OB DYSTOCIA Stages of Labor

Dr. Trasporto 1. First stage of labor

Start of regular uterine contractions to full cervical dilatation
Dystocia 2 phases of cervical dilatation:
Difficult labor o LATENT
Abnormally slow progress of labor o ACTIVE
Most common contemporary indication for CS 2. Second stage of labor
Full cervical dilatation to fetal delivery
Mechanistically simplified into three categories that include abnormalities of: Duration 20 mins (multi) to 50 mins (nulli)
The powersuterine contractility and maternal expulsive effort o Limit: 1 to 2hrs
The passengerthe fetus 3. Third stage of labor
The passagethe pelvis After delivery of the fetus until delivery of placenta
Duration < 10 mins; intervene if > 30 mins
Dystocia arises from four distinct abnormalities 4. Fourth stage of labor
1. Abnormalities of the expulsive forces. (POWER) Postpartum
o Uterine dysfunction 1 hour after delivery
Uterine contractions may be insufficiently strong Uteroplacental perfusion: 500 600 ml/ min
or inappropriately coordinated to efface and
dilate the cervix Puerperium
o Inadequate voluntary maternal muscle effort during second- Different from 4th stage or post partum
stage labor. Period of 6 weeks after childbirth (mothers reproductive organs return
2. Abnormalities of presentation, position, or development of the fetus. to their original non-pregnant condition)
(PASSENGER)
3. Abnormalities of the maternal bony pelvis (PASSAGES) Phases of Cervical Dilatation
o Pelvic contraction/contracted pelvis Latent phase
4. Abnormalities of soft tissues of the reproductive tract that form an Mean duration: 8.6 hrs
obstacle to fetal descent Starts when mother perceives uterine contractions up to 3 5
cm
Diagnosis of Labor Affected by sedation, conduction anesthesia & unfavorable
Labor maybe presumed to the begun when the woman has regular cervix
uterine contractions that bring about demonstrative cervical Active phase
effacement and dilatation.
Mean duration: 4 - 9 hours
1. Acceleration phase:
3 Functional Divisions of Labor (Friedman)
1.2 cm/ hr (NULLI); 1.5 cm/ hr (MULTI)
1. Preparatory division
2. Phase of maximum slope: 6 7 cm/ hr
o Changes in the connective tissue component
3. Deceleration phase
o Little cervical dilatation
Start of fetal descent
o Affected by sedation &conduction anesthesia
Starts at 7 8 cm cervical dilatation
2. Dilatational division
o Most rapid rate of dilatation
o Not affected by sedation & conduction anesthesia
3. Pelvic division
o Cardinal movements of the fetus principally take place:

Seven Cardinal Movements

Engagement
Descent
Flexion
Internal rotation
Extension
External rotation
Expulsion

Dystocia Descriptors
Commonly used expressions such as cephalopelvic disproportionate and
failure to progress are used to describe ineffective labor. However,
these two expressions is NOT SPECIFIC
I Cephalopelvic Disproportionate
Term that came into use before the 20th century
Described obstructed labor resulting from disparity between the fetal
head and the maternal pelvis
Absolute disproportionate is now rare
Most cases results from:
o Malposition of the fetal head within the head (Asynclitism)
o Ineffective uterine contractions
True disportionate
o Tenuous diagnosis
o 2/3 undergoing caesarean delivery
II Failure to progress
Term reflects lack of progressive cervical dilatation or lack of fetal
descent
ABNORMALITIES OF THE POWERS II Hypertonic Uterine Contractions (Incoordinate)
Patterns of Uterine Activity Basal hypertonus
1ST stage of labor Distorted pressure gradient of myometrial activity without fundal
o 25mmHg at beginning to 50mmHg at end dominance
o 3 - 5 contractions per 10 minutes Painful but ineffective contractions
o uterine baseline tone = 8 - 12 mmHg Occurs during the latent phase
o 60 - 80 seconds duration Responds to sedation
2nd stage of labor
o 80 100 mmHg Management of Hypertonic Uterine Contractions (Incoordinate)
o 5 - 6 contractions per 10 minutes Sedation
o 60 - 80 sec duration Rest
Patterns of uterine activity: Pressure Arrest of labor
> 10 mmHg Clinically palpable
> 15 mmHg Contraction associated with PAIN and DILATATION
Minimum pressure required to distend the LUS and cervix
> 40 mmHg Hard uterine wall
Resist finger depression
Uterine contraction after birth are identical to those resulting in the
delivery of the infant.
The uterus that performs poorly before delivery is prone to ATONY and
HEMORRHAGE.

Origin and Propagation of Contractions

Normal contractive wave of labor originates near end of one of the
uterine and fallopian tube (pacemakers).
Right pacemaker usually predominates, and starts more contractile
wave
2 cm /sec = speed contraction spread throughout uterus
Whole uterus is depolarized in 15 seconds
Depolarization wave propagates downward toward the cervix
Intensity is greater in the fundus diminishes in the lower uterus SECOND STAGE ABNORMALITIES
All uterine parts are synchronized, reach peak pressure simultaneously Prolonged second stage longer than 1 - 2 hours
(+ 1 hour if under conduction analgesia)
HYPOTONIC After 3 hours in the second, delivery by cesarian or other
o Slow labor progress operative method increases progressively such that by 5 hours
o < 25 mmhg the prospect for spontaneous delivery in the subsequent hour are
o Frequency < 2 contractions /10 min only 10 to 15%
NORMAL LABOR o Failure of descent
o 3 contractions/ 10 min o Arrest of descent
o Minimum of 3 contractions that average
> 25 mmhg, 4 min interval Precipitous Labor and Delivery
Extremely rapid
UTERINE DYSFUNCTION
5 - 10 cm/ hour cervical dilatation
I Hypotonic Uterine Contractions
I Maternal effects
Absence of basal hypertonus
Uterine rupture/ lacerations
Presence of normal gradient of myometrial activity with fundal
o Vagina, cervix, vulva, etc
dominance
Amniotic fluid embolism
Contraction pressure not enough to dilate cervix satisfactorily
Postpartum hemorrhage due to uterine atony
Usually occurs in active phase, > 4 cm cervical dilatation
II Fetal effects
Poor fetal oxygenation
Management Hypotonic uterine contractions
Intracranial trauma
Must be in active in active labor and cervix at least 4 cm (? 6 cm)
Brachial palsy
No cephalopelvic disproportion if:
Injury due to fall
o Normal diagonal conjugate
o Occiput presentation
Treatment:
o Sidewalls nearly parallel
Discontinue oxytocin
o Engaged fetal head
o Ischial spines not prominent General anesthesia
o Sacrum not flat
o Subpubic angle not narrow Inadequate Voluntary Muscle Effort of the Mother
Etiology:
Amniotomy
Heavy sedation
Oxytocin stimulation
Regional analgesia
Precautions
Intense pain of uterine contraction
True labor and 4 cm cervical dilatation
No cpd /abnormalities of birth canal
Two Approaches to Maternal Pushing in 2nd stage of labor (epidural anesthesia)
No abnormal presentation and overdistention 1. Pushing at full cervical dilatation despite regardless of the urge to push
Not done: 2. Delay pushing until regains the sensory urge to bear down
o Women > 35 years
o Women > para 5 There were no adverse maternal/ neonataloutcome linked to delayed pushing
o Previous uterine scar despite significantly prolonging 2nd stage of labor ( Hansen & colleagues, 2002)
Good fetal condition, no meconium staining of amniotic fluid
Monitor for signs of hyperstimulation
Continuous EFM
Contractions SHOULD NOT BE TETANIC because contractions take away Latent Phase
oxygenation from the fetus. Mild infrequent irregular contractions
Arrest of Descent WITH descent BEYOND STATION 0 Gradual change in cervical dilatation and effacement
Failure of Descent NO descent from station 0
Arrest of Dilatation
Prolonged Deceleration
No progress during the 2nd stage of labor for more than 4 hours in Nulli with
epidural > 3 hours?

Uterine tachysystole
A condition of excessively frequent uterine contractions
6 contractions in a 10-minute period
Uterine hypertonus
A single contraction lasting longer than 2 minutes.
Uterine hyperstimulation
Either condition leads to a nonreassuring fetal heart rate pattern

Prolonged Latent Phase Pattern (solid line)

Average Prolonged
Mechanism of Dystocia Nulliparous 6.4 hrs. 20 hrs.
Figure below, it demonstrates the mechanical process of labor and the Multiparous 4.8 hrs. 14 hrs.
potential obstacles. Dystocia cannot be diagnosed prior to the onset of active labor
CS section done for dystocia in the latent phase of labor are
inappropriate
Women should NOT be admitted to a maternity unit in the latent phase
of labor unless there is a medical indication

I At the end of pregnancy (Figure A)

The fetal head, to traverse the birth canal, must encounter a relatively
thicker lower uterine segment and undilated cervix.
The uterine fundus muscle is less developed and presumably less
powerful.
Uterine contractions, cervical resistance, and the forward pressure
exerted by the leading fetal part are the factors influencing the
progress of first-stage labor

II During the Second Stage of Labor (Figure B)

After complete cervical dilatation
o Mechanical relationship between the fetal head size and
position and the pelvic capacity, namely fetopelvic
proportion, becomes clearer as the fetus descends.
Abnormalities in fetopelvic proportions become more apparent once
the second stage is reached.

Uterine muscle malfunction can result from:

Uterine overdistension
Obstructed labor
Both
Thus, ineffective labor is generally accepted as a possible warning sign of fetopelvic
disproportion.

Causes of Labor Failure: These causes are closely interlinked

Uterine dysfunction
Fetopelvic disproportion
Protraction Disorder
Refer to slower than normal labor progress Curve: Arrest Disorder

A. Secondary arrest of dilatation pattern with documented cessation of

progression in the active phase
B. Prolonged deceleration phase pattern with deceleration phase duration
greater than normal limits
C. Failure of descent in the deceleration phase and second stage
D. Arrest of descent characterized by halted advancement of fetal station
in the second stage

Challenging the 2 Hour Limit

Extending the minimum period of oxytocin augmentation for active
phase labor arrest from 2 to at least 4 hours was effective and safe

Revised Dystocia Diagnosis

The implication of this viewpoint is that changing the diagnostic criteria
of abnormal labor will reduce the excessive caesarean birth rate
Curve: Protraction Disorder of Labor Reason for the revised
o CS rate increasing
o In US, 60% increase from 1996 to 2009 20.7% to 32.9%
respectively
o 60% of all CS deliveries in US are attributable to abnormal
labor
o New definitions for arrest labor recommended to prevent
unnecessary frst CS deliveries
o Reference: Workshop (Safe Labor Consorium) by the ACOG
and NICHD National Institute of Child Health
Evidence for Adequate and Arrested Labor * SPONG 2012
Arrestof The diagnosis of arrest labor should not be made until
A. Protracted active phase dilatation
Labor adequate time has elapsed
B. Protracted descent
Adequate Includes greater than 6cm dilation with membrane rupture
Labor plus either:
Arrest Disorder
4 hours of adequate contraction (> 200
Refer to Complete cessation of progress
Montevideo Units)
Uterine contraction pattern of 200 Montevideo units??
6 hours if contractions inadequate with no
cervical change
Second Stage No progress:
of Labor > 4 hours in nulliparous women with an epidural
> 3 hours in nulliparous without an epidural
No Caesarean before these time limitsin the presence of reassuring
maternal and fetal status

Active Phase Disorders

When will abnormal active phase progress be considered?
Rouse, et. al., 1999 and 2001: 542 patients
o After achieving 200 Montevideo units, they waited at least
4 hours before doing
o If the average pattern was less than 200 Montevideo units
they waited 6 hours before resorting to CS
o They achieved 92% vaginal delivery rate
o Of the 126 women who had no progress after 2 hours of
oxytocin, 80% ultimately achieved a vaginal delivery
Zhang, 2010
o Increase in the rate of cervical dilatation more gradual than
Friedmans
o Both nulliparas and multiparas may take >6 hours to dilate
from 4-5 cm and >3 hrs from 5-6cm
o Beyond dilatation of 6 cm, rates of cervical dilatation are
more rapid for multiparas
 Active Phase Criteria
Williams OB 24th edition 3-5cm in the presence of uterine
WHO 4 cm
ALARM Effacement and dilatation after 3-4 cm
in nulliparous, or 4-5 cm in multiparous
POGS CPG on CS (2012) 4 cm
ACOG and SMFM, OB&GYNE, 6 cm
March 2014

Descent Disorder
Descent occurs during the pelvic division of labor
Disorders are diagnosed only during the deceleration phase and second
stage of labor

Prolonged Second stage

Labor pattern Nullipara Multipara
First stage
Duration 24.7 hours 18.8 hours
Protracted dilation <1.2 cm/hr <1.5 cm/hr
Arrested dilation >2 hours >2 hours
Second stage
Arrest of descent >3 hours >2 hours
(Epidural)
Arrest of descent >2 hours >1 hours
(No epidural

Prolonged second stage

Reassess maternal and fetal status
Oxytocin if hypocontractile uterine activity
Observation
Operative vaginal delivery
CS section
Clinical Features on the Functional Divisions of Labor
Char. Preparatory Div Dilatational Div Pelvic Division WHO Partograph
Functions Contractions Cervix actively Pelvis
coordinated; dilated negotiated;
polarized, mechanism of
oriented; cervix labor, fetal
prepared descent;
delivery
Intervals Latent & Phase of Deceleration
Acceleration Maximum slope Phase & Second
phase stage
Measurement Elapsed duration Linear rate of Linear rate of
Fetal heart rate, amniotic fluid, moulding
dilatation descent
Diagnosable D/O Prolonged latent Protracted Prolonged
phase dilatation; Deceleration;
Protracted 2o arrest of
descent dilatation; arrest
of descent;
failure of
descent

Arrest in descent
Descent initially occurred and then ceased
Fetal head must have gone beyond station 0 Plot Cervical Dilatation (X), Fetal head descent (O)
Change in fetal head from station -2 to -1 and then at -1 is not arrest in Descent of the fetal head in fifths palpable abdominally
descent Alert time - A line starts at 4cm of cervical dilation to the point of
Failure of Descent expected full dilation at the rate of 1 cm per hour
No descent has occurred during the deceleraton phase and second stage, Action time - Parallel and 4 hours to the right of alert line
fetal head did not go beyond station 0
Arrest in cervical dilatation at 5 cm with fetal head still at station at -1 is
not failure of descent

Poor/No progression in the first stage

Full assessment of maternal and fetal well being
Rule out cephalopelvic disproportionate
o Expectant/observation
o Amniotomy
o Oxytocin
WHO Partograph
Cervical dilation: Assessed at every vaginal examination and marked with
a cross (X). Begin plotting on the partograph 4 cm
Partograph, Alert line
o In the active phase of labor, plotting of cervical dilatation will
normally remain on, or to the left of, to alert line
o Moving to the right of the alert line is a warning that labor
may be prolonged. The woman may have to be transferred to
a tertiary facility
Partograph, Action line
o Parallel and 4 hours to the right of alert line
o If labor curve reaches the line, woman must be carefully
reassessed to determine the possible reason for lack of
progress and a decision made on further management