ABNORMAL LABOR

Definitions

 Time limits and progress milestones have been identified

that define normal labor.
 Failure to meet these normal labour milestones defines
abnormal labor, which suggests an increased risk of an
unfavorable outcome
 Dystocia of labor is defined as difficult labor or abnormally
slow progress of labor.
 Other terms that are often used interchangeably with
dystocia are dysfunctional labor, failure to progress (lack
of progressive cervical dilatation or lack of descent), and
cephalopelvic disproportion (CPD).

Abnormal Labor Indicators

Indication Nullipara Multipara

Prolonged latent phase >20 h >14 h

Average second stage 50 min 20 min

Prolonged second stage without (with) epidural >2 h (>3 h) >1 h (>2 h)

Protracted dilation <1.2 cm/h <1.5 cm/h

Protracted descent <1 cm/h <2 cm/h

Arrest of dilation* >2 h >2 h

Arrest of descent* >2 h >1 h

Prolonged third stage >30 min >30 min

 Abnormal labor constitutes any findings that fall outside

the accepted normal labor curve.
 In general, abnormal labor is the result of problems with
one of the 3 P' s.
 Passenger (infant size, fetal presentation [occiput
anterior, posterior, or transverse])
 Pelvis or passage (size, shape, and adequacy of the
pelvis)
  Power (uterine contractility)

Epidemiology

 Of all cephalic deliveries, 8-11% are complicated by an

abnormal first stage of labor.
 Dystocia occurs in 12% of deliveries in women without a
history of prior cesarean delivery.
 Dystocia may account for as many as 60% of cesarean
deliveries

Etiology

 Prolonged latent phase: A prolonged latent phase is

defined as exceeding 20 hours in patients who are
nulliparas or 14 hours in patients who are multiparas.
 The most common reason for prolonged latent phase is
entering labor without substantial cervical effacement.
 Power: Power is defined as uterine contractility multiplied
by the frequency of contractions.
 Montevideo units (MVUs) refer to the strength of
contractions in millimeters of mercury multiplied by the
frequency per 10 minutes as measured by intrauterine
pressure transducer.
 The uterine contraction pattern should repeat every 2-3
minutes.
 The uterine contractile force produced must exceed 200
MVUs/10 min for active labor to be considered adequate.
 For example, 3 contractions in 10 minutes that each reach
a peak of 60 mm Hg are 60 X 3 = 180 MVUs.
 An arrest disorder of labor cannot be diagnosed until the
patient is in the active phase and the contraction pattern
exceeds 200 MVUs for 2 or more hours with no cervical
change.
 Extending the minimum period of oxytocin augmentation
for active-phase arrest from 2 up to 4 hours may be
considered as long as fetal reassurance is noted with fetal
heart rate monitoring.
 Pelvis or the size of the passageway inhibiting delivery :
The shape of the bony pelvis (eg, anthropoid or
platypelloid) can result in abnormal labor.
 A patient who is extremely short or obese, or who has had
prior severe trauma to the bony pelvis, may also be at
increased risk of abnormal labor.
 Abnormal labor could also be secondary to the passenger,
the size of the infant, and/or the presentation of the
infant.
 In addition to problems caused by the differential in size
between the fetal head and the maternal bony pelvis, the
fetal presentation may include asynclitism or head
extension.
 Asynclitism is malposition of the fetal head within the
pelvis, which compromises the narrowest diameter
through the pelvis.
 Fetal macrosomia and other anomalies (including
hydrocephalus, encephalocele, fetal goiter, cystic
hygroma, hydrops, or any other abnormality that
increases the size of the infant) are likely to cause
deviation from the normal labor curve.
 Other factors include either a low-dose epidural or
combined spinal-epidural anesthetics that minimize motor
block and may contribute to a prolonged second stage.
 These have also been associated with an increase in
oxytocin use and operative vaginal delivery.
 Intravenous oversedation has also been implicated as
prolonging labor in both the latent and active phases.

Pathophysiology

 A prolonged latent phase may result from oversedation or

from entering labor early with a thickened or uneffaced
cervix.
 It may be misdiagnosed in the face of frequent prodromal
contractions.
 Protraction of active labor is more easily diagnosed and is
dependent upon the 3 P’s.
 The first P, the passenger, may produce abnormal labor
because of the infant's size (e.g. macrosomia) or from
malpresentation.
 The second P, the pelvis, can cause abnormal labor
because its contours may be too small or narrow to allow
passage of the infant.
 Both the passenger and pelvis cause abnormal labor by a
mechanical obstruction, referred to as mechanical
dystocia
 With the third P, the power component, the frequency of
uterine contraction may be adequate, but the intensity
may be inadequate.
 Disruption of communication between adjacent segments
of the uterus may also exist, resulting from surgical
scarring, fibroids, or other conduction disruption.
 Whatever the cause, the contraction pattern fails to result
in cervical effacement and dilation.
 This is called functional dystocia.
 Uterine contractile force can be quantified by the use of
an intra-uterine pressure catheter.
 Use of this device allows for direct measurement and
calculation of uterine contractility per each contraction
and is reported in Montevideo units (MVUs).
 For uterine contractile force to be considered adequate,
the force produced must exceed 200 MVUs during a 10-
minute contraction period.
 Arrest disorders cannot be properly diagnosed until the
patient is in the active phase and had no cervical change
for 2 or more hours with the contraction pattern
exceeding 200 MVUs.
 Uterine contractions must be considered adequate to
correctly diagnose arrest of dilation

Clinical manifestation:

History

 Evaluate every pregnant patient who presents with

contractions in the labor and delivery unit.
 Any patient in labor is at risk for abnormal labor
regardless of the number of previous pregnancies or the
seemingly adequate dimensions of the pelvis.
 Plot the progress of any patient in labor, and evaluate it
on a labor curve

Physical

 Upon admission to the labor and delivery unit, determine

and document clinical findings.
 Clinical pelvimetry, which is best performed at the first
prenatal care visit, is important in order to assess the
pelvic type (e.g. android, gynecoid, platypelloid,
anthropoid).
 Evaluate the position of the fetal head in early labor
because caput and moulding complicate correct
assessment as labor progresses.
 Establish and document an estimated fetal weight.
 Monitor fetal heart rate and uterine contraction patterns
to assess fetal well-being and adequacy of labor.
 Perform a cervical examination to determine whether the
patient is in the latent or active phase of labor.
 Addressing these issues allows for an assessment of the
current phase of labor and anticipation of whether
abnormal labor from any of the 3 P' s may be
encountered.

Treatment

Medical care

 Gabbe and colleagues state the following

 For those in the latent phase, the treatment of choice is
rest for several hours.
 During this interval, uterine activity, fetal status, and
cervical effacement must be evaluated to determine if
progress to the active phase has occurred.
 Approximately 85% of patients so treated progress to the
active phase
 Approximately 10% will cease to have contractions, and
the diagnosis of false labor may be made.
 For the approximately 5% of patients in whom therapeutic
rest fails and in patients for whom expeditious delivery is
indicated, oxytocin infusion may be used
 In cases of dysfunctional labor resulting from functional
dystocia or an abnormal uterine contractility pattern and
in which oxytocin implementation has not improved the
outcome, a beta-blocker may be considered.
 Low-dose administration of intravenous propranolol in
abnormal labor augmented with oxytocin reduced the
need for cesarean delivery, particularly among patients
with inadequate uterine contractility
 Anecdotal reports have stated that simply repositioning
the patient frequently relieves a seemingly obstructed
labor.
 Medication: A protocol called active management of labor
can be applied to nulliparous women with singleton
cephalic presentations at term.
 This method involves the use of high-dose oxytocin, with a
starting rate of 6 mU/min and increasing by 6 mU/min
every 15 min to a maximum of 40 mU/min.
 The goal is no more than 7 uterine contractions per 15
min.
 Under this protocol, cesarean delivery is performed if
vaginal delivery has not occurred or is not imminent 12
hours after admission or for fetal compromise.
 Dinoprostone and misoprostol are prostaglandin analogs
used to stimulate cervical dilation and uterine
contractions; they are pharmacologic alternatives to using
laminaria or placing a Foley bulb in the cervix.
 Using prostaglandin analogs with a scarred uterus (eg,
from prior cesarean or myomectomy) for labor induction is
absolutely contraindicated due to the significant risk for
uterine rupture
 treatment for dystocia in spontaneous labor revealed that
a single 1-mg dose of PgE2 vaginal gel
 Oxytocin (pintocin): Has a half-life of 3-5 min, and reaches
steady state in approximately 40 min
 Common protocol: Start infusion at 1-2 mU/min IV and
increase by 1-2 mU/min q30 min; continue until adequate
contractions (>200 MVUs/10 min) achieved or (at some
institutions) maximum rate of 20 mU/min achieved
 Beta-adrenergic blocking agents: Another option for
abnormal labor secondary to inadequate uterine
contractility is a beta-blocker
 propranolol: 2 mg IV; repeat one time only in 1 h if no
progress observed

Surgical Care

 Amniotomy is often used and has become an accepted

practice once the patient has reached the active phase of
labor, although it has not been shown to result in shorter
labor.
 This practice is not recommended in the latent phase of
labor because it may only serve to increase the risk of
intrauterine infection or cord prolapse
 If one of the arrest or protraction disorders is identified
and fails to respond to conservative measures, or if the
fetal heart pattern is nonreassuring, expedient delivery is
justified; this includes operative vaginal delivery (if
appropriate) or cesarean delivery as indicated.