Andrew J Satin, MD hristian Macedonia, MD

Abnormal labor: Protraction and arrest disorders A newer version of UpToDate is now available, and the information in this version may no longer be current.

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INTRODUCTION (abor refers to uterine contractions resulting in progressive dilation and effacement of the cervi) and accompanied by descent and e)pulsion of the fetus. Abnormal labor, dystocia, and failure to progress are terms used to describe a difficult labor pattern that deviates from that observed in the ma#ority of women who have spontaneous vaginal deliveries. This problem is the most common indication for primary cesarean birth, accounting for three times more cesarean deliveries than malpresentation or fetal heart rate abnormalities *$+. As an e)ample, one study of ,!! women with unplanned cesareans reported -. percent were due to lac/ of progress in labor' the diagnosis was made after four centimeters dilation in ,0 percent of the patients *%+. NORMAL LABOR 1 2riedman, in his classic studies, divided labor into three stages *!+3 4 2irst stage3 time from the onset of labor until complete cervical dilatation 4 Second stage3 time from complete cervical dilatation to e)pulsion of the fetus 4 Third stage3 time from e)pulsion of the fetus to e)pulsion of the placenta The first stage was further subdivided into the latent and active phases, and the active phase subdivided into three additional phases3 acceleration phase, phase of ma)imum slope, and deceleration phase 5show figure $6. 7umerous investigations have confirmed that a rapid change in the rate 5slope6 of cervical dilation occurs at ! to & centimeters when cervical dilatation is plotted against time. This is the beginning of the active phase. The e)istence of a latent phase and subphases of active labor are more controversial. (atent phase is typically characteri8ed by mild, infre9uent, irregular contractions with gradual change in cervical dilation 5usually :$ cm per hour6 and effacement. ;y comparison, the active phase is characteri8ed by painful contractions of increasing fre9uency, intensity, and duration accompanied by more rapid 5usually <$ cm hour6 cervical change. 5See =>rolonged latent phase of labor=6. The median duration of the second stage of labor in nulliparous and multiparous women is 0" and %" minutes, respectively. The upper limit of duration associated with a normal perinatal outcome had been defined as two hours *&+, but was subse9uently lengthened *0,-+. ?pidural analgesia, duration of the first stage, parity, maternal si8e, birth weight, and station at complete dilation all play a role in predicting duration of the second stage *,+. @owever, a stepwise multiple linear regression demonstrated that these factors together accounted for less than %0 percent of observed variation in duration of the second stage *,+. 2or these reasons, the American ollege of Abstetricians and Bynecologists 5A AB6 recommends that the normal duration of second stage of labor be based upon parity and presence of regional anesthesia, with no intervention as long as the

fetal heart rate pattern is normal and some degree of progress is observed 5show table $6 *-+. The total duration of labor also varies between nulliparous and parous parturients. Ane report of %0,""" women at term revealed the average duration of active labor 5onset defined as ! cm dilation6 in nulliparous and parous women was -.& and &.hours, respectively *.+. Cn addition, the labor curve of grand multiparas 5para 0 or more6 appears to differ from that of lower parity women3 progress is slower prior to - cm *D+. Normal uterine activit 1 Uterine activity can be monitored by palpation, e)ternal tocodynamometry, or internal uterine pressure catheters. ?)ternal and intrauterine monitoring devices appear to perform e9ually well, although the latter may wor/ better in obese women *$"+. 7inetyEfive percent of women in labor will have three to five contractions per $" minutes. Although numerous methods for 9uantifying uterine activity have been reported, Montevideo units 5ie, the pea/ strength of contractions in mm@g measured by an internal monitor multiplied by their fre9uency per $" minutes6 are most often employed. Cn a retrospective report, D$ percent of women in spontaneous active labor achieved contractile activity greater than %"" Montevideo units and &" percent reached !"" Montevideo units *$$+. CLA!!I"ICATION 1 Ane practical classification system to categori8e labor abnormalities is shown in Table $ 5show table $6 *-+3 4 >rotraction disorders refer to slowerEthanEnormal labor progress 4 Arrest disorders refer to complete cessation of progress. Ct is important to emphasi8e that the rates of cervical change listed in Table $ are two standard deviations from the mean and thereby used to define abnormal' they do not represent the mean or median rates. >rogressive dilation slower than the rate shown in Table $ is suggestive of a protraction disorder. An arrest disorder can be diagnosed when the cervi) ceases to dilate after reaching four or more centimeters dilation despite a uterine contraction pattern of greater than or e9ual to %"" Montevideo units for two or more hours *-+. >rotraction and arrest disorders may occur in both the first and second stage of labor. INCID#NC# 1 Cn one large series, the incidence or protraction or arrest disorders in the first stage of labor was $! percent *$%+, second stage abnormalities appeared to be as common *-+. Arrest disorders in the second stage of labor have received attention in the United States as a possible reason for differences in the cesarean delivery rates between the United States and Creland, where active management of labor is practiced. As an e)ample, four American trials of active management of labor 5AM(6 found that the incidence of cesarean birth in the second stage was higher in the United States than at the 7ational Maternity @ospital in Dublin 5over ! and ".% percent, respectively6 *$!E$-+. Although active management of labor at the 7ational Maternity @ospital has been associated with shorter labors and a cesarean delivery rate lower than that found at most hospitals in the United States, the cesarean

delivery rate at that Cnstitution has increased somewhat in recent years and the best controlled randomi8ed trials to date do not show a decrease in cesarean birth associated with implementation of active management. 5See =Active management of labor=6. #TIOLO$% O" PROTRACTION AND ARR#!T DI!ORD#R! 1 Abnormal labor can be the result of one or more abnormalities of the cervi), uterus, maternal pelvis, or fetus 5ie, power, passenger, or pelvis6. Fis/ factors for abnormal labor are shown in Table % 5show table %6. @ypocontractile uterine activity is the most common cause of protraction or arrest disorders in the first stage of labor. This entity refers to uterine activity that is either not sufficiently strong or not appropriately coordinated to dilate the cervi) and e)pel the fetus. Ct occurs in ! to . percent of parturients and can be 9uantified as uterine contraction pressures less than %"" Montevideo units. D stocia related to e&idural anal'esia The potential impact of epidural analgesia on uterine activity, fetal malposition, and, ultimately, arrest disorders has received much attention as a possible source of increasing rates of cesarean delivery. Cn a metaEanalysis of eleven studies involving more than !""" women, epidural analgesia was associated with an increased duration of the first and second stages of labor, incidence of fetal malposition, use of o)ytocin, and operative vaginal delivery *$,+. @owever, epidural anesthesia was not shown to increase the cesarean rate. This report was unable to determine whether certain types of epidural 5narcotic or lowEdose anesthetics6 could decrease the incidence of dystocia. onse9uences of withdrawing the bloc/ before the second stage of labor, appropriate use of o)ytocin, delayed pushing in the second stage, and timing of administration also need to be considered. 5See =>revention and treatment of adverse effects of neura)ial anesthesiaEC= section on Areas of controversy6. The American ollege of Abstetricians and Bynecologists has stated that the decision to place an epidural anesthetic depends upon the patientGs wishes with consideration of factors, such as parity, also ta/en into account *$.+. Cn particular, women should not be re9uired to reach an arbitrary cervical dilation such as & to 0 cm before receiving epidural anesthesia. D stocia due to ce&(alo&elvic dis&ro&ortion The disproportion between the si8e of the fetus relative to the mother can lead to a diagnosis of dystocia due to cephalopelvic disproportion 5 >D6. This diagnosis is currently based upon slow or arrested labor during the active phase. @owever, it is usually do to fetal malposition 5eg, e)tended or asynclitic fetal head6 or malpresentation 5mentum posterior, brow6, rather than a true disparity between fetal and maternal pelvic dimensions. 5See =2etal presentation in labor=6. >rediction of >D re9uiring cesarean delivery based upon clinical assessment of maternal 5show figure &AE;6 versus fetal si8e 5show figure & 6 has been disappointing . Cn a recent decision analysis and subse9uent clinical study, a group of investigators found that in women without diabetes, the level of intervention and economic costs of prophylactic cesarean delivery for fetal macrosomia diagnosed by ultrasound are e)cessive *$D,%"+. A prophylactic cesarean delivery policy with either a &""" or &0"" gram definition of macrosomia threshold would re9uire more than $",""" cesarean births and millions of dollars to prevent a single permanent brachial ple)us in#ury. Cn addition, four trials of pelvimetry for

fetal cephalic presentation at term in over $""" women found that those undergoing pelvimetry were twice as li/ely to be delivered by cesarean *%$+' no impact on perinatal outcome was detected. Thus, there is no evidence to support the use of radiographic pelvimetry in women with cephalic presentations. D stocia due to mal&osition Aver D0 percent of fetuses present in cephalic presentation at term. Appro)imately 0 percent of these e)perience malposition with persistent occiput posterior 5A>6 position or transverse arrest. Cn two studies including over $",""" deliveries, persistent A> position was associated with a longer duration of active labor and second stage *%%,%!+. Cn another series of $-,,.$ nulliparas, persistent A> position was related to arrest of descent re9uiring operative delivery *%&+. The rates of instrumental vaginal or cesarean delivery for A> position compared to occiput anterior 5AA6 were && and %& percent rates 5A> and AA instrumental deliveries6 or &% and $& percent 5A> and AA cesarean deliveries6. Multiparous women with persistent A> are more li/ely to achieve spontaneous vaginal delivery than nulliparas 500 to 0, versus %- to %D percent6 *%!,%0,%-+. >regnant women are often advised to perform e)ercises to facilitate anterior rotation of the fetus, but there is no good evidence that these maneuvers are effective. The lac/ of benefit was best illustrated by a large, multicenter, randomi8ed, controlled trial that assigned %0&, women at !- to !, wee/s of gestation to one of two e)ercise programs *%,+. Broup $ was told to ta/e a daily wal/ and Broup % was as/ed to assume a hands and /nees position with slow pelvic roc/ing for $" minutes twice a day until labor began. The incidence of persistent A> position at birth or before instrumental rotation was similar in both groups 5about . percent6. APPROAC) TO T)# PATI#NT *IT) ABNORMAL LABOR 1 Management of labor includes several components3 a disciplined approach to the diagnosis of labor, careful monitoring of labor progress, and assessment of maternal and fetal wellEbeing. Homen should undergo cervical e)amination every one to two hours once active labor is diagnosed to determine whether progression is ade9uate *!+. >rogress can be noted on a partogram 5show figure %6. D stocia in t(e +irst sta'e3 4 Amniotomy 4 @ypo contractile uterine activity is treated with o)ytocin 7umerous protocols varying in initial dose, incremental dose increases, and time intervals between doses have been studied 5show table %6. A)ytocin is typically infused to titrate dose to effect, as prediction of a womenGs response to a particular dose is not possible (ow dose regimens3 5to avoid uterine hyperstimulation6 @igh dose regimens3 5shorten labor 6 Active phase arrest is diagnosed when a protraction disorder persists despite o)ytocin therapy to achieve < or I %"" Montevideo units for greater than two

hours' cesarean delivery is typically performed at this point. @owever, a trial in 0&% women with an arrest or protraction disorder in which the obstetrician waited four to si) hours 5instead of two6 before operating reported high vaginal delivery rates *!$+. Jaginal deliveries occurred in D$ percent of parous women and ,& percent of nulliparas with an arrest or protraction disorder lasting two hours despite o)ytocin administration and in .. and 0- percent of multiparas and nulliparas, respectively, in whom the disorder lasted for four hours of o)ytocin infusion. The authors concluded that e)tending the minimum period of o)ytocin augmentation for active phase labor arrest from two to at least four hours was both effective and safe. The same group subse9uently used a standardi8ed protocol to manage 0"$ consecutive term spontaneously laboring women with a protraction or arrest disorder *!%+. The protocol involved use of an intrauterine pressure catheter and administration of o)ytocin to achieve at least %"" Montevideo units for four hours before considering cesarean delivery. Jaginal delivery occurred in .0 percent of nulliparous women who sustained this threshold of uterine activity, ,& percent of those who achieved but were unable to sustain it, and in .! percent of women who never achieved it. orresponding figures for parous women were D&, D&, and D, percent. Mean and 0th percentile rates of cervical dilatation were $.& and ".0 cmKh in nulliparas and $.. and ".0 cmKh in multiparas. This study confirmed that augmentation of a protraction disorder for at least four hours is both safe an effective for achieving vaginal delivery. Ct also showed that success was often possible despite levels of uterine activity and rates of cervical dilatation that were below the normal range considered effective. Ather interventions, such as ambulation *!!+ and continuous labor support, may increase the comfort of the parturient, but have not been shown to be clinically effective interventions for treatment of protraction or arrest disorders *-+. 5See = ontinuous intrapartum support=6. D stocia in t(e second sta'e 1 Fis/ factors include nulliparity, diabetes, macrosomia, epidural anesthesia, o)ytocin usage, and chorioamnionitis *!&+.

4 ontinued observation. 4 Attempt at operative vaginal delivery. 4 esarean delivery. Observation 1 Most women with a prolonged second stage ultimately deliver vaginally. Cn one study of 0!% term singleton pregnancies with second stage over two hours, over D- percent of patients who reached the second stage of labor delivered vaginally within %&" minutes *!&+ .The rates of vaginal delivery at $%$ to %&" minutes and after %&" minutes were D" and -- percent, respectively *!&+. 7eonatal outcome was similar in pregnancies with second stages less than and greater than $%" minutes. Dense motor bloc/s from epidural analgesia may impair a womanGs ability to push. Thus, some authors have advocated turning down the epidural to facilitate progress during a prolonged second stage. As an e)ample, one study of epidural anesthesia compared ".$%0 percent bupivicaine versus saline infusion in the

second stage and found saline was associated with a shorter second stage, fewer operative deliveries, but more pain *!0+. Ather noninvasive interventions that have been proposed include changes in maternal position *!-,!,+, continuous emotional support of the parturient *!.+, delaying pushing if the fetal head is high in the pelvis at full dilatation and the woman has no urge to do so *!D,&"+, and active management using high dose o)ytocin. 5See =Active management of labor=6. Assisted va'inal deliver 1 5eg, e)traction or rotation6 Aperative vaginal delivery and choice of instrument re9uire careful assessment of the mother and fetus. 2urthermore, success is dependent upon the training and s/ill of the obstetrician. A discussion of the indications, contraindications, use, and complications of instrumental deliveries is presented separately. Occi&ut &osterior &osition Acciput posterior 5A>6 position is associated with a longer second stage, higher incidence of operative delivery, larger episiotomies, and more severe perineal lacerations than occiput anterior position *%%,%&,%0+. A small increase in second stage length in the presence of a reassuring fetal heart rate, favorable clinical assessment of fetal relative to maternal si8e, and progress in the second stage does not mandate rotation or operative delivery. The management of a definite arrest of descent of the A> fetus is not clear. 7o randomi8ed trial of rotation to occiput anterior versus operative delivery from the A> position has been performed. Treatment options include operative delivery from A> position, manual or instrumental rotation to occiput anterior, or cesarean delivery. Aur algorithm for managing these patients is shown in figure &. R#COMM#NDATION! 1 A general labor management algorithm is outlined in 2igure ! 5show figure !6. The /ey points are listed below3 4 Monitor progress in active labor with cervical e)ams at $ to % hour intervals. 4 Cf the patient in active labor fails to progress ade9uately for two hours, then intact membranes should be ruptured and o)ytocin administered to achieve uterine contractions greater than %"" Montevideo units. These patients can be observed for two to four hours as long as clinical assessment of fetal and maternal si8e is favorable and the fetal heart rate is reassuring. 4 The decision to perform an operative vaginal delivery 5eg, e)traction or rotation6 in the second stage versus continued observation or cesarean birth is based upon clinical assessment of mother and fetus and the s/ill and training of the obstetrician. Re+erences $. Shiono, >@, Mc7ellis, D, Fhoads, BB. Feasons for the rising cesarean delivery rates3 $D,.E$D.&. Abstet Bynecol $D.,' -D3-D-. %. Bifford, DS, Morton, S , 2is/e, M, et al. (ac/ of progress in labor as a reason for cesarean. Abstet Bynecol %"""' D030.D. !. 2riedman, ?A, ed. (abor clinical evaluation and management. %nd ed 7ew Lor/. AppletonE entury E rofts, $D,.. &. @ellman, (M, >rystows/y, @. The duration of the second stage of labor. Am J Abstet Bynecol $D0%' -!3$%%!.

0. ohen, HF. Cnfluence of the duration of second stage labor on perinatal outcome and puerperal morbidity. Abstet Bynecol $D,,' &D3%--. -. A AB >ractice ;ulletin 7umber &D, December %""!3 Dystocia and augmentation of labor. Abstet Bynecol %""!' $"%3$&&0. ,. >iper, JM, ;olling, DF, 7ewton, ?F. The second stage of labor3 factors influencing duration. Am J Abstet Bynecol $DD$' $-03D,-. .. unningham, 2B, MacDonald, > , Brant, 72, ed. Hilliams Abstetrics %"th ed. onnecticut. Appleton and (ange, $DD,. D. Burewitsch, ?D, Diament, >, 2ong, J, @uang, B@. The labor curve of the grand multipara3 Does progress of labor continue to improve with additional childbearingM. Am J Abstet Bynecol %""%' $.-3$!!$. $". hua, S, Nurup, A, Arul/umaran, S, Fatnam, SS. Augmentation of labor3 does internal tocography result in better obstetric outcome than e)ternal tocographyM. Abstet Bynecol $DD"' ,-3$-&. $$. @auth, J , @an/ins, BD, Bilstrap ( , !rd, et al. Uterine contraction pressures with o)ytocin inductionKaugmentation. Abstet Bynecol $D.-' -.3!"0. $%. Satin, AJ, (eveno, NJ, Sherman, M(, et al. @igh versus lowEdose o)ytocin for labor stimulation. Abstet Bynecol $DD%' ."3$$$. $!. Sadler, ( , Davison, T, Mc owan, (M?. A randomi8ed controlled trial and metaEanalysis of active management of labour. ;JAB %"""' $",3D"D. $&. (ope8EOeno, JA, >eaceman, AM, Adashe/, JA, Socol, M(. A controlled trial of a program for the active a management of labor. 7 ?ngl J Med $DD%' !%-3&0". $0. 2rigoletto, 2D, (ieberman, ?, (ang, J, et al. A clinical trial of active management of labor. 7 ?ngl J Med $DD0' !!!3,&0. $-. Fogers, F, Bilson, BJ, Miller, A , etal. Active management of labor, does it ma/e a differenceM Am J Abstet Bynecol $DD,' $,,30DD. $,. @owell, J. ?pidural versus nonEepidural analgesia for pain relief in labour. ochrane Database Syst Fev %"""' 3 D"""!!$. $.. American ollege of Abstetricians and Bynecologists. Abstetric analgesia and anesthesia. A AB practice bulletin P!-. Abstet Bynecol %""%' $""'$,,. $D. Fouse, DJ, Awen, J, Boldenberg, F(, Aliver, S>. The effectiveness and costs of elective cesarean delivery for fetal macrosomia diagnosed by ultrasound. JAMA $DD-' %,-3$&.". %". Fouse, DJ, Awen, J. >rophylactic cesarean delivery for fetal macrosomia diagnosed by means of ultrasonographyEEA 2austian bargainM. Am J Abstet Bynecol $DDD' $.$3!!%. %$. >attinson, F . >elvimetry for fetal cephalic presentations term 5 ochrane Feview6. Cn The ochrane (ibrary &, %""". A)ford3 Update Software. %%. Bardberg, M, Tuppurainen, M. >ersistent occiput posterior presentationEEa clinical problem. Acta Abstet Bynecol Scand $DD&' ,!3&0. %!. >on/ey, S?, ohen, A>, @effner, (J, (ieberman, ?. >ersistent fetal occiput posterior position3 obstetric outcomes. Abstet Bynecol %""!' $"$3D$0. %&. Si8er, AF, 7irmal, DM. Accipitoposterior position3 associated factors and obstetric outcome in nulliparas. Abstet Bynecol %"""' D-3,&D. %0. 2it8patric/, M, McQuillan, N, AG@erlihy, . >ersistent occiput posterior position and delivery outcome. Abstet Bynecol %""$' D.3$"%,. %-. 2loberg, J, ;elfrage, >, Ahlsen, @. Cnfluence of the pelvic outlet capacity on fetal head presentation at delivery. Acta Abstet Bynecol Scand $D.,' --3$%,. %,. Nariminia, A, hamberlain, M?, Neogh, J, Shea, A. Fandomised controlled trial of effect of hands and /nees posturing on incidence of occiput posterior position at birth. ;MJ %""&' !%.3&D". %.. 2raser, HD, Turcot, (, Nrauss, C, ;rissonE arrol, B. Amniotomy for shortening spontaneous labour. ochrane Database Syst Fev %"""' 3 D""""$0.

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