Abnormal Labor

J Pisculli - 28 3/7

Labor

Uterine Contractions that cause Progressive dilation and effacement of cervix Descent of fetus

Expulsion of fetus and placenta

Normal Labor Limits

Nullip
First Stage Duration Protracted Dilation Arrest >24 hours <1.2 cm/hr

Multip
>18 hours <1.5 cm/hr

>2 hours >3 hours

>2 hours >1 hour

Second Stage

Arrest of descent

Labor Curve in Nulliparous

Zhang et al. AJOG, 2002 Oct:187 (4)

Study of 1329 nulliparous women

Singleton, term, vertex, normal birth weight,

spontaneous labor Excluded women who went to C-Section

Active Phase average of 5.5 hours to dilate from 4 to 10 cm Before 7 cm no cervical change for 2 hours was not uncommon

Active Phase Labor Arrest

Rouse et al, Obstet Gynecol 2001 Oct

Labor Arrest for 2 hours with adequate contractions (200 MVU) C/S? Multips 1.8 cm/hr, primips 1.4 cm/hr 38 women had arrest >2 hours
Of these, 23 delivered vaginally Increased rates of chorio and endometritis (26%) 3 had shoulder dystocia, but no injuries

Pitocin augmented labor is slower, criteria for 2 hours labor arrest are insufficient

Textbook Labor not Normal

Pitocin augmented labor doesnt follow Friedmans curve Pimiparous womens labor does not follow Friedmans curve Falling off Friedman's Curve may not be an indication for C/S

Abnormal Labor - Dystocia

Power
Inadequate contractions

Passenger
size (macrosomia or anomaly) Presentation (OA, face)

Pelvis
Contracted pelvis, previous fractures, position

Power - Contractions

Power Inadequate Contractions

Frequency, Amplitude, Duration

Adequate contractions
Montevideo Units 200 - 250 MV units in 10

minutes

Calculate the Montevideo Units

Passenger

Passenger - Occiput Anterior

Occiput Posterior

Passenger - Face Presentation

Is the Pelvis a fixed ring?

Stand and Deliver

Position in Second Stage

Terry, J Am Osteopath Assoc. 2006

Low risk women - 100 supine - 98 nonsupine (sitting, squatting, kneeling) Nonsupine women had less tearing, less vuvlvar edema, less blood loss. Second stage was shorter but not statistically significant

Second Stage Labor Position

Gardosi et al. Lancet 1989 Jul 8

427 primip (218 squatting, 209 semi recumbent) Fewer forceps deliveries 9% vs 16% shorter 2nd stage (31 min vs. 45 min) fewer perineal tears blood loss, APGARs, vuvlar edema the same

Cesarean Section

>50% of primary c/s due to dystocia

C/S rate rising currently at all time high 29.1% of all births by C/S in 2004 (more than doubled since 1990)

Presenting in Latent vs. Active Phase of Labor

Bailit J et al, Obstet Gynecol 2005 Jan

Study of term, single, vertex, low risk from 1993-2001 6000 women in active, 2700 in latent labor Latent labor
more likely to be nulliparas More active arrest (OR 2.2)

Cesarean Section
Nullip 14.2% vs 6.7%

multip 3.1% vs 1.4%

Cesarean Section

WHO target C/S rate is 10-15%

Dystocia is most common reason for primary C/S In Maine, in 1993-2002 the proportion of C/S increased by 25% (rate of VBACs declined) In Maine (2001) rate of VBACs was the lowest in New England

Early Labor Assessment

McNivin et al. Birth 1998 March

209 low risk nulliparous women

Labor Assessment Group Direct Admission Group

Labor assessment group

Shorter labors Decreased epidurals Greater satisfaction with labor C/S rates unchanged