Abstract Introduction: To protect normal birth, admission of pregnant women in labour units is one of the most important decisions. This study developed a protocol for admission of women during labour in order to improve the accuracy of the diagnosis of onset of labour. Methods: First the admission processes of 25 pregnant women were observed in the study hospital. Then the multi-disciplinary team searched and reviewed the Iranian database using related key words. Evidence-based medicine resources and other databases were searched using related key words for the most important symptoms in relation to the onset of active labour as well as early labour assessment programs. Results: The results of observation of the admission process in the study hospital and review of the literature indicated that low-risk pregnant women in labour were admitted using different criteria. The evidence-based protocol for admission of women in labour was developed using these criteria to provide a guide, which lists the necessary measures in dealing with women in various situations during the onset of labour. Presence of regular uterine contractions, cervical dilatation ≥ 4 cm and effacement should be considered as signs of starting labour, which may be accompanied by spontaneous rupture of membranes or bloody show. Conclusions: Protocols are appropriate clinical tools for the design and standardization of clinical processes based on the available evidence. This protocol could be used in a multi-center clinical trial to assess its effectiveness.
WHO. Care in normal birth: Apractical guide Geneva: World Health organization; 1996 [cited 2019]. Available from: http://whqlibdoc.who.int/hq/1996/WHO_FRH_MSM_96.24.pdf?ua=1〉.y.com.
Neal JL, Lamp JM, Buck JS, Lowe NK, Gillespie SL, Ryan SL. Outcomes of nulliparous women with spontaneous labor onset admitted to hospitals in preactive versus active labor. J Midwifery Womens Health. 2014;59(1):28-34. doi: 10.1111/jmwh.12160 pmid: 24512265
Janssen PA, Still DK, Klein MC, Singer J, Carty EA, Liston RM, et al. Early labor assessment and support at home versus telephone triage: a randomized controlled trial. Obstet Gynecol. 2006;108(6):1463-9. doi: 10.1097/01.AOG.0000247644.64154.bb pmid: 17138781
Marowitz A. Caring for women in early labor: can we delay admission and meet women's needs? J Midwifery Womens Health. 2014;59(6):645-50. doi: 10.1111/jmwh.12252 pmid: 25335992
Cheyne H, Terry R, Niven C, Dowding D, Hundley V, McNamme P. ‘Should I come in now?’: a study of women's early labour experiences. Brit J Midwifery. 2007;15(10):604-9. doi: 10.12968/bjom.2007.15.10.27341
Cheyne H, Hundley V, Dowding D, McNamee P, Niven C, Bland JM, et al. A cluster randomised trial to investigate the use of a decision aid for the diagnosis of active labour in term pregnancy. Early Labour Stud Scotland. 2007.
Lauzon L, Hodnett E. Antenatal education for self‐diagnosis of the onset of active labour at term: The Cochrane Library; 2013 [cited 2013]. Available from: http://www.thecochranelibrary.com.
Greulich B, Tarrant B. The latent phase of labor: diagnosis and management. J Midwifery Womens Health. 2007;52(3):190-8. doi: 10.1016/j.jmwh.2006.12.007 pmid: 17467585
Naghi Zadeh S, Sehhatie Shafaie F, Ghojazadeh M. The Effects of Early Admission of Pregnant Women During Latent Phase on Pregnant Outcomes in Tabriz Taleghani Hospital. Int J Women's Health Reprod Sci. 2014;2(4):254-9. doi: 10.15296/ijwhr.2014.38
Heidarnia M, Rahnama P, Montazeri A, Ebadi M, Rahmati Najarkolaei F. [Relationship between early admission of pregnant women in labor and its complications]. J Health Sci Res Inst. 2007;7(3):235-9.
Cheyne H, Dowding D, Hundley V, Aucott L, Styles M, Mollison J, et al. The development and testing of an algorithm for diagnosis of active labour in primiparous women. Midwifery. 2008;24(2):199-213. doi: 10.1016/j.midw.2006.12.005 pmid: 17337315
Albassam AN. The outcome of latent phase vs. Active phase admission to labour room of low risk nulliparous women in labour. J Fac Med. 2010;52(2):149-53.
Davey MA, McLachlan HL, Forster D, Flood M. Influence of timing of admission in labour and management of labour on method of birth: results from a randomised controlled trial of caseload midwifery (COSMOS trial). Midwifery. 2013;29(12):1297-302. doi: 10.1016/j.midw.2013.05.014 pmid: 23890679
Rahnama P, Faghihzadeh S, Garshasbi E. [The relationship between admission nulliparous women in active phase and latent phase of labor with cesarean rate and reasons of cesarean]. J Fac Tehran Univ Med Sci. 2005;63(12):980-5.
Vaziri F, Rambod M. [Comparison of the Labor Outcomes of the Hospitalized Nulliparous Women in Latent and Active Phase and some related factor in women who refered to Bandarabbasshariati hospital during 2008-9]. J Commun Health. 2009;4(1):1-6.
Sehati F, Naghi Zadeh S, Ghojazadeh M. [Comparison of during childbirth in women admitted in latent and active phase of Labor in Tabriz Taleghani Hospital]. J Obstet Gynecol Infert. 2012;15(20):19-27.
Mikolajczyk R, Zhang J, Grewal J, Chan L, Petersen A, Gross M. Early versus late admission to labor affects labor Progression and risk of cesarean section in nulliparous Women. Front Med. 2016;3(26):1-7.
Jackson S, Gregory KD. Management of the first stage of labor: potential strategies to lower the cesarean delivery rate. Clin Obstet Gynecol. 2015;58(2):217-26. doi: 10.1097/GRF.0000000000000102 pmid: 25860323
Sehati F, Naghi Zadeh S, Ghojazadeh M. [Comparison of Maternal Outcomes in Women Admitted In Latent and Active Phases of Labor]. J Obstet Gynecol Infert. 2013;16(53):18-28.
Hanley GE, Munro S, Greyson D, Gross MM, Hundley V, Spiby H, et al. Diagnosing onset of labor: a systematic review of definitions in the research literature. BMC Pregnancy Childbirth. 2016;16:71. doi: 10.1186/s12884-016-0857-4 pmid: 27039302
Trojner Bregar A, Lucovnik M, Verdenik I, Jager F, Gersak K, Garfield RE. Uterine electromyography during active phase compared with latent phase of labor at term. Acta Obstet Gynecol Scand. 2016;95(2):197-202. doi: 10.1111/aogs.12818 pmid: 26575523
Cappelletti G, Nespoli A, Fumagalli S, Borrelli SE. First-time mothers' experiences of early labour in Italian
Adv Nurs Midwifery Abasian Kasegari et al.
maternity care services. Midwifery. 2016;34:198-204. doi: 10.1016/j.midw.2015.09.012 pmid: 26656472
Lauzon L, Hodnett E. Labour assessment programs to delay admission to labour wards: The Cochrane Library; 2009 [cited 2019]. Available from: http://www.thecochranelibrary.com.
Cheyne H, Dowding DW, Hundley V. Making the diagnosis of labour: midwives' diagnostic judgement and management decisions. J Adv Nurs. 2006;53(6):625-35. doi: 10.1111/j.1365-2648.2006.03769.x pmid: 16553671
Rahnama P, Ziaei S, Faghihzadeh S. Impact of early admission in labor on method of delivery. Int J Gynaecol Obstet. 2006;92(3):217-20. doi: 10.1016/j.ijgo.2005.12.016 pmid: 16434043
Zare F, Karimzadeh Meybodi M. [The Effects of admission of women in latent phase on cesarean section rate]. J Shahid Sadoughi Univ Med Sci. 2003;11(1):12-6.
Janssen P, Nolan ML, Spiby H, Green J, Gross MM, Cheyne H, et al. Roundtable discussion: Early labor: what's the problem? Birth. 2009;36(4):332-9. doi: 10.1111/j.1523-536X.2009.00361.x pmid: 20002426
Janssen PA, Weissinger S. Women's perception of pre-hospital labour duration and obstetrical outcomes; a prospective cohort study. BMC Pregnancy Childbirth. 2014;14:182. doi: 10.1186/1471-2393-14-182 pmid: 24884415
Delaram M, Hassanpour A, Norian K, Kazemeian A. [Impact of early admission in labor on maternal and neonatal outcomes in Hajar health-care center of Shahr-e-Kord]. J Birjand Univ Med Sci. 2007;14(3):61-7.
Villar J, Carroli G, Zavaleta N, Donner A, Wojdyla D, Faundes A, et al. Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. BMJ. 2007;335(7628):1025. doi: 10.1136/bmj.39363.706956.55 pmid: 17977819
Ulfsdottir H, Nissen E, Ryding EL, Lund-Egloff D, Wiberg-Itzel E. The association between labour variables and primiparous women's experience of childbirth; a prospective cohort study. BMC Pregnancy Childbirth. 2014;14:208. doi: 10.1186/1471-2393-14-208 pmid: 24938280
Nolan M, Smith J. Women's experiences of following advice to stay at home in early labour. Brit J Midwifery. 2010;18(5):286-91. doi: 10.12968/bjom.2010.18.5.47856
Ostovar R, Pourreza A, Rashidian A, Rashidi BH, Hantooshzadeh S, Haghollai F, et al. Appropriateness of cesarean sections using the RAND Appropriateness Method criteria. Arch Iran Med. 2012;15(1):8-13. doi: 012151/AIM.005 pmid: 22208436
Miri Farahani L, Abbasi Shavazi M. [Caesarean Section Change Trends in Iran and Some Demographic Factors Associated with them in the Past Three Decades]. J Fasa Univ Med Sci. 2002;2(3):127-34.
Shahu R, Rostami F, Khosravi F, Rnayy F, Hasheminasab L, Hesami K. [The lived experience of women choosing cesarean delivery: a phenomenological study]. J Obstet Gynecol Infert. 2014;17(104):1-10.
Burqa N, Burqa A, Kashani E, Khaddam H. [Comparing the two groups, vaginal delivery and cesarean section in all of hospitals of Golestan State]. J Mazandaran Univ Med Sci. 2005;15(48):82-91.
Cheyne H, Hundley V, Dowding D, Bland JM, McNamee P, Greer I, et al. Effects of algorithm for diagnosis of active labour: cluster randomised trial. BMJ. 2008;337:a2396. doi: 10.1136/bmj.a2396 pmid: 19064606
Beebe KR, Humphreys J. Expectations, perceptions, and management of labor in nulliparas prior to hospitalization. J Midwifery Womens Health. 2006;51(5):347-53. doi: 10.1016/j.jmwh.2006.02.013 pmid: 16945782
Yang YS, Hur MH, Kim SY. Risk factors of cesarean delivery at prenatal care, admission and during labor in low-risk pregnancy: multivariate logistic regression analysis. J Obstet Gynaecol Res. 2013;39(1):96-104. doi: 10.1111/j.1447-0756.2012.01908.x pmid: 22672671
Jaspers MW, Smeulers M, Vermeulen H, Peute LW. Effects of clinical decision-support systems on practitioner performance and patient outcomes: a synthesis of high-quality systematic review findings. J Am Med Inform Assoc. 2011;18(3):327-34. doi: 10.1136/amiajnl-2011-000094 pmid: 21422100
Aghlmand S, Akbari F, Lameei A, Mohammad K, Small R, Arab M. Developing evidence-based maternity care in Iran: a quality improvement study. BMC Pregnancy Childbirth. 2008;8:20. doi: 10.1186/1471-2393-8-20 pmid: 18554384
Kinsman L, Rotter T, James E, Snow P, Willis J. What is a clinical pathway? Development of a definition to inform the debate. BMC Med. 2010;8:31. doi: 10.1186/1741-7015-8-31 pmid: 20507550
Vitaz TW, McIlvoy L, Raque GH, Spain D, Shields CB. Development and implementation of a clinical pathway for severe traumatic brain injury. J Trauma. 2001;51(2):369-75. pmid: 11493802
Yeh T-M, Pai F-Y, Huang K-I. Effects of clinical pathway implementation on medical quality and patient satisfaction. Total Qual Manag Busin Excel. 2014;26(5-6):583-601. doi: 10.1080/14783363.2013.863529
McNiven PS, Williams JI, Hodnett E, Kaufman K, Hannah ME. An early labor assessment program: a randomized, controlled trial. Birth. 1998;25(1):5-10. pmid: 9534499
Sadler LC, Davison T, McCowan LM. Maternal satisfaction with active management of labor: a randomized controlled trial. Birth. 2001;28(4):225-35.
MOHME. National Guidelines for Normal Delivery. Tehran: Ministry of Health and Medical Education of Islamic Republic of Iran; 2012.
Lameei A, Mosaferyadegary A, Nasiripour A, Maleky M. [The development of clinical pathway for natural birth process in Imam Reza (AS) Urmia]. J Hosp. 2012;10(4):9-20.
Simbar M, Nahidi F, Dolatian M, Akbarzadeh A. Assessment of quality of prenatal care in Shahid Beheshti Medical Science University centers. Int J Health Care Qual Assur. 2012;25(3):166-76. doi: 10.1108/09526861211210394 pmid: 22755472
Gross MM, Petersen A, Hille U, Hillemanns P. Association between women's self-diagnosis of labor and labor duration after admission. J Perinat Med.
Abasian Kasegari et al. Adv Nurs Midwifery
;38(1):33-8. doi: 10.1515/JPM.2010.005 pmid: 19954412
Cheng YW, Shaffer BL, Bryant AS, Caughey AB. Length of the First Stage of Labor and Associated Perinatal Outcomes in Nulliparous Women. Obstet Anesthesia Digest. 2012;32(1):21. doi: 10.1097/01.aoa.0000410779.64556.e4
Graseck AS, Odibo AO, Tuuli M, Roehl KA, Macones GA, Cahill AG. Normal first stage of labor in women undergoing trial of labor after cesarean delivery. Obstet Gynecol. 2012;119(4):732-6. doi: 10.1097/AOG.0b013e31824c096c pmid: 22433336
Laughton SK, Branch DW, Beaver J, Zhang J. Changes in Labor Patterns Over 50 Years. Obstet Anesthesia Digest. 2013;33(2):113. doi: 10.1097/01.aoa.0000429147.33822.4a
Petersen A, Penz SM, Gross MM. Women's perception of the onset of labour and epidural analgesia: a prospective study. Midwifery. 2013;29(4):284-93. doi: 10.1016/j.midw.2012.08.006 pmid: 23079870
Dolatian M, Hasanpour A, Montazeri S, Heshmat R, Alavi Majd H. The effect of reflexology on pain intensity and duration of labor on primiparas. Iran Red Crescent Med J. 2011;13(7):475-9. pmid: 22737514
Sekhavat L, Karbasi SA, Fallah R, Mirowliai M. Effect of hyoscine butylbromide first stage of labour in multiparus women. Afr Health Sci. 2012;12(4):408-11. pmid: 23515202
Faranesh R, Salim R. Labor progress among women attempting a trial of labor after cesarean. Do they have their own rules? Acta Obstet Gynecol Scandinavica. 2011;90(12):1386-92. doi: 10.1111/j.1600-0412.2011.01263.x
Hui J, Hahn PM, Jamieson MA, Palerme S. The duration of labor in adolescents. J Pediatr Adolesc Gynecol. 2010;23(4):226-9. doi: 10.1016/j.jpag.2010.01.001 pmid: 20371193
Khresheh R. Support in the first stage of labour from a female relative: the first step in improving the quality of maternity services. Midwifery. 2010;26(6):e21-4. doi: 10.1016/j.midw.2008.11.003 pmid: 19128863
Ismail MT, Hassanin MZ. Neuraxial analgesia versus intravenous remifentanil for pain relief in early labor in nulliparous women. Arch Gynecol Obstet. 2012;286(6):1375-81. doi: 10.1007/s00404-012-2459-3 pmid: 22810619
Dixon L, Skinner J, Foureur M. Women's perspectives of the stages and phases of labour. Midwifery. 2013;29(1):10-7. doi: 10.1016/j.midw.2012.07.001 pmid: 22906490
Dixon L, Skinner J, Foureur M. The emotional journey of labour-women's perspectives of the experience of labour moving towards birth. Midwifery. 2014;30(3):371-7. doi: 10.1016/j.midw.2013.03.009 pmid: 23664311
Darwish HS, Zaytoun HA, Kamel HA, Habash YH. Sonographic assessment of first stage of labor progress (ULTRASONIC PARTOGRAM). Egypt J Radiol Nuclear Med. 2013;44(3):673-80. doi: 10.1016/j.ejrnm.2013.04.009
Dencker A, Berg M, Bergqvist L, Lilja H. Identification of latent phase factors associated with active labor duration in low-risk nulliparous women with spontaneous contractions. Acta Obstet Gynecol Scandinavica. 2010;89(8):1034-9. doi: 10.3109/00016349.2010.499446
Cohen WR, Friedman EA. Perils of the new labor management guidelines. Am J Obstet Gynecol. 2015;212(4):420-7. doi: 10.1016/j.ajog.2014.09.008 pmid: 25218127
Cunningham F, Leveno K, Bloom S, Spong C, Dashe J, Hoffman B, et al. Williams Obstetrics. New York: McGraw-Hill; 2014.
Zhang J, Landy HJ, Branch DW, Burkman R, Haberman S, Gregory KD, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol. 2010;116(6):1281-7. doi: 10.1097/AOG.0b013e3181fdef6e pmid: 21099592
Kominiarek M, Zhang J, Van Veldhuisen P, Troendle J, Beaver J, Hibbard J. Contemporary labor patterns: the impact of maternal body mass index. Am J Obstet Gynecol. 2011;205(3):1-8.
Rotter T, Kinsman L, James E, Machotta A, Gothe H, Willis J, et al. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev. 2010(3):CD006632. doi: 10.1002/14651858.CD006632.pub2 pmid: 20238347
Aniza I, Saperi S, Aljunid S. Clinical pathway as a strategy in improving healthcare quality and cost containment. Med Health. 2008;3(2):239-46.
Zhang AH, Liu XH. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Int J Evid Based Healthcare. 2011;9(2):191-2. doi: 10.1111/j.1744-1609.2011.00223.x
Grove WM, Zald DH, Lebow BS, Snitz BE, Nelson C. Clinical versus mechanical prediction: a meta-analysis. Psychol Assess. 2000;12(1):19-30. pmid: 10752360
Kahneman D, Frederick S. Representativeness Revisited: Attribute Substitution in Intuitive Judgmen