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INTRODUCTION |
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Background: In order to define
abnormal labor, a definition of normal labor must be understood and accepted.
Normal labor is defined as uterine contractions that result in progressive
dilation and effacement of the cervix. By following thousands of labors
resulting in uncomplicated vaginal deliveries, certain time limits and progress
milestones have been identified. Failure to meet these milestones defines
abnormal labor, which suggests an increased risk of an unfavorable outcome.
Thus, abnormal labor alerts the obstetrician to consider alternative methods for
a successful delivery that minimizes risks to both the mother and infant.
Friedman’s original research in 1955 defined 3 stages of labor. The first
stage starts with uterine contractions leading to complete cervical dilation,
and it is divided into the latent and active phases. In the latent phase, there
are irregular uterine contractions but slow and gradual cervical effacement and
dilation. The active phase is evidenced by an increased rate of cervical
dilation and fetal descent. This active phase usually starts at 3-4 cm cervical
dilation and is subdivided into the acceleration, maximum slope, and
deceleration phases. The second stage of labor ranges from complete dilation to
the delivery of the infant. The third stage of labor involves delivery of the
placenta.
Abnormal labor constitutes any findings that fall outside the accepted normal
labor curve. However, we hesitate to apply the diagnosis of abnormal labor
during the latent phase because confusing prodromal contractions for latent
labor is easy.
Abnormal labor of the second stage often is a result of problems with one of
the 3 P's.
- Passenger (infant size and fetal presentation, eg, in cephalic-occiput
anterior or occiput posterior vs breech or transverse)
- Pelvis or passage (size and adequacy of the pelvis)
- Power (uterine contractility)
Pathophysiology: A prolonged latent phase may result
secondary to oversedation or entering labor early with a thickened or uneffaced
cervix. It also may be misdiagnosed in the face of frequent prodromal
contractions. Protraction of active labor is more easily diagnosed and is
dependent upon the 3 Ps.
The first P, the passenger, may produce abnormal labor because of the infant’s
size (eg, 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 dystocia.
Regarding the power component, the frequency of uterine contraction may be
adequate but the intensity inadequate. Disruption of communication between
adjacent segments of the uterus also may exist, resulting from surgical
scarring, fibroids, or other conduction disruption. Whatever the cause, the
contraction pattern fails to result in cervical effacement and dilatation.
Frequency:
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- In the US: Of all cephalic deliveries, 8-11% are
complicated by an abnormal first stage of labor. Dystocia occurs in 12% of
deliveries without a history of prior cesarean section. Dystocia may account
for as many as 60% of cesarean deliveries.
Mortality/Morbidity: Both maternal and fetal mortality and
morbidity increases with abnormal labor. This probably is an effect-effect
relationship rather than a cause-effect relationship. Nonetheless, some urgency
to identify abnormal labor and act appropriately to reduce these risks exists.
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CLINICAL |
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History:
- Evaluate every pregnant patient who presents with contractions in the
labor and delivery suite.
- 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.
- Therefore, plot the progress of any patient in labor and evaluate it on a
labor curve.
Physical:
- Upon admission to the labor and delivery suite, determine and document the
following clinical findings:
- Clinical pelvimetry, which is best performed at the first prenatal care
visit, is important to asses the pelvic type (android, gynecoid,
platypelloid, anthropoid).
- Also, evaluate the position of the fetal head in early labor, because as
labor progresses, caput and moulding complicate correct assessment.
- The next component is establishing and documenting an estimated fetal
weight.
- The physician also must monitor fetal heart rate and uterine contraction
patterns and assess fetal well-being.
- The final component includes a cervical exam to determine if the patient
is in the latent or active phase of labor.
- By addressing these issues, the physician is aware of the current phase of
labor and can anticipate whether abnormal labor from any of the 3 Ps will be
encountered.
Causes:
- The latent phase of labor is defined as the period of time starting with
the onset of regular uterine contractions and ending with the onset of the
active phase (3-4 cm cervical dilation).
- 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.
- Another cause for abnormal labor is power, defined as uterine
contractility multiplied by the frequency of contractions.
- Montevideo units (MVUs) refer to the strength of contractions in mm of
mercury multiplied by the frequency per 10 minutes as measured by
intrauterine pressure transducer.
- The uterine contraction pattern must repeat every 2-3 minutes.
- The uterine contractile force produced must exceed 200 MVU/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 MVU.
- An arrest disorder cannot be diagnosed until the patient is in the
active phase and the contraction pattern exceeds 200 MVUs for 2 hours with
no cervical change.
- Another cause for the abnormal labor could be the pelvis, size of the
passageway inhibiting the passenger to delivery.
- For example, diagnosing an anthropoid pelvis (pelvic type that is oval
with a vertical long side) alerts the physician to the possibility of the
infant presenting in the occiput posterior. As a result, the physician might
expect a prolonged labor course.
- A patient who is extremely short, very obese, or has had prior trauma to
the bony pelvis also may be at increased risk of abnormal labor.
- Finally, abnormal labor could also be secondary to the passenger, the size
of the infant and its presentation.
- 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, which compromises the narrowest diameter
through the pelvis.
- Fetal macrosomia and other anomalies (including hydrocephalus,
encephalocele, fetal goiter, cystic hygroma, hydrops, or anything that
increases the size of the infant) are likely to cause deviation from the
normal labor curve.
- Low-dose epidural and combined spinal-epidural anesthetics minimize motor
block that may contribute to prolonged second stage. Oversedation has been
implicated as prolonging labor in both the latent and active phases.
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DIFFERENTIALS |
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Other Problems to be Considered:
False labor
Placental abruption
Premature labor
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WORKUP |
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Lab Studies:
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- No specific laboratory studies are used to assess abnormal labor.
Imaging Studies:
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- X-ray pelvimetry and CT pelvimetry may be helpful to assess the maternal
bony pelvis.
- Most often, these studies are used to reassure clinicians of pelvic
adequacy when performing elective vaginal deliveries in breech
presentations.
- These studies are not error free because dystocia or abnormal labor can
arise from soft-tissue obstructions in the pelvic outlet, particularly in
women who are obese.
Other Tests:
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- The simplest test used to evaluate abnormal labor is to plot the patient’s
labor progress (cervical dilation vs duration in hours) on a labor curve.
- A second test used to address adequate labor is the review of the
uterine contraction pattern.
- Most importantly, the fetal heart tracing must be reassuring throughout
the labor course.
Procedures:
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- Clinical pelvimetry, at a minimum, must address the angles of the spinous
processes (convergent, divergent, straight), the bi-ischial diameter (>8 cm),
the distance to the sacral promontory from the symphysis pubis (>12 cm), and
the relation of the bony pelvis to the fetal head.
- Clinical pelvimetry takes experience and deliberate attention paid to
the question of pelvic adequacy.
- It cannot account for fetal size or strength/frequency of contractions,
but in experienced hands, it may reliably identify a pelvis as adequate,
borderline, or contracted.
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TREATMENT |
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Medical Care: A prolonged latent
phase is not indicative of dystocia in itself because this diagnosis cannot
be made in the latent phase. Gabbe stated the following:
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For those in the latent phase, the treatment of choice is rest or sleep 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 will 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.
- If the abnormal labor results from functional dystocia or an abnormal
uterine contractility pattern and oxytocin implementation has not improved the
outcome, a beta-blocker may be used.
- listing inclusion and exclusion criteria for beta-blocker use.
- Low-dose administration of IV propranolol in abnormal labor augmented
with oxytocin reduced the need for cesarean delivery, particularly among
patients with inadequate uterine contractility.
- There have been anecdotal reports stating that simply repositioning the
patient frequently may relieve a seemingly obstructed labor.
- Although not studied rigorously, there appears to be little harm in this
maneuver.
- In theory, it may unseat an asynclitic or malrotated presenting part and
allow it to engage in the pelvis more effectively.
Surgical Care:
- Amniotomy often is used and is an accepted practice once the patient has
reached the active phase of labor. However, 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 there is nonreassurance of the fetal heart
pattern, expedient delivery is justified; this includes operative vaginal
delivery or cesarean section as indicated.
Diet:
- Most institutions have standing orders that patients in labor remain NPO,
or nothing by mouth, as a precaution should the need for an emergent cesarean
section occur.
- Some institutions permit ice chips, and other institutions permit a clear
liquid diet.
- If patients have been carefully selected as low risk for labor
obstruction, a regular diet may be ordered.
- Pregnant women have delayed gastric emptying, and aspiration is a very
serious concern in the event of an anesthetic induction.
Activity:
- For patients in labor, remaining active and mobile while in the latent and
early active phase is best.
- However, once rupture of membranes has occurred or signs of fetal
nonreassurance exist, then bed rest and continuous fetal monitoring is
appropriate.
- Some physicians allow ambulation throughout labor as long as the fetal
head is well applied (minimizing risk of cord prolapse) and evidence of fetal
well-being exists (monitoring for 20 min/h without signs of fetal compromise).
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MEDICATION |
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A method called active management of labor is
practiced in Ireland. This method is applied to women who are nulliparous with
singleton cephalic presentations at term. It involves the use of high dose
oxytocin, starting rate at 6 mU/min and increasing by 6 mU/min every 15 minutes
to a maximum of 40 mU/min. The goal is no more than 7 uterine contractions per
15 minutes. Cesarean delivery is performed if delivery has not occurred or is
not imminent 12 hours after admission or for fetal compromise (diagnosed with
fetal scalp pH). Initially, the Irish cesarean section rate was quoted at 4.8%
but now has doubled, which is attributed to widespread use of epidural
anesthesia. Other studies using the active management protocol describe similar
cesarean section rates to that of the low-dose protocol.
Dinoprostone and misoprostone are prostaglandin analogs used to stimulate
cervical dilation and uterine contractions, and are pharmacologic alternatives
to using laminaria or placing a Foley bulb in the cervix.
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Drug Category: Abortifacients -- Oxytocin is
the only Food and Drug Administration (FDA)-approved medication recommended for
labor augmentation. Other options include misoprostol and dinoprostone.
Drug Name
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Oxytocin (Pitocin) --
Produces rhythmic uterine contractions and can stimulate the gravid uterus,
as well as vasopressive and antidiuretic effects. Can also control
postpartum bleeding or hemorrhage.
Has a half-life of 3-5 min and reaches steady state in approximately 40 min.
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Adult Dose |
Common protocol: Start
infusion at 1-2 mU/min and increase by 1-2 mU/min q30 min; continue until
adequate contractions (>200 MVU/10 min) achieved or (at some institutions) a
maximum rate of 20 mU/min is achieved |
Pediatric Dose |
Not established |
Contraindications |
Documented
hypersensitivity; pregnant patients with severe toxemia; unfavorable fetal
positions; a contracting uterus with hypertonic or hyperactive patterns;
labor where vaginal delivery should be avoided such as invasive cervical
carcinoma, cord presentation or prolapse, active herpes genitalis, total
placenta previa, and vasa previa |
Interactions |
Pressor effect of
sympathomimetics may increase when used concomitantly with oxytocic drugs,
causing postpartum hypertension |
Pregnancy |
X - Contraindicated in
pregnancy |
Precautions |
A uterus that is
overstimulated can be hazardous to both mother and fetus; hypertonic
contractions can occur in a patient whose uterus is hypersensitive to
oxytocin, regardless of whether it was administered appropriately; has
intrinsic antidiuretic effect that when administered by continuous infusion
and patient is receiving fluids by mouth, can cause water intoxication |
Drug Name
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Misoprostol (Cytotec) --
Prostaglandin analog that causes cervix to thin and dilate and uterus to
contract as it does during labor. Not FDA approved for this use. |
Adult Dose |
25-50 mcg tab inserted
intravaginally (paracervically); may readminister after 4 h if patient
reassessment is reassuring (<3 contractions/10 min) |
Pediatric Dose |
Not established |
Contraindications |
Documented
hypersensitivity; do not administer if >3 uterine contractions/h or in
patients with uterine scar (eg, previous cesarean section, myomectomy) |
Interactions |
None reported |
Pregnancy |
X - Contraindicated in
pregnancy |
Precautions |
A uterus that is
overstimulated can be hazardous to both mother and fetus; hypertonic
contractions can occur; therefore patient must be under continuous medical
supervision; caution when exceeding 150-200 mcg; monitor for tachysystole of
uterine contractions (if this occurs, medication should be washed out
of vagina with NS); not FDA approved for this indication |
Drug Name
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Dinoprostone (Cervidil) --
Prostaglandin E2 causes cervix to thin and dilate and uterus to contract as
it does during labor. Do not start oxytocin within 6 h of dinoprostone. |
Adult Dose |
Gel: 0.5 mg/syringe
intracervically or 10 mg vaginal insert placed in posterior vaginal fornix
(removed after active labor or after 12 h); reassess cervical change in 4-6
|
Pediatric Dose |
Not established |
Contraindications |
Documented hypersensitivity
|
Interactions |
None reported |
Pregnancy |
X - Contraindicated in
pregnancy |
Precautions |
A uterus that is
overstimulated can be hazardous to both mother and fetus; hypertonic
contractions can occur; therefore, patient must be under continuous medical
supervision; abdominal or stomach cramps, diarrhea, fever, nausea, or
vomiting may occur |
Drug Category: Beta-adrenergic blocking agents
-- Another option for abnormal labor secondary to inadequate uterine
contractility is a beta-blocker. See Picture 4 for
inclusion and exclusion criteria.
Drug Name
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Propranolol (Inderal) --
Nonselective, beta-adrenergic receptor blocker. |
Adult Dose |
2 mg IV; repeat one time
only in 1 h if no progress observed |
Pediatric Dose |
Not established |
Contraindications |
Documented
hypersensitivity; uncompensated congestive heart failure; bradycardia,
cardiogenic shock; A-V conduction abnormalities |
Interactions |
Coadministration with
aluminum salts, barbiturates, NSAIDs, penicillins, calcium salts,
cholestyramine, and rifampin may decrease propranolol effects; calcium
channel blockers, cimetidine, loop diuretics, and MAOIs may increase
toxicity of propranolol; toxicity of hydralazine, haloperidol,
benzodiazepines, and phenothiazines may increase with propranolol |
Pregnancy |
C - Safety for use during
pregnancy has not been established. |
Precautions |
Beta-adrenergic blockade
may decrease signs of acute hypoglycemia and hyperthyroidism; abrupt
withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid
storm; withdraw drug slowly and monitor closely |
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FOLLOW-UP |
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Complications:
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- Maternal infection is a risk, especially when rupture of membranes occurs
for more than 18 hours. Administer antibiotics when it appears that this time
will be exceeded or for signs/symptoms of chorioamnionitis.
- Fetal compromise can occur from the inability to tolerate labor (eg,
uterine hyperstimulation) or infection, and it must be closely evaluated.
Fetal heart monitoring often reveals signs of compromise with decelerations,
and fetal scalp pH is an option when indicated.
- Probably the most common complication of the medical induction of labor is
hyperstimulation of the uterus. If unrecognized and untreated, excessive
stimulation of the uterus can result in fetal compromise, cord compression and
uteroplacental insufficiency. Uterine rupture, postpartum uterine atony and
postpartum hemorrhage may be seen as very serious and life-threatening
complications.
Prognosis:
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- The prognosis of subsequent pregnancies depends on the cause for abnormal
labor. For example, if it occurs from macrosomia, the next infant may not be
macrosomic. However, if the abnormal labor was secondary to a contracted
pelvis with a normal-sized or small infant, then the likelihood for a
recurrence of abnormal labor is high.
Patient Education:
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- The patient must be aware of all risks involved with labor, including the
potential for emergent cesarean section if there is fetal compromise.
Furthermore, inform her of status throughout the labor course, especially if a
change in management is anticipated. Counsel patients early in pregnancy that
maternal weight gain correlates with fetal weight gain, and excessive gain is
a risk factor for abnormal labor.
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MISCELLANEOUS |
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Medical/Legal Pitfalls:
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- The primary goal in labor is to provide the safest outcome for both the
mother and infant.
- The primary medicolegal issue in abnormal labor is failure to diagnose.
- Any change from the normal labor curve requires reassessment regarding
the 3 Ps.
- Once the cause of labor dysfunction is identified, correct it if
possible, and closely monitor the labor.
- If the corrective measures are unsuccessful in resolving the abnormal
labor, then consider an operative delivery.
- Fetal heart tracing must be reassuring in order to continue with
expectant management. However, if fetal compromise exists, anticipate
expedited delivery.
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BIBLIOGRAPHY |
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- American College of Obstetricians and Gynecologists: Dystocia and the
Augmentation of Labor. ACOG Technical Bulletin, No. 218. 1995; 218: 1-7.
- Creasy RK, Resnik R, Bowes WA: Clinical aspects of normal and abnormal
labor. In: Maternal-Fetal Medicine. 4th ed. 1999:543-549.
- Cunningham FG, MacDonald PC, Gant NF: Abnormal labor. In: Williams
Obstetrics. 20th ed. Appleton & Lange; 1997:415-434.
- Friedman EA: Primigravid Labor: A graphicostatistical analysis. Obstet
Gynecol 1955; 6: 567-589.
- Friedman EA: Labor in Multiparas: A graphicostatistical analysis. Obstet
Gynecol 1956; 8: 691-703.
- Gabbe SJ, O'Brien WF, Cefalo RC: Labor and delivery. In: Obstetrics:
Normal and Problem Pregnancies. 3rd ed. 1996:378-381.
- Gifford DS, Morton SC, Fiske M, et al: Lack of progress in labor as a
reason for cesarean. Obstet Gynecol 2000 Apr; 95(4): 589-95[Medline].
- Repke JT, Johnson TR, Ludmir J: Prolonged second stage of labor: What
would you do? OBG Management 2001; 13: 72-83.
- Sanchez-Ramos L, Quillen MJ, Kaunitz AM: Randomized trial of oxytocin
alone and with propranolol in the management of dysfunctional labor. Obstet
Gynecol 1996 Oct; 88(4 Pt 1): 517-20[Medline].
- Socol ML, Peaceman AM: Active management of labor. Obstet Gynecol Clin
North Am 1999 Jun; 26(2): 287-94[Medline].
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