Abnormal Labor

Latent Phase
• The onset of latent labor as defined by Friedman is
the point at which regular uterine contractions are
perceived.
• Friedman found the mean duration of latent labor
was 6.4 hours for nulliparas and 4.8 for multiparas.
• The 95th percentiles for maximum length in latent
labor was 20 hours for nulliparous women and 14
hours for multiparous women.These are considered
the upper limits for time spent in latent labor.
 Disorders of the Latent Phase

• Latent phase arrest implies that labor has not truly begun.
• Prolonged latent phase refers to a latent phase lasting
longer than 20 hours for nulliparas women and 14 hours
or longer for multiparas women.
• Because the duration of latent labor is highly variable,
expectant management is most appropriate.
• Some women can spend days in latent labor; provided
there is no indication for delivery, awaiting active labor is
appropriate.
• If expeditious delivery is indicated, then augmentation of
labor may be initiated with a pharmacologic agent such as
oxytocin.
• Another option is to administer “therapeutic rest” especially
if contractions are painful, with an analgesic agent such as
morphine.
• A recommended dosing regimen is a single administration of
15 to 20 mg of morphine subcutaneously or intramuscularly.
• Often this will help abate or alleviate painful contractions
and allow the patient to rest comfortably until active labor
begins.
• The onset of regular contractions is often
unpredictable after amniotomy and,
therefore, is not recommended in nulliparas
with prolonged latent phase.
• Early amniotomy may increase the risk of
prolonged membrane rupture and its
associated infectious morbidity.
 Active Phase

• Active labor demarcates a rapid change in

cervical dilatation.
• The active phase begins once cervical dilatation
progresses at a minimum rate of 1.2 cm/h for
nulliparous women and 1.5 cm/h for multiparous
women.
• In the presence of regular uterine contractions
accompanied by cervical dilatation of 5 cm, the
threshold for active labor has likely been reached.
• Friedman observed that the mean duration of
active phase labor in nulliparas women was
4.9 hours, with a standard deviation of 3.4
hours.
• There was a large variation in his results, with
the maximum duration of active phase
reported to be 11.7 hours.
• Rates of cervical dilatation varied as much
from 1.2 to 6.8 cm/h.
 Disorders of the Active Phase

• Active-phase disorders may be divided into

protraction (primary dysfunctional labor) and
arrest (secondary arrest) disorders.
• Protraction is defined as a slow rate of cervical
change less than 1.2 cm/h for the nullipara and less
than 1.5 cm/h for the multipara.
• These rates represent less than the 5th percentile
for most gravidas
• Rates of cervical change may be protracted by the
use of epidural anesthesia.
• Women receiving epidural analgesia required more
oxytocin for longer intervals and had longer first
and second stages of labor.
• The total admission to delivery interval was
prolonged by approximately 2 hours.
• These data suggest that patients receiving epidural
analgesia may require modification of the
guidelines for labor progress in the first stage.
Similar modifications have been established for the
second stage of labor with epidural use
• The most common cause of a protraction disorder is
inadequate uterine activity.
• External tocodynamometry is used to evaluate the
duration of and time interval between contractions
but cannot be used to evaluate the strength of
uterine contractions.
• The external monitor is held against the abdominal
wall and records a relative measurement of uterine
contraction intensity reflecting its movement with
uterine shape change.
• Precise measurements of uterine activity must
be obtained with an intrauterine pressure
catheter (IUPC).
• After amniotomy, an IUPC can be placed into
the uterus to measure the pressure generated
during a uterine contraction.
• An IUPC is frequently used when inadequate
uterine activity is suspected owing to a
protraction or arrest disorder.
• It can also be used to monitor and titrate
oxytocin augmentation of labor to desired
uterine effect.
• The lower limit of contraction pressure
required to dilate the cervix is observed to be
15 mm Hg over baseline.
• Normal spontaneous contractions often exert
pressures up to 60 mm Hg.
• Once inadequate uterine activity is diagnosed with an
IUPC, oxytocin is usually administered.
• Typically, the dose is increased until there is normal
progression of labor, resulting in strong contractions
occurring at 2- to 3-minute intervals lasting 60 to 90
seconds, with a peak intrauterine pressure of 50 to 60
mm Hg and a resting tone of 10 to 15 mm Hg, or in
uterine activity equal to 150 to 350 Montevideo units.
• Montevideo units are calculated by subtracting the
baseline uterine pressure from the peak contraction
pressure of each contraction in a 10-minute window
and adding the pressures generated by each
contraction.
• Another common cause of protraction
disorders is abnormal positioning of the fetal
presenting part.
• When persistent OP position is present, labor
is reported to be prolonged an average 1 hour
in multiparous women and 2 hours in
nulliparous women.
• The prevalence of persistent OP position at
the time of vaginal delivery regardless of
parity was 5.5 percent, 7.2 percent in
nulliparas and 4.0 percent in multiparas.
• The OP position was found to be associated with
longer first and second stages, and a lower rate of
vaginal delivery.
• Most fetuses in the OP position undergo spontaneous
anterior rotation during the course of labor, and
expectant management is generally indicated.
• However, approximately 5 percent remain in
persistent OP position or transverse arrest, which
often requires either an operative vaginal delivery or
cesarean delivery.
• Cephalopelvic disproportion (CPD) refers to the
disproportion between the size of the fetus relative to
the mother and can be the cause of a protraction or
arrest disorder.
• This is a diagnosis of exclusion, often made at the time
a protracted labor course is observed.
• Most frequently, malposition of the fetal presenting
part is the culprit rather than true CPD.
• Unfortunately there is no way to accurately predict CPD.
• It is estimated that thousands of unnecessary cesarean
deliveries would need to be performed in low-risk
pregnancies to prevent one diagnosis of true CPD.
• Secondary arrest is defined as cessation of previously normal
active phase cervical dilatation for a period of 2 hours or
more.
• Evaluation of this disorder includes an assessment of uterine
activity with an IUPC, performance of clinical pelvimetry, and
evaluation of fetal presentation, position, station, and
estimated fetal weight.
• Amniotomy and oxytocin therapy can be initiated if uterine
activity is found to be inadequate.
• The majority of gravidas respond to this intervention, and
resume progression of cervical dilatation and achieve vaginal
delivery.
• At least 4 hours of oxytocin augmentation can be
administered before secondary arrest of labor is diagnosed
without incurring additional maternal or fetal compromise.
• Combined Disorder
• A combined disorder of active phase dilatation is
defined as arrest of dilatation occurring when a
patient has previously exhibited a primary
protracted labor.
• This pattern is associated with less favorable
outcomes with regard to vaginal delivery when
compared with patients with secondary arrest
alone.
• If diagnosed, an evaluation of uterine activity is
necessary, as is an assessment of pelvic capacity,
fetal position, station, and estimated fetal weight.
 Disorders of the Second Stage

• Protraction of descent is defined as descent of the

presenting part during the second stage of labor
occurring at less than 1 cm/h in nulliparas women
and less than 2 cm/h in multiparas women.
• Arrest (failure) of descent refers to no progress in
descent.
• Both diagnoses require prompt evaluation of uterine
activity, maternal expulsive efforts, fetal heart rate
status, fetal position, clinical pelvimetry, and a
reevaluation of estimated fetal weight.
• Decisions then may be made regarding
interventions, such as increasing or initiating
oxytocin infusion to improve maternal
expulsion efforts, or proceeding with
operative vaginal or cesarean delivery.
• Management of the second stage of labor can
be difficult, and decisions regarding
intervention must be individualized.
• The median duration of the second stage is 50
minutes for nulliparas and 20 minutes for
multiparas, but this is highly variable, and these
estimations do not account for anesthesia.
• The upper limit for the duration of the second
stage of labor was previously defined to be 2
hours.
• However, the use of regional anesthesia increases
the mean duration of the second stage by 20 to 30
minutes.
• Other factors influence the length of the second
stage as well such as parity, maternal size, birth
weight, occiput posterior position, and fetal station
at complete dilatation.
• Many authors have studied the perinatal effects of
a prolonged second stage and found no increase in
infant morbidity or mortality with a second stage
lasting longer than 2 hours, although the rate of
vaginal delivery precipitously decreases after 3
hours in the second stage.
• For nulliparous women, the diagnosis for a
prolonged second stage should be considered
when the second stage exceeds 3.5 hours if
regional anesthesia has been administered or
3 hours if no regional anesthesia is used.
• In multiparous women, the diagnosis can be
made when the second stage exceeds 2.5
hours with regional anesthesia or 2 hour
without.
• Although perinatal outcomes are not
compromised with a prolonged second stage of
labor, there is evidence that maternal morbidities
such as perineal trauma, chorioamnionitis,
instrumental delivery, and postpartum
hemorrhage, increase with prolonged second
stages lasting greater than 2 hours.
• Effective management of the second stage
should be individualized.
 Third Stage

• The third stage of labor refers to the time period from delivery
of the infant to the expulsion of the placenta.
• Separation of the placenta is the consequence of continued
uterine contractions.
• Signs of placental separation include a gush of blood,
lengthening of the umbilical cord, and change in shape of the
uterine fundus from discoid to globular with elevation of the
fundal height.
• The interval between delivery of the infant and delivery of the
placenta and fetal membranes is usually less than 10 minutes
and is complete within 15 minutes in 95 percent of deliveries.
• The most important risk associated with a
prolonged third stage is hemorrhage; this risk
increases proportionally with increased duration.
• Because of the associated increased incidence of
hemorrhage after 30 minutes, most practitioners
diagnose retained placenta after this time
interval has elapsed. Interventions to expedite
placental delivery are usually undertaken at this
time
• Management of the third stage of labor may be expectant or
active.
• Expectant management refers to the delivery of the placenta
without cord clamping, cord traction, or the administration
of uterotonic agents such as oxytocin.
• Active management consists of early cord clamping,
controlled cord traction, and administration of a uterotonic
agent.
• Oxytocin is the usual uterotonic agent given, but others have
been used, such as misoprostol or other prostaglandin
compounds.
• Comparing active to expectant management of the third
stage, there appears to be a reduced risk of postpartum
hemorrhage and prolongation when active management is
used.
• Retained placenta can usually be treated with
measures such as manual removal.
• If attempt at manual removal is not successful, a
sharp curettage can be performed under
sonographic guidance.
• Prophylactic broad-spectrum antimicrobial agents
are often administered when manual removal of
the placenta is performed, although there is little
evidence to support (or refute) their use.
Precipitous Labor
• Precipitous labor refers to delivery of the infant in less than 3
hours.
• This occurs in approximately 2 percent of all deliveries in the
United States.
• Precipitous labor and delivery alone is not usually associated
with significant maternal and infant morbidity and mortality.
• Short labors can be associated with placental abruption, uterine
tachysystole, and recent maternal cocaine use—all of which are
major contributors to poor outcomes for mothers and infants.
• Other investigators have looked at intrapartum risk factors
associated with permanent brachial plexus injury and found
that a precipitous second stage is the most common labor
abnormality associated with shoulder dystocia, although the
rates of permanent injury did not increase.