Abnormal labor

Prepared by

Dr. HANI MAHDI

Modified Sep 2022
 Introduction
• “Abnormal labor,”
• “dystocia,
• “obstructed labor” and
• “failure to progress”
• These are traditional but imprecise terms that have
been used to describe a labor pattern deviating from
that observed in the majority of women who have
spontaneous vaginal deliveries.
 Introduction
• Cephalopelvic disproportion is a term that came into use before
the 20th century to describe obstructed labor resulting from
disparity between the fetal head size and maternal pelvis.
• True disproportion is a tenuous diagnosis because two thirds or
more of women undergoing cesarean delivery for this reason
subsequently deliver even larger newborns vaginally.
• Failure to progress reflects lack of progressive cervical dilatation
or lack of fetal descent. Neither of these two expressions is
specific.
• These labor abnormalities are best described as protraction
disorders (ie, slower than normal progress) or arrest disorders (ie,
complete cessation of progress).
 Prevalence
• About 20 percent of all labors ending in a live birth involve a protraction
and/or arrest disorder.
• The risk is highest in nulliparous women with term pregnancies.
• In a prospective Danish study, 37 percent of healthy term nulliparas with
no indication for induction or elective cesarean delivery experienced
dystocia during labor.
• Protraction or arrest of labor is the most common indication for
primary cesarean delivery. In one study of 733 women who had
unplanned cesareans, 68 percent of the cesarean deliveries were due to
lack of progress in labor.
 Categorization of Labor Events
• Labor is divided into three stages:
• 1. First stage: from onset of labor to full dilation of the cervix
• 2. Second stage: from full dilation of the cervix to delivery of
the infant.
• 3. Third stage: from delivery of the infant to delivery of the
Placenta.
• Pritchard and MacDonald2 described a fourth stage of labor,
comprising the hour immediately following delivery of the
placenta.
Characterization of normal progress
• Friedman (historic) data
• In the mid-1950s, Emanuel Friedman conducted his now classic studies to
define the spectrum of normal labor.
• The norms established by his data, depicted as the “Friedman curve” were
widely accepted as the standard for assessment of normal labor
progression.
• Based on these data, the transition from the latent phase to active phase
appeared to occur at 3 to 4 cm cervical dilation, and the minimum rate of
normal cervical dilation during the active phase was 1.2 cm/hour for
nulliparous women and 1.5 cm/hour for multiparous women.
• An abnormally long second stage for nulliparas and multiparas was
defined as two hours and one hour, respectively.
Composite of the average dilatation curve for nulliparous labor. The first stage is divided into a relatively flat latent phase
and a rapidly progressive active phase. In the active phase, there are three identifiable component parts that include an
acceleration phase, a phase of maximum slope, and a deceleration phase. (Courtesy of Dr. L. Casey; redrawn from
Friedman, 1978.)
 Revised Dystocia Diagnosis
• In 2009, the total cesarean delivery rate for all births in the United
States reached a record high of 32.9 percent.
• It is estimated that 60 percent of all cesarean deliveries in the United
States are ultimately attributable to the diagnosis of abnormal labor.
• To address this increasing cesarean delivery rate, a workshop was
convened by the National Institute of Child Health and Human
Development (NICHD) and the American College of Obstetricians and
Gynecologists.
• The workshop recommended new definitions for arrest of labor
progress to prevent unnecessary first cesarean deliveries.
 New studies and analysis
• Several studies evaluated labor curves in contemporary women to
establish contemporary thresholds for normal labor progression.
These new thresholds are somewhat different from, and generally
longer than, those cited by Friedman.

• The Safe Labor Consortium report by Zhang and associates (2010) was
a multicenter retrospective study using abstracted 2002 to 2008 data
from electronic medical records in 19 hospitals across the United
States. One purpose of this study was to analyze labor patterns and
develop contemporary criteria for labor progress in nulliparas.
Study cohort for the analysis of
spontaneous labor in the Safe Labor
Consortium. NICU = neonatal intensive
care unit.
(Data from Zhang, 2010.)
 Zhang curve
• Gradual increase in the rate of cervical dilation as labor
progresses. (>50% did not dilate at > 1cm/ hour until reaching
5 to 6 cm dilation).
• Beyond a dilation of 6 cm, rates of cervical dilation are more
rapid
• No deceleration phase at the end of the first stage.
• No abrupt change in the rate of cervical dilation
• Zhang observed that the median (95thpercentile) times for the
cervix to dilate from 4 to 10 cm in nulliparas 5.3 hours (16.4)
and in multiparas 3.8 hours (15.7)
A

A. Characteristics of the average cervical dilation curve for nulliparous labor.

B, Zhang labor partogram. The 95th percentiles of cumulative duration of labor from
admission among singleton term nulliparous women with spontaneous onset of labor
Characterization of Normal Progress
Contemporary data

• These new thresholds are longer than those cited by Friedman.

• First stage
• Contemporary women with rates of cervical dilation less than 1 cm per hour
before reaching 6 cm dilation often go on to have normal spontaneous vaginal
births.
• Indeed, both nulliparas and multiparas may take more than six hours to dilate
from 4 to 5 cm and more than three hours to dilate from 5 to 6 cm and still go
on to have a normal spontaneous vaginal birth.
• Beyond a dilation of 6 cm, rates of cervical dilation are more rapid in both
nulliparas and multiparas.
• Thus, it is clinically practical to consider all women to be in active labor once
they have reached a dilation of 6 cm or more.
Stages of Labor: Normal Variations
 Characterization of Normal Progress
Contemporary data

• Second stage
• Zhang observed that the median (95th percentile) duration of the
second stage in nulliparous and parous women with epidural
anesthesia was 1.1 hours (3.6) and 0.4 hours (2.0), respectively.
• Without epidural anesthesia, the median (95th percentile) was
0.6 hours (2.8) and 0.2 hours (1.3), respectively.
• The recent document by Spong et al recommends extending
prior proposed limits for diagnoses of arrest in the second stage
by an hour.
Stages of Labor: Normal Variations
• Second stage
• Zhang observation
Unintended consequences

• Among nulliparous women undergoing cesarean

for labor failure, 38% of those in spontaneous
labor and 63% of those being induced had their
cesarean performed at or before 6 cm dilation
was reached.
PROTRACTION AND ARREST
DISORDERS
 First stage - Latent Phase:
• According to the data by Friedman, latent phase is
considered prolonged if it exceeds 20 hours in nulliparas or
14 hours in multiparas.
• Most women with a prolonged latent phase ultimately will
enter the active phase with expectant management.
• Thus, a prolonged latent phase (eg, >20 hours in nulliparous
women and >14 hours in multiparous women) should not
be an indication for cesarean delivery.
 First stage - Protraction:
• Median rate of dilation in active phase is 1.8 cm/hr in
nullipara and 2.5 cm/hr in multipara.
• Rates of dilation slower than those shown previously are
diagnostic of a protraction disorder.(95th % SD 0.4 cm
/hour)
• Slow but progressive labor in the first stage of labor
should not be an indication for cesarean delivery.
First stage – Arrest:
 Second stage – Protraction:

• Protraction:
• Protraction had traditionally been defined as a second stage
longer than two hours in nulliparas (three hours when regional
analgesia is used), and longer than one hour in multiparas (two
hours with regional analgesia).
• Contemporary data suggest that many women will have
successful vaginal deliveries with second stages longer than
these times.
“No cesarean before these time limits … in
the presence of reassuring maternal and
fetal status.”
 PROGRESS IN INDUCED LABORS

• The time to dilate 1 cm in latent phase (dilation less

than 6 cm) is significantly longer in women
undergoing induction than in those in spontaneous
labor, and can take several hours.
• The duration of the first stage is significantly longer in
induced labor:
 Median (95th percentile) Time for
Nulliparous Women to Dilate
Dilate from Induced labor Spontaneous labor

3 cm to 4 cm 1.4 hours (8.1 hours) 0.4 hours (2.3 hours)

4 cm to 5 cm 1.3 hours (6.8 hours) 0.5 hours (2.7 hours)

5 cm to 6 cm 0.6 hours (4.3 hours) 0.4 hours (2.7 hours)

 PROGRESS IN INDUCED
LABORS cont.

• Induction should not be defined to have failed in the latent

phase unless oxytocin has been administered for at least
24 hours or for 12 hours after membrane rupture.
• The diagnosis of an arrest disorder in women undergoing
induction should not be made unless the woman has
entered the active phase of labor.
• It is considered appropriate to temporize before declaring
that an induction has failed in women being induced for
conditions that are not likely to worsen with time and
whose membranes remain intact.
 Reconsidering current clinical
standards
• First stage
• A 2-hour threshold may be too short before 6 cm whereas a 4-hour limit
may be too long after 6 cm. Given that the speed of cervical dilation is not
constant, a graduated threshold based on the level of cervical dilation may
be a more appropriate approach to defining labor arrest than a “one-size-
fits-all” method.
• Cervical examinations every 2 hours prior to 6 cm dilation, is no longer a
reasonable practice pattern based on current evidence.
• The majority of women will reach complete dilation, regardless of parity,
within 30 minutes of having an examination of 9 cm, should the
recommended intervals of cervical examination be shorter in the later part
of the active phase of labor?
 Reconsidering current clinical
standards cont.
• Second stage
• A question encountered in every day practice :
• when should pushing start and how should women push?
• A metaanalysis reported in 2008 suggested that, compared with
immediate pushing, delayed pushing was associated with increased
spontaneous vaginal deliveries, decreased operative vaginal deliveries,
and decreased duration of active pushing.
• Three recent publications suggest that as the second stage of labor
continues, beyond the first hour, regardless of management approach,
there is an associated dose-response increase in maternal and neonatal
morbidities
 Etiology and Risk Factors
• Older maternal age • Nulliparity
• Pregnancy complications • Short stature (less than 150
• Nonreassuring fetal heart cm)
rate • High station at full dilatation
• Epidural anesthesia • Chorioamnionitis
• Macrosomia • Postterm pregnancy
• Pelvic contraction • Obesity
• Occiput posterior position
 Impact of fetal gender on the labor
curve
• Male fetuses are associated with longer active
phase of the first stage of labor and, specifically,
may need to be considered in the setting of
arrest diagnoses.
 Diagnosis of Poor Progress of
Labor
• Poor progress has conventionally been related to the
three ‘P’s namely:
• (a) powers – adequacy of the uterine contractions;
• (b) passages – resistance of the birth canal;
• (c) passenger – relating to the size, position, degree of
flexion, etc., of the baby.
• To these can be added a fourth ‘P’: poor practice.
UTERINE CONTRACTIONS
(“POWER”)
• The most common cause of protraction and/or arrest disorders.
• Monitored by palpation, external tocodynamometry, or by using
intrauterine pressure catheters (IUPCs).
• Recent studies suggest that the use of an IUPC instead of external
tocodynamometry does not affect the outcome in cases of abnormal
labor.
• For cervical dilation and fetal descent to occur, each uterine
contraction must generate at least 25 mm Hg of peak pressure.
• Optimal intrauterine pressure is 50 to 60 mm Hg.
• A minimum of three contractions in a 10-minute interval, often
described as "adequate.
 UTERINE CONTRACTIONS
(“POWER”) cont.
• A Montevideo (MVU) unit is defined as peak of
contractions in millimeters of mercury minus baseline
uterine pressure multiplied by the frequency of contractions
per 10-minute period.
• Normal progress of labor is usually associated with 200- 350
Montevideo units.
• In a study of women with spontaneously beginning normal
labor, uterine activity averaged about 100 MVUs in the early
first stage of labor, 175 MVUs in the advanced first stage,
and 250 MVUs in the second stage
Cardiotocography
Showing
Calculation of
Montevideo
Units
Uterine Tachysystole is defined as:
• More than 5 contractions in 10 minutes, averaged
over a 30-minute window.
• Uterine hypertonus is described as a single
contraction lasting longer than 2 minutes.
• Uterine hyperstimulation is when uterine
tachysystole leads to a nonreassuring fetal
heart rate pattern.
 FETAL FACTORS (“PASSENGER”)
• A large fetus (weight >4000 g) may not easily be
able to be born vaginally even if the pelvis is
normal in size.
• A large fetus is a risk of shoulder dystocia and fetopelvic
disproportion
• Some genetically programmed mothers
habitually produce large babies, as do some
diabetic mothers.
• Fetal anomalies, such as hydrocephaly and soft tissue
tumors, may also cause dystocia.
 FETAL FACTORS (“PASSENGER”)
• Evaluation of the passenger includes:
• clinical estimation of fetal weight
• clinical evaluation of:
• fetal lie
• presentation
• position
• attitude
 FETAL FACTORS (“PASSENGER”)
cont.

• The presentation of the fetus may cause prolongation

of labor:
• Brow presentation (about 1 in 3000 deliveries)
• Face presentation (about 1 in 600 to 1000 deliveries)
• A persistent occipitoposterior position is also associated with longer
labors (approximately 1 hour in multiparous patients and 2 hours in
nulliparous patients).
• Compound presentations (about 1 in 700 deliveries)
• 15% to 20% of compound presentations associated with umbilical
cord prolapse.
A fontanelle can be palpated when the
cervix is slightly dilated
 Occipito Transverse Arrest
• Persistent OT position is an OT position that is maintained for
an hour or more into the second stage of labor:
• High transverse arrest (arrest above station +2 on a -5 cm to +
5 cm scale)
• Deep transverse arrest (arrest below station +2 on a -5 cm to +
5 cm scale)
• ETIOLOGY — Persistent OT position is thought to result from
constraint to rotation by the bony pelvis ( the platypelloid or
android pelvis) and/or inadequate power from contractions
and pushing to induce rotation.
 Occipito Transverse Arrest
MANAGEMENT
• Oxytocin — If hypocontractile uterine activity is present,
contractions should be augmented with oxytocin.
• Expectant management — If there is any progress in descent and
the fetal heart rate is reassuring, expectant management is the
preferred option.
• Cesarean delivery — for management of high transverse arrest
despite adequate uterine activity and maternal expulsive effort.
• Manual rotation, Cesarean delivery, and instrumental rotation are
options for management of deep transverse arrest.
• Manual rotation should be attempted before instrumental rotation.
 FETAL FACTORS
(“PASSENGER”)
• Asynclitism If the fetal head is asynclitic (turned to
one side; asynclitism) or extended (extension), a
larger cephalic diameter is presented to the pelvis,
thereby increasing the possibility of dystocia.
• Anterior asynclitism
• Posterior asynclitism
Synclitism and Anterior Asynclitism
Synclitism and Anterior
Asynclitism
 MATERNAL FACTORS (“PASSAGE”)
• Dystocia can result from maternal skeletal or soft-tissue
anomalies that obstruct the birth canal.
• The progress of descent of the presenting part in labor is the
best test of pelvic adequacy.
• Soft-tissue causes of dystocia include abnormalities of the
cervix, tumors or other lesions of the colon or adnexa,
distended bladder, uterine fibroids, an accessory uterine
horn, and morbid obesity.
 MATERNAL FACTORS (“PASSAGE”)
cont.

• Neuraxial anesthesia
• A 2011 Cochrane review of randomized trials concluded
that neuraxial labor anesthesia compared to non-neuraxial
anesthesia or no analgesia was not associated with a
significant increase in duration of the first stage of labor or
cesarean delivery.
• There were small but statistically significant increases in
the second stage of labor.
MATERNAL FACTORS (“PASSAGE”)
cont.

• Maternal obesity
• Increasing maternal body mass index (BMI) correlates
with an increasing length of the first stage of labor.
• In one study, for example, the median time to dilate from
4 to 10 cm in nulliparous women with BMI <25 kg/m2 and
>40kg/m2 was 5.4 and 7.7 hours, respectively.
• Maternal obesity is not independently correlated with
the length of the second stage of labor.
Female Pelvis
Classic measurements
(cms)
Transverse-Oblique-AP
• Brim 13 12 11
• Cavity 12 12 12
• Outlet 11 12 13

Female pelvis responds to

relaxin and progesterone
= MOVEMENT IN LABOUR
Cephalopelvic Disproportion (CPD)
• The term CPD was originally used to describe disparity
between the size of the fetus and maternal pelvis.
• In contemporary practice, this diagnosis is often based
upon observation of protracted or arrested labor
during the active phase.
Cephalopelvic Disproportion (CPD)
• Classically, CPD is classified as follows:
• 1- Absolute:
• Fetal hydrocephalus.
• Congenitally abnormal pelvis
• A pelvis that has been grossly distorted from osteomalacia.
• 2- Relative: Fetal malposition
malpresentation
Congenital malformations :These include Naegele’s pelvis and
Robert’s pelvis, and are due to the defective development of
one or both sacral lateral masses, causing the sacrum to fuse
with the ilium on one or both sides.
 Cephalopelvic Disproportion (CPD) cont.
• Antepartum: Clinical and radiologic assessments of the maternal
pelvis and fetal size (ie, pelvimetry) are inexact and poorly
predict the course and outcome of labor.
• Intrapartum: Some overlap of the parietal and occipital bones at
the lambdoid sutures and overlap of the parietal and frontal
bones at the coronal sutures is common in normal labor.
• A protracted or arrested descent with severe molding,
especially overlap of the parietal bones at the sagittal suture, is
suggestive of CPD.
 OBSTRUCTED LABOR
• The end result of a poorly managed or neglected labor
• In a first labor the uterus contracts strongly for a while
and then, failing to overcome the obstruction, becomes
hypoactive, developing secondary arrest.
• If the obstruction occurs in a subsequent labor, the
uterus continues to contract strongly in an attempt to
push the fetus through the maternal pelvis. With each
contraction there is some myometrial shortening
(retraction), the upper uterine segment becoming
progressively thicker and shorter, and the lower segment
becoming progressively stretched and thinner.
• The junction between the two segments becomes
 OBSTRUCTED LABOR

• Bladder becomes abdominal and there will be retention of

urine.
• In late stages, there may be hematuria.
• In neglected situations:
• there may be pressure necrosis leading to fistula
formation.
• uterus may rupture, there will be severe postpartum
hemorrhage leading to shock and sepsis.
• the patient becomes dehydrated, with a
coated tongue and dry lips and tachycardia
Threatened rupture of the uterus in a
case of cephalopelvic disproportion and
obstructed labor.
 OBSTRUCTED LABOR

• Treatment is urgent:
• the dehydration should be corrected
rapidly
• a caesarean section performed under
antibiotic cover as soon as possible, even
if the fetus is dead.
 The key Components of Active
Management of Labor
• Special antenatal classes to prepare women for labor
• Strict criteria for diagnosing labor
• Routine 2-hourly vaginal examination
• Early amniotomy
• Early recourse to oxytocin
• A designated midwife in constant attendance and
continuous one-to-one support during labor
• A guarantee that labor would last no longer than 12 h.
Differences between true and false
labor
 Management of abnormal labor
• A disciplined approach to the diagnosis of labor.
• Assessment of maternal and fetal well-being.
• Careful monitoring of labor progress. Once active labor is
diagnosed, serial cervical examinations are performed to
determine whether progression is adequate.
• The results can be noted on a partogram, which is a graphical
representation that clearly shows the patient's labor in
comparison to the expected lower limit of “normal progress.”
• Deviation from this curve is diagnostic of a protraction or
arrest disorder.
PARTOGRAPH
 Use of Partogram
• In two RCTs including 1590 women,
compared to no partogram, the use of the
partogram is not associated with
significant effects on:
• cesarean delivery
• oxytocin augmentation
• duration of the fist stage of labor
• Apgar score <7 at 5 minutes
 Differences Between the
Partograph and the Labor Care
Guide
Partograph Labor Care Guide
• Active phase defined as • Active phase defined as
starting from 4 cm of starting from 5 cm of
cervical dilatation cervical dilatation
• Fixed 1 cm/hour ‘alert’ • Evidence-based time limits
line and ‘action’ lines at each centimeter of
• No second-stage section cervical dilatation
• No recording of • Intensified monitoring in
supportive care 2nd stage
interventions • Explicit recording of labor
companionship, pain relief,
 Differences Between the
Partograph and the Labor Care
Guide
Partograph Labor Care Guide
• Records strength, duration • Records duration and
and frequency of uterine frequency of uterine
contractions contractions
• No explicit requirement to
respond to deviations from • Requires deviations to be
expected observations of highlighted and the
any labor parameter, other corresponding response to
than cervical dilatation be recorded by the provider
alert and action lines
 FIRST-STAGE - LATENT PHASE
• A prolonged latent phase is one that exceeds 20 hours in a nulliparous
patient or 14 hours in a multiparous patient.
• Options for management: observation and sedation (therapeutic rest
induced with morphine):
• 1-The patient may stop having contractions
• 2-May go into active labor (85%)
• 3-May continue experiencing prolonged labor into the active phase.
• A prolonged latent phase (eg, >20 hours in nulliparous women and >14
hours in multiparous women) should not be an indication for cesarean
delivery.
 FIRST STAGE - ACTIVE PHASE
• Confirm that the patient is in the active phase (cervix is at least 6 cm).
• Administer oxytocin, and wait four hours while monitoring the mother and
fetus.
• It is reasonable to administer oxytocin to women with protracted labor,
regardless of documentation of hypocontractile uterine activity.
• Evidence:
• In a 2013 meta-analysis of eight randomized trials of 1338 low risk women in
the first stage of labor at term, early use of oxytocin (intervention group)
compared to placebo/no treatment/delayed use of oxytocin (control group)
resulted in a significant two-hour reduction in the mean duration of labor,
but no difference in cesarean delivery or instrumental delivery rates.
 What is Oxytocin?
• A peptide hormone made in the hypothalamus and
released from the posterior pituitary in a pulsatile
manner.

• In patients with documented disorders of labor, what

percentage responds to oxytocin infusion resulting in
a vaginal delivery?
• 80%.
 What is the Mechanism of Action of
Oxytocin?
• On binding to its receptor, phospholipase C is activated. This
increases intracellular calcium by stimulating the release of
intracellular calcium and by initiating influx of extracellular
calcium.
• Mean plasma half-life of oxytocin is?
• 3 to 4 minutes, but shorter when high doses are infused.
• The interval to reach a steady-state concentration of oxytocin
in plasma is approximately?
• 24 minutes.
 Oxytocin Augmentation
• High versus a low dose:
• Either a high or low dose oxytocin regimen is acceptable oxytocin
regimen.
• A 2010 systematic review of randomized trials of high versus low dose
oxytocin for augmentation of women in spontaneous labor (10 trials, n =
5423 women) found that high dose oxytocin:
• Decreased the cesarean delivery rate and increased the rate of
spontaneous vaginal delivery.
• Decreased the total duration of labor.
• Increased the frequency of tachysystole.
• Resulted in similar maternal and neonatal morbidities.
Oxytocin Augmentation
 Assessing Effectiveness
• Traditionally, active phase arrest was diagnosed when oxytocin augmentation did not
result in labor progress after two hours of contractions that achieved ≥200 Montevideo
units.
• Contemporary data: evaluate cervical change after four hours of adequate uterine
contractions with oxytocin or six hours of inadequate uterine contractions with
oxytocin prior to making a diagnosis of labor arrest and performing a cesarean
delivery.
• Evidence confirmed that oxytocin augmentation of a protraction disorder for at least
four hours is both safe and effective for achieving vaginal delivery.
• A prospective study found that women who had not progressed (≤1 cm additional
dilation) after two hours of oxytocin administration went on to achieve vaginal delivery
(91 percent of multiparas and 74 percent of nulliparas). Similarly, most women who
had not progressed after four hours of oxytocin administration went on to achieve
vaginal delivery (88 percent of multiparas and 56 percent of nulliparas).
Patience with Progress
 Other Approaches
• Oxytocin and amniotomy
• For women in spontaneous labor who develop a delay in the first stage, a
2013 systematic review of randomized trials found that use of both early
amniotomy and early oxytocin did not statistically shorten the first stage of
labor compared with routine care.
• There was no more than a modest reduction in the rate of cesarean delivery.
• Risks of amniotomy: fetal heart rate decelerations due to cord compression
and an increased incidence of chorioamnionitis.
• (FHR) should be evaluated both before and immediately after rupture of the
membranes.
• Ambulation and continuous labor support may increase the comfort of the
parturient, but there is no evidence that these interventions are clinically
effective for treatment of established protraction or arrest disorders.
AMNIOTOMY
Is Amniotomy Beneficial for the
Patient with Prolonged Latent Phase?
• Amniotomy can shorten the latent phase of labor if
used with active management of labor protocols.
• One meta-analysis found that it shortened the first
stage by up to 39 minutes.
 Second Stage
• ACOG’s recommends that the duration of the second stage of
labor be based upon parity and presence of regional
anesthesia, with no intervention to deliver the fetus as long as
the fetal heart rate pattern is normal and some degree of
progress is observed.
• Cautions:
 Second Stage Options

Operative intervention is indicated when

cephalopelvic disproportion is suspected.
With that in mind, after how many
hours in the second stage has it been
shown that the chance of vaginal
delivery significantly decreases while
maternal morbidity increases?
• 4 hours.
• The incidence of vaginal delivery with a
second stage <2 hours is 99%, 2 to 4 hours is
91%, and >4 hours is only 66%.
Prolonged Third stag of labor
 Ineffective Interventions
• Turning down the neuraxial anesthetic to facilitate progress during a
protracted second stage did not result in a reduction in instrumental
delivery nor was there any statistically significant difference in rates
of other delivery outcomes.(2004 meta-analysis including five
randomized trials).
• There is no strong evidence that a change in maternal position (eg,
upright posture, lateral, or hands and knees position instead of
supine) is useful for treatment of second stage arrest.
• Women should be encouraged to give birth in the position they find
most comfortable.
• Radiographic pelvimetry is of no value and is not recommended
when cephalopelvic disproportion is suspected.
 Outcome
• Contemporary data on the outcome of protracted labor are
limited, but generally show good neonatal outcomes after a
protracted first stage.
• A prolonged second stage has been associated with
increased maternal risks:
• Chorioamnionitis,
• Postpartum hemorrhage,
• Operative vaginal delivery,
• Third/fourth degree perineal lacerations
 Prevention
• There is no strong evidence that any intervention will prevent protracted labor.
• Amniotomy with or without oxytocin — routine amniotomy did not clearly
shorten the first stage of spontaneous labor.
• Active management of labor —A 2000 meta-analysis of randomized trials of the
active management of labor approach reported a reduction in the duration of the
first stage of labor, but no significant decrease in the rate of cesarean delivery.
• Volume replacement —Two small randomized trials in laboring women observed
that nulliparous women in labor given intravenous fluids at 250 mL/hour had a
lower frequency of prolonged labor and possibly less need for oxytocin than those
who received the traditional 125 mL/hour .
• Another randomized trial showed that nulliparous women receiving intravenous
fluids with dextrose were less likely to have a prolonged labor and had a reduction
in the duration of the second stage of labor
 Prevention cont.

• Avoidance of occiput posterior —Pregnant women are often advised to perform

exercises to facilitate anterior rotation of the fetus, but there is no good evidence that
these maneuvers are effective. (multicenter, randomized trial)
• Pelvic floor muscle exercises — Training the muscles of the pelvic floor may prevent
some cases of prolonged second stage.
• Delayed pushing —Pooled data from seven randomized trials (n = 2827 women)
indicated that passive descent statistically increased a woman's chance of having a
spontaneous vaginal birth, decreased her risk of having an instrument-assisted
delivery, and decreased pushing time, with trends toward reductions in rates of
cesarean delivery, genital laceration and episiotomy.
• Delayed pushing predictably increased the duration of the second stage (by 54
minutes), and resulted in lower umbilical cord blood pH, but no difference was
detected in overall neonatal morbidity. Maternal position and technique do not appear
to affect the length of the second stage. (Randomized multicenter trial (n = 1862))
 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.
• A precipitous second stage is the most common labor abnormality
associated with shoulder dystocia, although the rates of permanent
injury did not increase.
 Precipitate Labor
• This is an overactive labor in which the baby is expelled soon
after the start of labor usually within 2–3 h.
• The incidence is 2–3 %.
• Short labors can be associated with placental abruption,
uterine tachysystole, and recent maternal cocaine use.
• The abnormal pattern of uterine contractions:
• the strong intensity
• the frequency, which is very rapid.
 Precipitate Labor
Maternal Risks
• Lacerations of the cervix and the perineum
• Postpartum hemorrhage (PPH)
• Amniotic fluid embolism
Fetal Risks
• Fetal hypoxia because of strong, frequent uterine
contractions
• Intracranial hemorrhage
• Skull fractures
• Rupture of cord
 Precipitate Labor Management
• In all anticipated cases, the patient should be in the bed
throughout the labor to avoid sudden delivery and injury to
the mother and fetus.
• Generous episiotomy to protect the perineum.
• Proper support to the perineum and controlled delivery of
the head.
• Lower genital tract is examined carefully for any injury after
delivery.
• Patient with a history of precipitate labor may be admitted
before term to deliver under controlled conditions.
 Meconium
• Between 15 and 20% of term pregnancies are associated with
meconium staining of the amniotic fluid.
• Meconium may be demonstrated in the fetal gut in the first trimester,
but in utero passage is rare before 34 weeks.
• Meconium aspiration can occur with intrauterine gasping or when
the baby takes its first breath, and accounts for 2% of perinatal
deaths.
• The appearance of fresh meconium in labor should prompt
evaluation of fetal well-being. Continuous electronic fetal monitoring
should be instituted.
• Meconium Thick and Thin.
Thank You