title: Likelihood of cesarean delivery after applying leading active labor diagnostic guidelines.
abstract: Friedman, the United Kingdom's National Institute for Health and Care Excellence (NICE), and the American College of Obstetricians and Gynecologists/Society for Maternal-Fetal Medicine (ACOG/SMFM) support different active labor diagnostic guidelines. Our aims were to compare likelihoods for cesarean delivery among women admitted before vs in active labor by diagnostic guideline (within-guideline comparisons) and between women admitted in active labor per one or more of the guidelines (between-guideline comparisons).
  
  
  
  Active labor diagnostic guidelines were retrospectively applied to cervical examination data from nulliparous women with spontaneous labor onset (n = 2573). Generalized linear models were used to determine outcome likelihoods within- and between-guideline groups.
  
  
  
  At admission, 15.7%, 48.3%, and 10.1% of nulliparous women were in active labor per Friedman, NICE, and ACOG/SMFM diagnostic guidelines, respectively. Cesarean delivery was more likely among women admitted before vs in active labor per the Friedman (AOR 1.75 [95% CI 1.08-2.82] or NICE guideline (AOR 2.55 [95% CI 1.84-3.53]). Between guidelines, cesarean delivery was less likely among women admitted in active labor per the NICE guideline, as compared with the ACOG/SMFM guideline (AOR 0.55 [95% CI 0.35-0.88]).
  
  
  
  Many nulliparous women are admitted to the hospital before active labor onset. These women are significantly more likely to have a cesarean delivery. Diagnosing active labor before admission or before intervention to speed labor may be one component of a multi-faceted approach to decreasing the primary cesarean rate in the United States. The NICE diagnostic guideline is more inclusive than Friedman or ACOG/SMFM guidelines and its use may be the most clinically useful for safely lowering cesarean rates.
authors.affiliation: Vanderbilt University School of Nursing, Nashville, TN, USA.
authors.forename: Jeremy L
authors.identifier: 0000-0003-4648-2239
authors.initials: JL
authors.lastname: Neal
authors.affiliation: College of Nursing, University of Colorado, Aurora, CO, USA.
authors.forename: Nancy K
authors.initials: NK
authors.lastname: Lowe
authors.affiliation: Vanderbilt University School of Nursing, Nashville, TN, USA.
authors.forename: Julia C
authors.initials: JC
authors.lastname: Phillippi
authors.affiliation: Clinical Nursing, The Ohio State University College of Nursing, Columbus, OH, USA.
authors.forename: Sharon L
authors.initials: SL
authors.lastname: Ryan
authors.affiliation: Nursing Quality Improvement & Patient Safety at The Ohio State University Wexner Medical Center, Columbus, OH, USA.
authors.forename: Amy M
authors.initials: AM
authors.lastname: Knupp
authors.affiliation: Schools of Nursing and Medicine at Vanderbilt University, Nashville, TN, USA.
authors.forename: Mary S
authors.initials: MS
authors.lastname: Dietrich
authors.affiliation: Department of Obstetrics & Gynecology, The Ohio State University, Columbus, OH, USA.
authors.forename: Stephen F
authors.initials: SF
authors.lastname: Thung
mesh_terms: D000293:Adolescent; D000328:Adult; D002585:Cesarean Section / Q000009:adverse effects / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007745:Labor Onset / Q000502:physiology*; D007751:Labor, Induced / Q000379:methods / Q000706:statistics & numerical data*; D016014:Linear Models; D007744:Obstetric Labor Complications / Q000453:epidemiology*; D010121:Oxytocin / Q000627:therapeutic use; D010298:Parity; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011256:Pregnancy Outcome; D012189:Retrospective Studies; D012955:Societies, Medical; D013222:State Medicine; D006113:United Kingdom; D014481:United States; D055815:Young Adult
chemical_list: D010121:Oxytocin
keywords: cesarean section; labor onset; nulliparity; oxytocin; parturition