Abnormal Labor

Obstetrics

Clinicals - History

Fact Explanation
Prolonged labor Abnormal labor or Dystocia of labor is defined as slow or abnormal progression of labor. This may affect the 1st, 2nd and 3rd stages of labor. Labor progress can be assessed retrospectively by the total length of labor or prospectively by the rate of cervical dilation. The second method is more preferred. Duration of labor depends on the parity. Administration of regional anesthesia impairs uterine contractions due to the inhibitory effect on pelvic nerves. Multiparous women usually show more rapid progress. An active phase lasting more than 12h hence a cervical dilation rate of less than 0.5cm per hour is considered abnormal for the first stage of labor. The second stage is considered delayed if the lasts more the 2.8h in nulliparous women and more than 1h in multiparous women. Prolonged labor
Abnormal labor or Dystocia of labor is defined as slow or abnormal progression of labor. This may affect the 1st, 2nd and 3rd stages of labor. Labor progress can be assessed retrospectively by the total length of labor or prospectively by the rate of cervical dilation. The second method is more preferred. Duration of labor depends on the parity. Administration of regional anesthesia impairs uterine contractions due to the inhibitory effect on pelvic nerves. Multiparous women usually show more rapid progress. An active phase lasting more than 12h hence a cervical dilation rate of less than 0.5cm per hour is considered abnormal for the first stage of labor. The second stage is considered delayed if the lasts more the 2.8h in nulliparous women and more than 1h in multiparous women.
Maternal exhaustion Due to prolonged straining. Maternal exhaustion
Due to prolonged straining.
Fetal distress : Fetal tachycardia and Cardiotocography (CTG) changes. Fetal blood supply is diminished during uterine contractions. The prolonged labor augmented with oxytocin may impair fetal blood flow. Fetal distress : Fetal tachycardia and Cardiotocography (CTG) changes.
Fetal blood supply is diminished during uterine contractions. The prolonged labor augmented with oxytocin may impair fetal blood flow.
Risk factors/ Aetiology A past history of prolonged labor or obstructed labor may suggest cephalopelvic disproportion. Suspect fetal macrosomia in a patient with diabetes during the antenatal period. Risk factors/ Aetiology
A past history of prolonged labor or obstructed labor may suggest cephalopelvic disproportion. Suspect fetal macrosomia in a patient with diabetes during the antenatal period.

Clinicals - Examination

Fact Explanation
General examination : Exhaustion Due to prolonged labor General examination : Exhaustion
Due to prolonged labor
General examination : Features of dehydration Due to prolonged straining. The lips and mouth may appear dry. The eyes may appear shrunken, capillary refill time is prolonged. In severe cases there may be tachycardia and hypotension. Measure the urine output. General examination : Features of dehydration
Due to prolonged straining. The lips and mouth may appear dry. The eyes may appear shrunken, capillary refill time is prolonged. In severe cases there may be tachycardia and hypotension. Measure the urine output.
Abdominal examination : Assess uterine contractions Palpate the abdomen during contractions and determine the frequency and the length of contractions. A contraction frequency of less than 2 per 10 minutes with each lasting less than 40s is considered ineffective. Abdominal examination : Assess uterine contractions
Palpate the abdomen during contractions and determine the frequency and the length of contractions. A contraction frequency of less than 2 per 10 minutes with each lasting less than 40s is considered ineffective.
Abdominal examination : Non-engaged head Finding of 3/5 or more of the fetal head palpable above the pelvic brim is supportive for cephalopelvic disproportion. Abdominal examination : Non-engaged head
Finding of 3/5 or more of the fetal head palpable above the pelvic brim is supportive for cephalopelvic disproportion.
Abdominal examination : Fetal lie Transverse and oblique lie predisposes to prolonged labor. Abdominal examination : Fetal lie
Transverse and oblique lie predisposes to prolonged labor.
Abdominal examination : Malposition The occipitoposterior position is a risk factor for prolonged labor. On abdominal examination there is subumbilical flattening, difficulty in palpating the fetal back and easily palpable fetal limbs. The fetal heart sound are heard more towards the flanks. Abdominal examination : Malposition
The occipitoposterior position is a risk factor for prolonged labor. On abdominal examination there is subumbilical flattening, difficulty in palpating the fetal back and easily palpable fetal limbs. The fetal heart sound are heard more towards the flanks.
Abdominal examination : Fetal tachycardia To detect fetal compromise. Abdominal examination : Fetal tachycardia
To detect fetal compromise.
Vaginal examination : Cervical dilatation During the first stage of labor cervical dilatation provides valuable information regarding progression of labor. During the latent phase the rate of dilatation is variable. During the active phase the normal rate in 1cm per hour. The exact value used requires further evaluation. Vaginal examination : Cervical dilatation
During the first stage of labor cervical dilatation provides valuable information regarding progression of labor. During the latent phase the rate of dilatation is variable. During the active phase the normal rate in 1cm per hour. The exact value used requires further evaluation.
Vaginal examination : Descent of the presenting part The position of the presenting part is measured in relation to the ischial spines. Progression of the labor can be monitored by assessing the descent of the fetus. Vaginal examination : Descent of the presenting part
The position of the presenting part is measured in relation to the ischial spines. Progression of the labor can be monitored by assessing the descent of the fetus.
Vaginal examination : Easily felt anterior fontanelle and difficulty in feeling the posterior fontanelle Due to deflexed fetal head. Face presentation may also be detected. Vaginal examination : Easily felt anterior fontanelle and difficulty in feeling the posterior fontanelle
Due to deflexed fetal head. Face presentation may also be detected.

Investigations - Diagnosis

Fact Explanation
The diagnosis is clinical Prolonged labor is diagnosed by studying labor management documents. The partogram which has being advocated since 1994 by the WHO has significantly improved the diagnosis and management of labor dystocia. Cervical dilatation and fetal descent are mapped in the partogram. Progression towards the alert or action line indicates the need for interventions. Poor uterine contraction, malpresentation, malposition and cephalopelvic disproportion can be identified by physical examination. The diagnosis is clinical
Prolonged labor is diagnosed by studying labor management documents. The partogram which has being advocated since 1994 by the WHO has significantly improved the diagnosis and management of labor dystocia. Cervical dilatation and fetal descent are mapped in the partogram. Progression towards the alert or action line indicates the need for interventions. Poor uterine contraction, malpresentation, malposition and cephalopelvic disproportion can be identified by physical examination.
Cardiotocography Cardiotocography provides valuable information regarding uterine contractions and fetal heart rate. The uterine contraction frequency, duration and basal tone of the myocardium can be assessed. Fetal tachycardia and late decelerations suggest fetal distress. Cardiotocography
Cardiotocography provides valuable information regarding uterine contractions and fetal heart rate. The uterine contraction frequency, duration and basal tone of the myocardium can be assessed. Fetal tachycardia and late decelerations suggest fetal distress.
Fetal scalp blood sampling To identify fetal acidosis due to reduced blood supply Fetal scalp blood sampling
To identify fetal acidosis due to reduced blood supply

Investigations - Management

Fact Explanation
Serum electrolytes To identify electrolyte imbalances. Serum electrolytes
To identify electrolyte imbalances.
Arterial blood gas analysis Lactic acidosis may develop in prolonged labor. Arterial blood gas analysis
Lactic acidosis may develop in prolonged labor.

Management - Supportive

Fact Explanation
Patient reassurance The patient may be anxious and worried. Provide adequate information regarding the condition and reassure her with regular updates about progression of labor. Explain the treatment options/interventions about to be undertaken. Patient reassurance
The patient may be anxious and worried. Provide adequate information regarding the condition and reassure her with regular updates about progression of labor. Explain the treatment options/interventions about to be undertaken.
Correct dehydration and electrolyte imbalances Maintain adequate hydration with oral fluids. Intravenous fluids may be required in certain women. Certain studies have shown that increased intravenous hydration during labor may even reduce the risk of labor dystocia and the need for augmentation with oxytocin. Correct dehydration and electrolyte imbalances
Maintain adequate hydration with oral fluids. Intravenous fluids may be required in certain women. Certain studies have shown that increased intravenous hydration during labor may even reduce the risk of labor dystocia and the need for augmentation with oxytocin.
Nutrition A simple snack or fluids can be provided to avoid hypoglycaemia. IV Dextrose may be needed in severe patients. Nutrition
A simple snack or fluids can be provided to avoid hypoglycaemia. IV Dextrose may be needed in severe patients.
Pain relief Provide adequate pain relief. Epidural anesthesia is the optimum pain relief method. There is minimum effect on the duration of the first stage of labor but may affect the second stage. Epidural anesthesia does not increase the risk of caesarean section and rarely predisposes to labor dystocia. If not available intramuscular opioids can be used. Pain relief
Provide adequate pain relief. Epidural anesthesia is the optimum pain relief method. There is minimum effect on the duration of the first stage of labor but may affect the second stage. Epidural anesthesia does not increase the risk of caesarean section and rarely predisposes to labor dystocia. If not available intramuscular opioids can be used.
Antibiotic therapy The risk of infections is increased in prolonged labor. Antibiotics can be used for prophylaxis and treatment of infections. Antibiotic therapy
The risk of infections is increased in prolonged labor. Antibiotics can be used for prophylaxis and treatment of infections.
Be prepared for emergency operative delivery Inform the theater, obstetric team, anesthetist and neonatologist in patients who fail to respond to medical therapy. Equipment required for resuscitation, delivery forceps, neonatal resuscitator should be quickly available. Be prepared for emergency operative delivery
Inform the theater, obstetric team, anesthetist and neonatologist in patients who fail to respond to medical therapy. Equipment required for resuscitation, delivery forceps, neonatal resuscitator should be quickly available.

Management - Specific

Fact Explanation
Use of partography in all pregnancies The partogram should be maintained with continuous monitoring of maternal, fetal and labor parameters. The alert line is marked to indicate the expected progression of cervical dilatation. The action line is marked with a 4 hour difference. Progression beyond the action line indicates the need for operative intervention. Use of partography in all pregnancies
The partogram should be maintained with continuous monitoring of maternal, fetal and labor parameters. The alert line is marked to indicate the expected progression of cervical dilatation. The action line is marked with a 4 hour difference. Progression beyond the action line indicates the need for operative intervention.
Caesarean section Gross cephalopelvic disproportion, malpresentation and fetal distress requires termination of pregnancy by caesarean section. Avoid augmentation of labor in these circumstances. Caesarean section
Gross cephalopelvic disproportion, malpresentation and fetal distress requires termination of pregnancy by caesarean section. Avoid augmentation of labor in these circumstances.
Augmentation of labor Artificial rupture of membranes should be carried out if the membranes are still intact. Oxytocin infusion can be started if ARM alone fails to expedite the labor progress. Gradually titrate the oxytocin infusion to achieve 3 or 4 good uterine contractions per 10 minutes. Augmentation of labor in multiparous women should be carried out with caution due to the risk of uterine hyperstimulation and rupture. Consider caesarean section in patients who fail to respond to adequate augmentation. Augmentation of labor
Artificial rupture of membranes should be carried out if the membranes are still intact. Oxytocin infusion can be started if ARM alone fails to expedite the labor progress. Gradually titrate the oxytocin infusion to achieve 3 or 4 good uterine contractions per 10 minutes. Augmentation of labor in multiparous women should be carried out with caution due to the risk of uterine hyperstimulation and rupture. Consider caesarean section in patients who fail to respond to adequate augmentation.
Management of postpartum hemorrhage Prolonged labor increases the risk of uterine atony due to exhaustion of the myocardium due to prolonged contractions. Genitial tract trauma is also commonly encountered. The third stage of labor should be actively managed with fundal massage, controlled cord traction and utero-tonics. Oxytocin or ergometrine can should be administered after delivery of the fetal anterior shoulder. An oxytocin infusion can be used to further prevent bleeding. Monitor the patient during the first 24h for bleeding. Management of postpartum hemorrhage
Prolonged labor increases the risk of uterine atony due to exhaustion of the myocardium due to prolonged contractions. Genitial tract trauma is also commonly encountered. The third stage of labor should be actively managed with fundal massage, controlled cord traction and utero-tonics. Oxytocin or ergometrine can should be administered after delivery of the fetal anterior shoulder. An oxytocin infusion can be used to further prevent bleeding. Monitor the patient during the first 24h for bleeding.
Neonatal care The risks to the newborn are hypoxia, acidosis, asphyxia, infections and stillbirth. An experienced pediatrician should be present at the time of the delivery. Resuscitate the newborn if required and monitor during the first 24-48h. Neonatal care
The risks to the newborn are hypoxia, acidosis, asphyxia, infections and stillbirth. An experienced pediatrician should be present at the time of the delivery. Resuscitate the newborn if required and monitor during the first 24-48h.

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  1. EL-SAYED YY. Diagnosis and management of arrest disorders: duration to wait. Semin Perinatol [online] 2012 Oct, 36(5):374-8 [viewed 22 August 2014] Available from: doi:10.1053/j.semperi.2012.04.022
  2. GARITE TJ, WEEKS J, PETERS-PHAIR K, PATTILLO C, BREWSTER WR. A randomized controlled trial of the effect of increased intravenous hydration on the course of labor in nulliparous women. Am J Obstet Gynecol [online] 2000 Dec, 183(6):1544-8 [viewed 22 August 2014] Available from: doi:10.1067/mob.2000.107884
  3. JAVED I, BHUTTA S, SHOAIB T. Role of partogram in preventing prolonged labour. J Pak Med Assoc [online] 2007 Aug, 57(8):408-11 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17902525
  4. LAVENDER T, ALFIREVIC Z, WALKINSHAW S. Effect of different partogram action lines on birth outcomes: a randomized controlled trial. Obstet Gynecol [online] 2006 Aug, 108(2):295-302 [viewed 22 August 2014] Available from: doi:10.1097/01.AOG.0000226862.78768.5c
  5. LETIć M. Inaccuracy in cervical dilatation assessment and the progress of labour monitoring. Med Hypotheses [online] 2003 Feb, 60(2):199-201 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12606235
  6. LOWE NK. A review of factors associated with dystocia and cesarean section in nulliparous women. J Midwifery Womens Health [online] 2007 May-Jun, 52(3):216-28 [viewed 22 August 2014] Available from: doi:10.1016/j.jmwh.2007.03.003
  7. LU MC, MUTHENGI E, WAKEEL F, FRIDMAN M, KORST LM, GREGORY KD. Prolonged second stage of labor and postpartum hemorrhage. J Matern Fetal Neonatal Med [online] 2009 Mar, 22(3):227-32 [viewed 22 August 2014] Available from: doi:10.1080/14767050802676709
  8. MAALøE N, SORENSEN BL, ONESMO R, SECHER NJ, BYGBJERG IC. Prolonged labour as indication for emergency caesarean section: a quality assurance analysis by criterion-based audit at two Tanzanian rural hospitals. [online] December, 119(5):605-613 [viewed 22 August 2014] Available from: doi:10.1111/j.1471-0528.2012.03284.x
  9. MARTINO V, ILICETO N, SIMEONI U. [Occipito-posterior fetal head position, maternal and neonatal outcome]. Minerva Ginecol [online] 2007 Aug, 59(4):459-64 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17923836
  10. MYLES TD, SANTOLAYA J. Maternal and neonatal outcomes in patients with a prolonged second stage of labor. Obstet Gynecol [online] 2003 Jul, 102(1):52-8 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12850607
  11. SELIN L, WALLIN G, BERG M. Dystocia in labour - risk factors, management and outcome: a retrospective observational study in a Swedish setting. Acta Obstet Gynecol Scand [online] 2008, 87(2):216-21 [viewed 22 August 2014] Available from: doi:10.1080/00016340701837744
  12. ZHANG J, YANCEY MK, KLEBANOFF MA, SCHWARZ J, SCHWEITZER D. Does epidural analgesia prolong labor and increase risk of cesarean delivery? A natural experiment. Am J Obstet Gynecol [online] 2001 Jul, 185(1):128-34 [viewed 22 August 2014] Available from: doi:10.1067/mob.2001.113874