M, Nease RF, Learman LA, Gates E, Blumberg B, Washington AE. Procedure-related miscarriages and Down syndrome-affected births: implications for prenatal testing based on women's preferences. Obstet Gynecol 2000; 96 (04) 511-516
    PubMedGoogle Scholar
  • 27 Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness—the curious resilience of the $50,000-per-QALY threshold. N Engl J Med 2014; 371 (09) 796-797
    CrossrefPubMedGoogle Scholar